Laser therapy of the face and body in young children

Prof James Roelofse  discusses laser therapy treatment of birthmarks in children, using procedural sedation and analgesia outside the hospital in primary care.

Birthmarks are marks on the skin in children that may be present at birth or appear shortly after. Some birthmarks disappear over time; others stay with the patient. They are mostly painless and harmless.

The question is, if the birthmark needs to be removed, how do we do this painlessly?

Laser therapy removal has become very popular when treating birthmarks in children. It is usually a painful procedure in young children and can be done in a hospital or outside the hospital in procedure rooms that meet the requirements for safe practice.

Two options are available to make this procedure more comfortable for young children: general anaesthesia in hospital or procedural sedation and analgesia outside the hospital in primary care. Procedural sedation is a technique where the patients receive drugs that make them comfortable, sleepy, calm, and take the pain away, and children usually do not remember the procedure.

General anaesthesia is a well-known technique, done in hospitals, where patients are unconscious. Unfortunately, the laser equipment for the treatment is not always available in hospitals, and laser therapy must be done in the procedure rooms of the doctor performing the treatment. In this case, we cannot offer general anaesthesia.

Although general anaesthesia is highly effective and reliable, it is becoming less important, especially as the cost demands of medical insurance place its availability at a premium.

So how did we become involved in doing laser therapy for children? It was crucial to get involved as there are only two procedure rooms in South Africa available for laser therapy for children. An important question is the age of the child when we accept them for laser therapy outside the hospital. Our guidelines say that children under 3 years old must have their procedure in hospital. This is not always possible, so children under a year old have received laser therapy in procedure rooms with no complications. 

In the Western Cape, the only hospital theatre available for laser therapy in young children under general anaesthesia was closed some years ago. We were approached about whether we would be comfortable treating children, some of them very young, under sedation outside the operating theatre in a procedure room. An alternative option for laser therapy is procedural sedation and analgesia, which is not so straightforward in young children. The doctors who carry out sedation must be qualified and have experience working with children. In these cases, children will not be unconscious during the procedure. 

As it is also impractical to treat all patients under anaesthesia, a variety of techniques implementing the basic principles of procedural sedation are utilized and developed to diminish anxiety-induced stress during diagnostic or therapeutic procedures and make patients comfortable. As a result, many procedures once performed only in traditional theatres have moved to other settings, both inside and outside hospitals. The benefits of relieving fear, anxiety, and pain in a patient are numerous. It ensures a calm, cooperative patient who can comfortably tolerate a sometimes-unpleasant procedure. 

The question often asked is: What are the goals of sedation in young children? This process allows children to tolerate unpleasant procedures by relieving anxiety, discomfort, and pain. Many patients are anxious or concerned about the prospect of being awake during an operation; they fear the theatre environment. The provision of sedation may allow the patient to sleep through all or part of the operation without losing consciousness. Certain procedures that require immobility may create a problem in children and adults who may be uncooperative or emotionally immature, even though they are not particularly uncomfortable. Procedural sedation may be used to manage behaviour and movement in these situations. Some operations may require the patient to remain immobile for a prolonged period. This may lead to discomfort, particularly if they need to remain in an awkward position for prolonged periods. Providing procedural sedation can make the procedure more comfortable and safer.

We sometimes need to ease the technical difficulties for the operator by improving patient cooperation, leading to operator satisfaction. Any pain during procedural sedation should be treated by administering supplements of local anaesthesia solutions. However, pressure and traction may be transmitted to deeper structures not anaesthetized by the local anaesthetic, making administration of additional drugs attractive to make the patient comfortable, leading to operator satisfaction.

A benefit for parents when children have treatment outside the operating room is that they can accompany their child into the procedure room and stay until the child is comfortable and relaxed. Behavioural management is extremely important in children. Children must be evaluated and seen before the procedure to make them more relaxed. The parents must be present and will also be more comfortable if we explain the whole procedure to them.

We usually give all children a sedative agent before we treat them. This makes them more comfortable, some even sleep. Parents accompany the anaesthesiologist into the procedure room. Children are more comfortable with their parents there. When the child is well sedated, usually sleeping, parents can leave, and we can place monitors on the child’s feet, arms, and body. This can be difficult if the child is awake. During the procedure, the child is monitored for safety, and the anaesthesiologist will not leave the child alone in the procedure room.

Children do not have severe pain after the procedure. The drugs that we give during the procedure will help to prevent pain. We also put water in a small balloon and keep it in a fridge overnight. When finished with the procedure, we use this cold balloon to roll it over the treated areas, which has a significant effect on pain. 

Patient satisfaction is a crucial part of any operation. Gaining a child’s trust is the primary factor in ensuring successful sedation. However, this can be challenging if the child has had negative experiences with general anaesthesia or sedation in the past. Therefore, all sedation techniques should involve planning behavioural management strategies, showing empathy and understanding, and adopting a patient specific approach. Empathy enables individuals to understand and respond to the emotional state of others, which contributes to compassionate behaviour and moral agency. Empathy means to see with the eyes of another, listen with their ears, and feel with their heart.  Empathy paves an emotional bridge, leading to better communication. Make eye contact, listen intently to the patient (or caregiver), try to hear the whole patient, and let them finish their whole story without interruption. Respond with effect and pay attention to your tone of voice. 

Nursing assistants also play a significant role. We do research by giving patients questionnaires about their experiences with sedation. Of those who experienced sedation for their children for laser therapy of the face, we have a parent satisfaction rate of nearly 100%. Parents are especially enthusiastic about children being fit to go home within 30 minutes of the procedure. After general anaesthesia, nausea and vomiting are significantly higher than with procedural sedation. We have not seen vomiting in children after laser therapy, which is a positive point for parents and children.

We find that children who have to come back again for laser therapy are much more comfortable coming the second or third time. This is usually because they have their parents with them in the procedure room, have no pain, and remember very little about the operation.

After the procedure, children remain with their parents in a recovery room until it is safe to send the child home. Parents are given guidelines to handle the child when going home and afterwards. For example, children are not allowed to be left alone, and medication must be given if they have pain. If parents are worried about anything, they must phone their doctor immediately.

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