14.3 Effects of Illness and Hospitalization on a Pediatric Client and Family

Pediatric clients can react to hospitalization and illness in a variety of ways. These reactions may be affected by their age, development level, cognitive status, temperament, and coping skills. Each child reacts differently, and nurses should not assume that children of similar ages will react to illness or hospitalization in a similar manner. Additional factors that can influence the child’s reactions are the seriousness of the illness or injury, whether or not the hospitalization was planned or emergent, the emotional reactions of parents or caregivers, and cultural and religious beliefs. For example, if a parent or caregiver of an ill or hospitalized child displays anxiety and worry, the child may mirror these reactions.^[1]

Common emotional reactions to illness and hospitalization by children and their parents or caregivers include anxiety, fear, or a feeling of loss of control. These emotions can cause longer healing times or behaviors such as lack of cooperation, agitation, or aggression. Research indicates that stressful experiences such as hospitalization can also affect the physical and emotional growth of a child.^[2]

Children may exhibit specific pediatric behavioral reactions during hospitalization such as separation anxiety, stranger anxiety, and regression. Being aware of these potential reactions to hospitalization can help the nurse plan effective care for the child and their family members and ensure good client outcomes.^[3]

Separation Anxiety

Children may feel anxiety or worry when separated from their caregivers, which is known as separation anxiety. See Figure 14.6^[4] for an image depicting separation anxiety. Separation anxiety is a normal part of pediatric development that starts around eight months of age and usually resolves in toddlerhood. Typical manifestations of separation anxiety in children of this age group include fearfulness and crying when their caregivers leave, but with time these emotions fade, and they calm down. Eventually, children learn that their caregivers will return after leaving, and their feelings of separation anxiety improve. Separation anxiety often occurs during transition periods for children. Therefore, it may be heightened during hospitalization due to the stress of being ill and being in an unfamiliar place.^[5] However, developmentally inappropriate and excessive fear or anxiety related to separation from loved ones that lasts more than four weeks is a type of anxiety disorder.^[6] This section will focus on developmentally appropriate separation anxiety.

Separation anxiety can be managed by nurses with the following tips^[7]:

• Encourage children to express their emotions.
• Encourage the use of positive coping skills. For instance, letting the small child hold a favorite stuffed animal when caregivers cannot be present.
• Develop routines when possible.
• Try to distract a child that is experiencing separation anxiety with a toy, activity, or songs.
• Teach parents/caregivers to not linger when saying goodbye to a child, as this can heighten feelings of anxiety. Goodbyes should be quick, and parents or caregivers should remain calm.

Stranger Anxiety

Stranger anxiety refers to distress a child may have when interacting with people they do not know. Although stranger anxiety develops around the same time as separation anxiety, there is a distinction between the two concepts. Signs of stranger anxiety include a frightened facial expression, crying, or hiding behind or clinging to the parent or caregiver. Stranger anxiety typically peaks by 15 months of age and then decreases.^[8]

Hospitalized children are often inundated with new and unfamiliar faces as they are cared for by hospital staff. This can be a difficult time for children with stranger anxiety. Nurses and parents or caregivers can help manage stranger anxiety by doing the following^[9]:

• Although this may not be possible in an emergency situation, gradually introducing new people to a pediatric client may help ease their anxiety. Additionally, having the same staff members consistently care for the child can ease anxiety, as it reduces the amount of new people in an already stressful time.
• Parents or caregivers should be encouraged to remain calm and positive when their children are feeling distressed due to stranger anxiety. Nurses should encourage parents or caregivers to talk to their children in a warm tone and hold their children, if possible.
• Encourage unfamiliar staff to offer the child a familiar object or toy to increase their comfort.

Regression

Regression refers to a child reverting to a previous developmental stage as a means of coping with trauma, frustration, or stress. See Figure 14.7^[10] for an image illustrating regression. Regression is commonly seen in toddlers and preschoolers. It can be exacerbated by the stress of hospitalization, but after the child’s needs are met, they typically return to the appropriate developmental stage. Signs of regression may include the following^[11]:

• Speaking in “baby talk”
• Becoming incontinent or asking to use diapers by a child who has already been toilet trained
• Engaging in temper tantrums or excessive crying
• Requiring an object of comfort such as a stuffed teddy bear or other methods of gratification beyond the typical development stage
• Having problems sleeping or eating
• Losing a previously achieved skill such as getting dressed independently

Nurses and parents or caregivers should show empathy to the child and encourage them to talk about their feelings. Regression can be managed by meeting the client’s physiological and emotional needs. Play should be encouraged because children use play to express their emotions. Older children may benefit from teaching about how to use deep breathing exercises or journaling to help relieve their stress. Although empathy and reassurance should be provided to pediatric clients as needed, it is also important for parents or caregivers and nursing staff to set limits regarding inappropriate behaviors.^[12]