A Patient's Guide for Pediatric Surgery
We recognize the importance of partnering with you in providing care for your child. We call this Patient and Family Centered Care. You are the expert on your child's behavior, preferences, expressions and the way your child deals with stress, fear and pain. We encourage you to share with our team of doctors, nurses and other healthcare professionals the best way to comfort and soothe your child.
What to Expect
Our multidisciplinary team of your child's healthcare providers make bedside rounds each morning. This is when we will discuss your child's condition, pain management, response to treatment and the plan of care for that day. Parents (and patients when age appropriate) are encouraged to be in attendance at these bedside rounds, to provide vital information regarding the care of your child. In addition the team will gladly respond to any questions you or your child might have.
We hope that your child's stay in our Pediatric Unit will be short and as positive an experience as possible. At any time during your stay, please do not hesitate to ask questions - we are all here to help your child and your family heal.
Preparing Your Child for Surgery
At Cedars-Sinai, we know that surgery can be an overwhelming, often frightening experience for children and families. Talking with your child about what to expect ahead of time may help your child feel less afraid. Some things to do beforehand:
- Listen to your child.
- Be honest about what will happen.
- Use short, simple terms to explain things.
- Encourage questions and expression of fears.
- Let your child know that having to go to the hospital does not mean he has done something wrong.
- Explain that he will have special medicine to help his body not be awake during surgery and that he will wake up when the procedure is over.
- Reassure him that if something hurts, there are ways to help the pain, including medicine, relaxation and distraction.
- Emphasize that the hospital stay is temporary and focus on what your child will be able to do when they go home.
Children understand things based on their developmental level and age. The younger the child, the closer to the event you should prepare them. Here are some ideas that may be helpful to you.
- For any age child, pack some special items from home. Familiar objects will help your child feel more comfortable in a strange place. A favorite toy can serve as a security blanket and can accompany your child into surgery, the recovery room or the intensive care unit. For older children, a favorite pillow or blanket may also offer comfort.
- Infants and toddlers: Infants and toddlers find the most comfort in familiarity with caregivers. A calm caregiver helps promote a calm child. If you need to be away for periods of time during your child’s hospitalization, plan for a family member or friend to be with your child.
- Preschool and young school age (2-6 year olds): As a child gets older, he can be told about going to the hospital and what to expect once there. It is very important to give clear and simple explanations…and to tell the truth. Encourage conversation about the upcoming surgery. To know what your child’s fears are will be helpful for you, as well as the hospital staff. Rather than ask, “How do you feel?” try saying something like, “I bet you’re wondering what will happen when we get to the hospital, aren’t you?” This approach is more likely to get your child to talk.
Children can engage in medical play by giving a doll or stuffed animal “shots” and “medicine.” A play medical kit can be a wonderful tool for this type of play and might make your child more comfortable expressing feelings. Offer reassurance that you’ll do your best to be with him when you can and that other people will take care of him when you aren't there.
- School age children (6-12 year olds): Depending on your individual child’s abilities and needs, many of our suggestions for younger children can also be helpful at this age group. Please keep in mind that older children may want more detail so they may ask more questions. It is okay to tell your child if you don’t know the answer and that there are people at the hospital you can talk to for the answer and then follow through. This keeps the bond of trust secure.
It’s important for children to know that following surgery, the doctors, nurses and other members of our healthcare team may do additional tests and/or procedures to make sure that he is healing well from surgery. Empower your child to speak for himself, particularly around the issue of pain. There is a pain assessment tool that is useful to children to rate their pain. There are medications to help manage pain but encourage such things as distraction, relaxation and deep breathing to augment pain medications. These techniques also offer children a bit more control over their situation.
- Teenagers: Speak to your teenager honestly and respectfully about his upcoming surgery. Encourage your teenager to talk to the doctors and nurses and remember to include your teenager in discussions and decisions. This enables your teenager to feel a bit of control and foster independence. Your nonverbal cues are as important as your words: your facial expressions, tone and body language can be powerful. If you appear anxious or scared, your teen might feel frightened, regardless of the words you choose.
Privacy is a big issue for teenagers. Reassure your teen that the hospital staff will be respectful by knocking and pausing before entering the room. Encourage your teenager to maintain contact with friends and family through phone calls, Skype, letters and cards. When appropriate, allow for visits from friends for peer support.
Managing Your Child's Pain
Your child's pain management is very important to us. There may be physical causes for pain, but your child's mental and emotional state can also affect the amount of pain your child experiences.
As a parent, you know your child best. Our multidisciplinary team will work closely with you to make sure your child is as comfortable as possible. We understand your child may feel pain from the surgery, as well as anxiety from being in the hospital. As pediatric experts, we do our best to ease both.
After using our pain assessment tools, medications can be given to children through an IV, by mouth as a pill or liquid to be swallowed or as a rectal suppository.
In addition to medicines that assist your child with pain, there are other things you can do to help him cope with pain, and the fear often associated with it. Some common things that help might include distraction, guided imagery, relaxation and deep breathing.
Child Life Services
At Cedars-Sinai, Child Life Specialists provide support to children and teens to help them prepare for their medical experience. Services include health education, therapeutic play, developmental activities and emotional support to minimize any psychological trauma, stress and anxiety associated with hospitalization. In turn, children and teens are better able to cope with and master their healthcare experience.
Frequently Asked Questions
Find answers to your most frequently asked questions about surgery for children.
As part of the usual pre-operative preparation, your child will be seen by a pediatrician or primary care physician for a history and physical prior to surgery. Occasionally, based on your child's medical condition or the type of procedure, a blood test or other diagnostic test may be ordered by your doctors
It is natural for you and your child to be anxious before surgery and to have many questions. Talking with your child about what to expect during surgery and anesthesia can be very helpful.
Learn all you can about the surgery. Be honest and tell your child why he/she is going to the hospital. Use words that are easy to understand. Give very simple explanations and choose your words carefully.
For example, you might want to say "the doctor is going to fix your leg", instead of "make a cut on your leg." Avoid saying "you will be put to sleep" because your child may remember what happened to a pet when it was put to sleep. Instead say something like "the doctors will give you special medicine for your body to be asleep during surgery."
Be reassuring in everything you say to your child. Focus that the hospital stay is a temporary one, and he/she will come home as soon as the doctor says it's okay. Make sure your child knows that surgery is not a punishment for anything "bad" that he/she has done. Instead, explain that your child is going to the hospital in order to get better.
Listen to your child's concerns. Support your child's feelings. Make sure he/she knows it is okay to feel scared, sad, or angry. Explain that being frightened is normal, even for grown ups. Be patient with your child during this stressful time. Understand that children may act out, or behave more childishly when stressed, and that this behavior should start improving after the surgery has passed.
Lastly, don't forget to take care of yourself. Get as much rest as you can. Understand your own feelings and fears. Talk about how you feel with a family member, or friend, or someone you trust.
Anesthesia medication that causes a loss of pain sensation and feeling given by an anesthesiologist to make your child comfortable during surgery or procedures. The anesthesiologist is a medical doctor who has been specifically trained in taking care of children and will give medications based on your child's medical condition and history.
The most common type of anesthesia for children having a surgery is general anesthesia. General anesthesia is a special kind of medications that cause sleep. When asleep, your child will experience no alertness or pain. General anesthesia can be given as a gas that your child breathes or as medications given through an intravenous ("IV") line. The IV is a tube that goes into a vein in the arm or leg that allows your child to receive fluids and medications.
During general anesthesia, the anesthesiologist’s most important responsibility is to monitor your child and keep him/her safe and asleep during the procedure. After the surgery is over, the anesthesiologist will wake your child up.
Depending on the type of surgery, your child may also receive regional anesthesia to help take away pain in the area where the surgery is being done. Regional anesthesia is given by a shot of local anesthetic drug or "numbing medicine" around the nerves in the part of the body having surgery. Regional anesthesia is temporary but may last several hours depending on the medication used.
In children having surgery, regional anesthesia is usually given after the child is asleep so he/she does not feel the injection. Common types of regional anesthesia, also called "blocks", are epidural, caudal, spinal and nerve.
When your child is asleep, the surgeon will often inject a local anesthetic drug or "numbing medicine" directly into the skin and area where the surgery is being done to cause a temporary loss of pain sensation and feeling in the surgical area.
An epidural block, also called an “epidural”, is done in the middle or lower back to help with pain in the chest, abdomen or legs. After carefully washing and cleaning the back, the anesthesiologist uses a needle to enter an area around the spinal cord called the epidural space. The anesthesiologist passes a small plastic tube called an epidural catheter into this space and then tapes the catheter onto the skin of your child’s back to keep it in place. Medications can be injected through this small catheter to cause temporary numbness and loss of pain sensation in the area where the surgery is being done. After the surgery is over, the epidural catheter allows pain medication to continue to be given during your child’s recovery in the hospital. After a few days, the epidural catheter is pulled out painlessly.
A caudal block, also called a “caudal”, is a very common type of epidural block used in children having surgery in the lower part of their body. First, the skin over the lower part of the back is carefully washed and cleaned by the anesthesiologist. A caudal is done by an anesthesiologist with a needle in the middle of the lower tailbone area. Local anesthetic drug or “numbing medicine” is injected causing temporary numbness and loss of pain to the lower abdomen, groin and legs. Unlike an epidural, a caudal usually involves a single injection of medication. After the medication is injected, the anesthesiologist takes the needle out.
The anesthesiologist may occasionally recommend a spinal block, also known as a “spinal”, for surgeries involving the abdomen or legs. After carefully washing and cleaning the lower back, the anesthesiologist uses a fine needle to enter an area around the spinal cord called the subarachnoid space. A local anesthetic drug or “numbing medicine” is injected into this space causing temporary numbness and loss of pain in the lower part of the body. Unlike an epidural, a spinal involves a single injection of medication. After the medication is injected, the anesthesiologist takes the needle out.
A nerve block may be given in surgeries involving an arm or a leg. In this type of block, the anesthesiologist injects a local anesthetic drug or “numbing medicine” around nerves in the arm or leg causing temporary numbness and loss of pain sensation in the area of the arm or leg where surgery is being done.
Children less than 6 months of age may:
- drink formula up to 6 hours before surgery
- drink breast milk up to 4 hours before surgery
- drink clear liquids up to 2 hours before surgery
Children between 6 months and 3 years of age may:
- eat solids up to 8 hours before surgery
- drink formula and regular milk up to 6 hours before surgery
- drink breast milk 4 hours before surgery
- drink clear liquids up to 2 hours before surgery
Children older than 3 years of age may:
- eat solids up to 8 hours before surgery
- drink clear liquids up to 2 hours before surgery
Clear liquids are any type of liquids that you can see through clearly when poured into a glass. There should be no solid material floating in the liquid, such as orange juice. Examples of clear liquids include water, apple juice, and Pedialyte®.
Be sure to ask your pediatrician or surgeon which home medications your child should take on the day of surgery. Most medications can be continued as scheduled, right up until the morning of surgery and taken with a small sip of water. However, some medications should not be taken, or should be taken in a smaller dose, on the day of surgery. If you are unsure, it is always a good idea to ask your doctor before giving your child any medications before surgery.
Consult your surgeon or pediatrician if your child has symptoms of a cold in the days just before surgery because it could affect your child’s breathing while under anesthesia. Sometimes in very mild cases of colds, it may still be safe to undergo anesthesia. If your child has a fever, it may mean he/she has an infection in which case your doctors may feel it may be safer to postpone surgery until your child has fully recovered. The decision to go ahead with surgery or not is one that will be made by both your anesthesiologist and surgeon based on your child’s medical history and condition. If surgery is postponed because of a cold or illness, it is usual to wait a few weeks to allow for the breathing passages to return to their normal condition.
- Identification card for your health insurance, or medical assistance information
- Important phone numbers, such as your child’s doctors, family members, and friends
- Proof of guardianship (for court appointed guardians)
- Your child’s favorite toy such as a stuffed animal, pacifier, or blanket to help comfort him/her on the day of the procedure
- Your child’s bottle or sippy cup for after surgery
- (For older children:) A favorite item from home, small toy, or personal CD or MP3 player with head phones
- A book or magazines for you to read during your child’s surgery
- Overnight items, such as bathrobe and toiletries, if hospitalization after surgery is planned
In the Preoperative Holding Area
In keeping with our theme of patient and family centered care, you and your child will meet the anesthesiologist in the preoperative holding area before surgery. This time will be used to talk about your child's medical history, condition and suggestions for helping your child through this experience. Your anesthesiologist will discuss with you the anesthesia plan and will talk to you about the risks of anesthesia. Usually this meeting happens on the day of surgery.
Your anesthesiologist may prescribe an anesthetic “premedication” before surgery. This is a calming medicine given before surgery. In young children who are anxious, this is often given in the form of a flavored drink a few minutes before going into the operating room. This is often done to assist with the child going into the operation. Older children may have an IV started in the preoperative holding area and receive premedication for anxiety. The goal is to make this experience less frightening for both the patient and parent.
In the Operating Room
When your child will be brought to the operating room the anesthesiologist will use special equipment to monitor your child’s vital signs: heart rate, blood pressure, oxygen level and breathing. Your child’s anesthesiologist will stay with your child during the entire operation.
Anesthesia may be given to your child with a plastic mask, or through an IV, or both. Anesthesia from a mask is gentle and painless, and does not involve getting a “shot”. Anesthesia from a mask is the most common way of “going to sleep” in children having routine surgery and procedures. After falling asleep, an IV is started. Occasionally, for safety reasons, the anesthesiologist may decide to start an IV in a young child before going to sleep first. If your child already has an IV, then anesthesia may be given as an injection this way.
Your child’s surgery begins only after he/she is asleep. The anesthesiologist will make sure your child is comfortable during the entire operation. When the surgery or procedure is completed, your anesthesiologist will wake your child up.
In the Recovery Room
Your child will be brought to the recovery room, also known as the post anesthesia care unit (PACU), to recover after surgery. This is where you will rejoin your child as he/she awakens from anesthesia. It is normal for your child to be groggy and sleepy as they awake. Children recovering from anesthesia may also experience a variety of emotions. They may be confused, scared, or even sad as they wake up. Your child may have some pain or feel uncomfortable as they awake. Occasionally, children waking up from anesthesia may also experience nausea or feel like vomiting. The PACU nurses are speciality trained professionals to take care of patients recovering from anesthesia and will provide medications to your child for pain or nausea.
When your child is fully awake, he/she will be discharged home, or admitted to the hospital to continue recovering. Sometimes, a child may not go the PACU and instead be admitted directly from the operating room to the pediatric intensive care unit where speciality trained professional nurses will take of him/her.
Your child's pain management is very important to us. We will provide information to you on how we evaluate your child's pain and seek your involvement on pain control. Your child may feel pain from the surgery, as well as anxiety from being in the hospital. Older children may be able to talk about what they’re feeling, but young children may not. The pain management team, consisting of surgeon, anesthesiologist and nurses, are familiar with the usual pain and discomfort associated with various procedures, and can prescribe medications to treat your child’s pain. Your doctors and nurses will watch for any signs that your child is in pain. They will ask your child if he/she is hurting and may ask him/her to “point to where it hurts”. Infants and toddlers will be evaluated on their pain by using behavior indicators. Parents will be asked to participate in pain management since you know your child best. Preschoolers may be shown a FACES scale with both happy and sad faces they can point to. Under each face is a number from 0 to 10 which can be used by the doctors and nurses to get an idea how much pain your child is feeling. School age children may be asked to use a number scale of 0 to 10 to tell us how much pain they are feeling. 0 means no pain, 1 to 3 means mild pain, 4 to 6 means moderate pain, and 7 to 10 means severe pain.
As a parent, you know your child best, and the team will work closely with you to make sure your child is as comfortable as possible. Pain medications can be given to children by mouth as pills or liquids to be swallowed, through an IV, or as rectal suppositories. Sometimes, the anesthesiologist may use regional anesthesia to help with your child’s pain after surgery. If your child’s pain is difficult to control, your doctors may consult a specialist from the pain management service to help the team with your child’s pain management.
Determining when your child can eat or drink again depends on the surgery and your child’s condition after surgery. Sometimes it is necessary to wait for drinking and eating until your child is completely awake and has made a full recovery. Eating or drinking too soon may cause your child to choke or vomit. Vomiting in a patient who is not yet fully awake from anesthesia can be dangerous.
In routine outpatient procedures, your child will most likely be allowed to drink a clear liquid as soon as he/she is awake enough but should start slowly with sips. Infants will usually be allowed to nurse once they are awake enough. Older children may be given some crackers to eat before being discharged from the post anesthesia recovery room.
It is helpful to give your child some prep time to talk about the surgery before it happens. When this should happen depends on the age and developmental level of the child, but please note that discussing the subject too early may actually lead to increased anxiety in your child.
What about siblings?
Brothers and sisters have feelings too, and they may have their own reactions to their sibling’s surgery and hospitalization. They may feel fear, anger, confusion, and even jealousy at all the attention the child having surgery is receiving. Listen to and try to understand the feelings of your child’s siblings. If your child is hospitalized after surgery, you may want to ask a friend or family member to stay with your child in the hospital a few hours so you can spend some time with your other children.
Cedars-Sinai Medical Center has certified Child Life Specialists who are healthcare professionals trained to use their knowledge of child development and age-appropriate interventions to educate, prepare and support children through hospital tests or procedures such as surgery and anesthesia. This preparation could involve a preoperative visit and tour of the hospital before surgery. If you feel your child would benefit from meeting with a member of Child Life Services, please make an appointment with them.
Child Life Services
Maxine Dunitz Children's Health Center
Cedars-Sinai Medical Center
8700 Beverly Blvd., Room 4247 North Tower
Los Angeles, California 90048
In addition, there are many books, DVDs and tapes on the market about preparing children for surgery that can serve as valuable resources.