‘PAWSitive’ interventions ease ‘rrrf’ times in pediatrics

Daniel, a 5-year-old child with asthma, is anxious and doesn’t want to keep his oxygen mask on during his much-needed nebulizer treatment. Teary eyed, 6-year-old Emily is recovering from gastroenteritis. She is cuddled up in her hospital bed, alone and afraid as she refuses her lunch. Twelve-year-old Erin, who is recovering from a ruptured appendix, has a low tolerance for her incisional pain. And 4-year-old Molly is anxious about setting foot in her pediatrician’s office for her wellness exam.

A common factor exists in all of these young patients with varying clinical needs—they might benefit from the simple, evidence-based intervention called animal-assisted activities (AAA). According to Pet Partners, a nationally respected AAA resource for healthcare and handler education, the focus of AAA is explained in their Standards of Practice for Animal-Assisted Activities and Therapy. “AAA support opportunities for motivational, educational, recreational, and/or therapeutic benefits to enhance quality of life. AAA are delivered in various settings by specially trained individuals, in association with animals that meet certain criteria.”

In essence, AAA are intentional support modalities for healing that incorporate a facilitated interaction between the patient and the trained animal. The Delta Society, recognized as the gold standard in animal-assisted care, states that these trained animals “partner with their human companions to bring comfort and healing to those in need.”

Nurses are in an ideal role to recommend and support complementary modes of healing such as AAA. This article focuses on the value of AAA for pediatric patients so you are well positioned to advocate for this option for patients who may benefit from it. The combination of my experience as a pediatric nurse and a practicing pet therapy dog handler places me in a unique position to “connect the dots” for you between evidence-based research and my bedside encounters.

Evidence-based practice

Several studies have shown the benefits of AAA in reducing pain level (and analgesic requirements), easing anxiety, and improving mood.

Reducing pain
Testimonial accounts from patients and families in a study by Stoffel and Braun referred to the therapy animals as “taking on” the patient’s pain. The researchers reported that 49% of critically ill pediatric patients experienced a reduction in pain during therapy dog sessions.


A study by Sobo and Kassity-Krich on the effectiveness of AAA in pediatric pain management for children after surgery showed that AAA led to lower physical pain, less emotional distress, and happier, calmer patients. The conclusion suggests that AAA is a positive adjunct to traditional pain management in this specific population.

Easing anxiety
Several research projects have found positive results in having a companion animal present during a physical exam. One study by Wu of 30 patients showed that AAA provided distraction during needed procedures, created a sense of normalcy, and was satisfying to pediatric patients and their parents. Another study by Cole and colleagues concluded that the presence of trained animals can help lower anxiety, epinephrine and norepinephrine levels, and systolic pulmonary artery pressure. In addition, a qualitative analysis of patient testimonials by Stoffel and Braun identified a common theme of relaxation, calmness, and peace in the data analysis of pediatric patients studied.

Improving mood
Research also suggests AAA as an avenue for improving mood in the pediatric patient. Coakley and Mahoney concluded, “Pet therapy is a low-tech, low-cost therapy that improved mood and was meaningful to hospitalized children.” Researchers Caprilli and Messen conducted a study at Anna Meyer Children’s Hospital in Italy in which children described their mood to be pleasurable because of the therapy dog’s presence. Several patients drew pictures of the dogs following the AAA.

University of Wisconsin researchers Kaminski and colleagues screened 70 hospitalized children on the efficacy of AAA versus playroom activities and the impact on patient mood. The researchers discovered positive mood changes in patients during animal-assisted sessions via a video camera. Parents witnessed a demonstration of positive emotions in their children when exposed to the animals, and perceived their children’s moods to be more positive following AAA than pretherapy or after playroom therapy. Parents also scored their children’s mood more positive after animal visits versus playroom activities.

One final and unexpected advantage that AAA provided in the Wisconsin study was the “touch” factor. The children were observed to initiate this safe and soothing contact with the animals. Researchers concluded that direct contact with the animals met a need to be nurtured that was often missing during lengthy hospitalizations, especially when families were unable to visit often.

Risks of AAA
Risks associated with the presence of an animal in a healthcare setting include bites, scratches, allergies, and zoonotic transfer of illness.

Risk prevention is the key to a safe AAA program. Dogs credentialed through nationally recognized animal assistance programs such as the Delta Society (transitioning to the new name of Pet Partners) are rigorously screened for behaviors that preclude them from being safe for visitation therapy and for diseases that would transmit to humans.

These vaccinated animals are bathed regularly. They are tested and treated for internal and external parasites making zoonotic conditions a rarity. A facility that allows AAA should maintain a current policy that includes a process for ruling out patients that would be inappropriate to visit. For example careful screening of immunocompressed patients and those in isolation should occur. Each facility’s infection prevention experts, physicians, and staff should work closely with AAA programs to provide guidance in patient selection criteria. The patient, the dog handler, caregivers, and any family members present should wash their hands before and after the visit.

Personal experience

I see the meaningful assistance that dogs can offer in my own experience. Two particular visits serve as examples.

Molly
Bentley, my Bernese Mountain dog, and I received an unusual request from staff at a pediatrician’s office who had heard about Bentley’s work in pediatrics. They asked if he could help an extremely anxious little girl in their practice. Four-year-old Molly became so upset with every office visit that she refused to get out of the car, and screamed and cried for most of her appointment.

Thinking as a pediatric nurse and a pet therapy dog owner, I gathered some history and understanding concerning Molly’s unsettled perception of health care, asking questions such as:

  • Has she had a bad experience in your office or with healthcare in the past?
  • Is she chronically ill and requires frequent medical interventions?
  • Do you know if she has grown up with animals?
  • Does she enjoy being around dogs?”

Molly’s mother shared that Molly was simply an anxious child, a worrier, and dreaded each trip to the doctor. As I contemplated this offer to assist this poor child who seemed to be miserably anxious about visits to the pediatrician, I considered several factors. Molly liked animals, and had a “big, rowdy” dog at home that she played with. Molly’s mother sounded desperate for some help with her daughter’s office phobia. I confidently replied, “Sure, Bentley and I would like to help you out.”

Molly’s mother and I spoke on the phone and came up with an action plan. I would send the storybook I wrote about Bentley, so Molly would become familiar with my dog, including his large size, and so she could visualize how Bentley helps children. Our plan included all of us arriving 15 minutes early for playtime. I suggested that Bentley demonstrate all interventions first before asking Molly to perform specific tasks

We arrived at the pediatrician’s office to find a brown-haired, sweet-faced, timid little girl standing in the glass doorway waving and smiling at us. I was thrilled to see that Molly had made it out of the car, and appeared excited about our arrival. Tucked gently under her arm was a stuffed animal that resembled Bentley. We introduced ourselves, validated with the office staff that no one with dog allergies was present, and washed our hands. I explained that Bentley came to have fun with her, and to help her with her check-up. I encouraged Molly to feel how soft he was. I pointed out Bentley’s therapy dog bandana, picture badge, and short leash that was just Molly’s size. I suggested to she that she should lead Bentley back to the exam room and show the nurse her new friend.

Bentley’s first two assignments were to be weighed and measured. Molly was mesmerized by my gentle, giant dog, as he climbed on the scale without hesitation, and then stood quietly by the measuring tape on the wall. Molly followed his lead and did the same. Bentley calmly watched and wagged his tail with approval of her accomplishments. Molly’s mom and I looked at each other and exchanged a quick thumbs up as Molly led Bentley into the exam room.

Molly’s pediatrician played along with our plan of Bentley going first in all interventions. After assessing Bentley and Molly’s eyes, ears, and mouth, it was time for Molly to get up on the exam table. Bentley seemed to know exactly what his role was that day. He intuitively stepped up on a stool and stood by Molly for the rest of her exam. Molly maintained her cooperative demeanor, which allowed the pediatrician to work quickly. Once the exam was finished, the pediatrician looked at all of us and said, “This is going so well. How would Bentley like a nasal flu mist?” Chuckling to myself I responded, “I’m sure he’d love one.” “Well great, I’ll bring two,” replied the pediatrician.

Bentley was a bit bug-eyed as I gently held his head across my chest and pretended to squirt a placebo nasal mist vaccine in his nose. Molly watched carefully with an unsure look of acceptance to the idea that she was to go next. Picking up on her uneasiness, I commented to her, “Molly, after you get your flu mist, I bet Bentley would do his silly dance for you.” She nodded without saying a word and tolerated her final intervention of this wellness exam. As she and Bentley headed out of the exam room, several staff members began to cheer for Molly and praise her for being such a good patient. Bentley responded to Molly’s gathered fan club with a slow, gentle bow.

Emily
As Bentley and I began our recent visit as an animal assistance team, we saw a youngster sitting up in bed, hunched over, staring out the window, with tears trickling down her face. Bentley and I stood at her doorway and watched her motionless body and somber affect for several seconds. Then I began our conversation by asking her if she liked dogs and if she would like to meet Bentley, the therapy dog. In a timid but inquisitive voice, she responded, “Yes.” I then said, “Bentley the therapy dog doesn’t want you to cry. Is it okay if we come in?”

After validating that this patient met the criteria for AAA, I allowed my tail-wagging partner to approach 6-year-old Emily’s bedside. Bentley picked up on her shyness and seemed to mimic her bashful behavior. He tucked his head and gently positioned his 109-pound fluffy frame within reach of his newly found friend. In response, the frail and pale child welcomed him with a sweet smile, hesitantly reaching toward him. “Aww, aren’t you cute,” she whispered. After helping Emily wash her hands so she could pet the dog, I saw Bentley’s intuitive skills at work as he demonstrated some silly antics. A few dog tricks from him without being cued to do so elicited a few reserved giggles. The longer we stayed, the chattier Emily became. She eventually sat up on her knees, looked Bentley in the eyes, stroked his fur, and told him that she was crying because she didn’t want her lunch. And if she didn’t eat her lunch, her physician said she couldn’t go home.

As we prepared to leave, I helped Emily wash her hands once again. After offering her some words of encouragement, I cued Bentley to raise his paw up to wave good-bye. He then followed with a thank-you bow. This newest pediatric member of Bentley’s fan club grinned and motioned with one raised hand as if to wave good-bye back to my fur coated interventionist. Her other hand grasped a generous bite of her lunch, which she began to eat.

Patient-centered therapy

The complementary, low-cost intervention of AAA is patient centered in every way. Skilled therapy dogs intuitively decipher how they can help each patient and act accordingly. The American College of Critical Care Medicine summarizes its view of animal-assisted involvement in patient care: “AAA supports a patient-centered care approach with an optimal environment for healing.”

Editor’s note: Access the PDF for photos of Bentley in action.

Selected references

Animal-assisted therapy study readies for pilot trial. Veterinary Practice News. April 12, 2012. http://www.veterinarypracticenews.com/vet-breaking-news/2012/04/12/animal-assisted-therapy-study-readies-for-pilot-trial.aspx.

Bibbo J. Staff members’ perceptions of an animal-assisted activity. Oncol Nurs Forum. 2013;40(4):320-326.

Caprilli S, Messeri A. Animal-assisted activity at A. Meyer Children’s Hospital: A pilot study. Evid Based Complement Alternat Med. 2006;3(3)379-83.

Coakley AB, Mahoney EK. Creating a therapeutic and healing environment with a pet therapy program. Complement Ther Clin Pract. 2009;15(3):141-6.

Cole KM, Gawlinski A, Steers N, et al. Animal-assisted therapy in patients hospitalized with heart failure. Am J Crit Care. 2007;16(6):575-85.

Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit. American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007;35(2):605-22.

Pet Partners. How to become a registered therapy animal team. http://www.petpartners.org/TAPinfo.

Johnson R, Odendaal J, Meadows R. Animal-assisted interventions research: issues and answers. West J Nurs Res. 2002;24(4):422-40.

Kaminski M, Pellino T, Wish J. Play and pets: the physical and emotional impact of child-life and pet therapy on hospitalized children. Children’s Health Care. 2002;31(4):321-335..

Lefebvre S, Golab G, Christensen E, et al. Guidelines for animal-assisted interventions in health care facilities. Amer J Infect Control. 2008;36(2):78-85.

Nagengast S, Baun M, Megel M, et al. The effects of the presence of a companion animal on physiological arousal and behavioral distress in children during a physical exam. Journal of Pediatric Nursing. 1998;12(8):323-30.

Pet Partners Therapy Animal Program. Delta Society. www.deltasociety.org.

Sehulster L, Chinn R. Guidelines for environmental infection control. MMWR Morb Mortal Wkly Rep. 2003;52(RR-10). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm.

Sobo EJ, Eng B, Kassity-Krich N. Canine visitation (pet) therapy: pilot data on decreases in child pain perception. J Holist Nurs. 2006;24(1):51-7.

Stoffel JM, Braun CA. Animal-assisted therapy: Analysis of patient testimonials. J Undergrad Nursing Scholarship. 2006. http://www.juns.nursing.arizona.edu/articles/Fall%202006/stoffel.htm.

Swift WB. The healing touch. Animal-assisted therapy. Animals. March, 1997: V36(2):78-85). http://www.highbeam.com/doc/1G1-19225851.html.

Wu A, Niedra R, Pendergast L, et al. Acceptability and impact of pet visitation on a pediatric cardiology inpatient unit. J Pediatr Nurs. 2002;17(5):354-62.

Janet Myers is director of risk and safety for Schneck Medical Center in Seymour, Indiana. She founded her hospital’s animal assistance program and actively volunteers with her dog, Bentley. Janet is the author of two books, The Visit: Healing Moments in Pet Therapy and Booboos, Band-aids and Bentley, The True Story of a Hospital Therapy Dog. Visit www.bentleythetherapydog.com.

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