I. General Guidelines

A. Consent
Before any procedure is performed, it is crucial to obtain informed consent from the parent or guardian by explaining the procedure, the indications, and any risks involved; answer questions; and discuss possible alternatives. Obtaining consent should not impede lifesaving, emergent procedures.

B. Documentation
It is important that the physician performing the procedure document the informed consent process. Include the date, time, additional providers present (if applicable), brief summary of the consent conversation, the diagnosis, recommended procedure, specific risks and benefits, and alternative treatments. It is equally important to document if a patient refuses a procedure and that the risks associated with refusal were discussed.

C. Risks

1. 1. All invasive procedures involve pain, risk for infection and bleeding, and potential injury to neighboring structures.
2. 2. Sedation and analgesia should be planned, and the risks of such explained to the parent and/or patient as appropriate. (See Chapter 6 and the AAP Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures.¹)
3. 3. Universal precautions and proper sterile technique should be followed for all patient contact that exposes the healthcare provider to bodily fluids.

D. Attending to the Needs of a Fearful Child²
Children represent a vulnerable population in that they often lack the capacity to understand why a potentially uncomfortable procedure is being performed. All efforts should be made to provide information about the procedure to the child at an age-appropriate level. Utilize child life specialists as able.

1. 1. Observe: Monitor how child reacts when you enter the room. If they are visibly fearful, you should take some time for them to get used to your presence.
2. 2. Engage: Talk about an unrelated subject to get their attention. When possible, allow the child to touch medical equipment. Mimic parts of the exam on toys or others so that the child can see the exam before experiencing it.
3. 3. Monitor: If your initial interaction was not successful, step back and try a different approach.