Nitrous oxide helps ease young patients’ anxiety during painful medical procedures

Most of the time Ava Jay is a happy kid. But when she has to go to the doctor’s office, her mood changes.

“When Ava thinks doctors, she thinks shots,” explained her mother, Micky Jay. “And when Ava thinks about shots, her anxiety just takes over.”

A little bit of whining or even a tear or two might be OK, Jay said, but Ava’s outsized reaction to medical procedures — especially those involving needles — can be distressing.

Not so long ago, Jay took Ava, 7, to the pediatrician’s office to investigate some ongoing stomach issues. She knew that at this appointment came with a vaccination and a blood draw, so she steeled herself: The visit could be hard for her daughter — and for her, too.

Once Ava and her mother arrived for their doctor’s appointment in Burnsville after a long drive from their home in Rush City, it didn’t take long for Ava’s anxieties to make themselves known.   

“Ava’s on high alert when she’s in a doctor’s office,” Jay said. “As soon as the doctor said, ‘I think we need to do some tests,’ I saw her face change. And when she realized that there’d be needles involved, Ava was crying and crying, almost hyperventilating. She was so scared.”

Even the pediatrician’s offer to apply a special numbing cream on her arm and her mother’s calm reassurance that everything would be OK did not help Ava feel less anxious. Jay, who’d in the past had to hold her daughter down so she could get a shot, had the sinking feeling that she’d have to do the same thing again.

“I really don’t like holding her down,” Jay said, adding that she felt that a forced approach to medical treatments only served to intensify Ava’s anxieties: “As a mom, it is a horrible feeling.” 

As the tension in the exam room began to build, the nurse took Jay aside.

“She asked, ‘Would you be interested in having Ava try some nitrous oxide?’” Jay said. She knew about dentists using nitrous oxide, or “laughing gas,” to calm nerves during fillings (she’d even used it herself), but she’d never heard of nitrous being used for medical procedures. Fairview, the nurse explained, had recently begun to use doses of the gas mixed with oxygen to help anxious young patients reduce their anxiety. Jay jumped at the opportunity.

“I said, ‘If if this could make it OK for Ava to have a blood draw or a shot, I’m doing it,’” she recalled.  

A new use for an old option

Kelly Fichmeller, RN, a pediatric nurse who was part of the group that started the nitrous oxide program at Fairview Ridges Hospital, explained that using doses of the gas to help anxious young patients cope with medical procedures is becoming more common worldwide.

“Nitrous has been used for a long time in the dental world,” Fichmeller said, adding that it is generally accepted as safe for use in children as young as 6 months. “My supervisor and I were at a pediatrics conference a few years ago and we learned about nitrous being used for anxiety in medical procedures. As we looked more into that we thought it was a good idea. We decided we wanted to bring it here.”

A small group of Twin Cities health care providers has been offering nitrous oxide to anxious patients since around 2009, Fichmeller said. Fairview is the first major health-care provider in the region to make it readily available to all who request its use. 

Some medical procedures, including lab draws, IV starts, lumbar punctures and catheterizations, cause anxiety for many children. And for a smaller group of kids, almost any medical procedure can be anxiety provoking.

Help for patients — and providers

While nitrous oxide can help a child feel better about undergoing a procedure, it can also help a doctor or nurse perform their job in a safer manner, Fichmeller said.

More involved procedures that do not require general anesthesia but still require a patient to remain calm and still, like CT scans or X-rays, can be performed quickly and easily when an anxious child has been given a dose of nitrous.

“It takes the worry away,” she said. “And it creates a bit of amnesia, where they don’t truly remember what’s going on. During treatment, patients are in this fuzzy state. They can respond appropriately to questions and stimulation, but they don’t care so much. Afterward, most don’t really have a clear memory of what happened.”

Amy Feeder, Fairview certified child life specialist, added that while parents can stay close to provide a comforting touch during some stressful procedures, there are other situations where parents have to step away. This can be particularly traumatic for children prone to anxiety.

“The great thing about nitrous from my perspective is we can use it whenever we have to do a test or procedure for kids in the hospital where we are limited in the types of comfort measures we can offer. There is a certain population of kids that get hyper-fixated on the procedure so it gets hard for them to relax or cope with it. Nitrous helps take them away from those worries. ”

And nitrous oxide is a relatively inexpensive option for sedation, Feeder added. 

“From a child-life perspective, it’s really hard if a kid’s anxiety spirals out of control. Sometimes you’ll have physicians who want to just do the procedure and get it over with or want to do a full sedation. That takes a long time and is expensive. Nitrous is an extra option that we have now. It is quick and easy. It helps that population of kids relax. They are awake, they know what is going on, but they are calmer and the doctor can do their job.” 

How laughing gas works

How nitrous oxide helps users stay calm is mysterious.

“Researchers haven’t been able to figure exactly out how it works,” Fichmeller said. “They don’t know what properties it has or how it physiologically affects the body. The Fairview physician who educated us on its use said they haven’t been able to explain what nitrous does to make people less anxious. It just helps.”

Nitrous oxide is safe, Fichmeller said. “It is not metabolized by the body. It goes in in the same form that it comes out. When you are finished using it, you replace it with 100 percent oxygen. Kids aren’t fully sedated with it. So there is no risk there. We only use nitrous in combination with oxygen to create a calm demeanor.”

In the article, “Efficacy and Safety of Nitrous Oxide in Alleviating Pain and Anxiety During Painful Procedures,” published in the Archives of Disease in Childhood, researchers studied the use of nitrous oxide for 99 children requiring complex medical procedures including lumbar puncture, bone marrow aspiration, venous cannulation, or dressing changes. The study’s authors concluded that, “Inhalation of nitrous oxide is effective in alleviating distress during painful procedures, with minimal side effects and short recovery time.”

Nitrous oxide does not have to be administered by a doctor, which also reduces its cost. At Ridges, pediatric nurses administer nitrous in the emergency department or for an outpatient blood draw.

“If we assess that the child is pretty anxious, we can call pediatrics and offer it right away,” Fichmeller said. “Or parents can walk in and share their child’s experiences with prior procedures and see what options are available.” 

Child-centered treatment

To get an anxious child comfortable with using nitrous oxide, nurses will often begin with  “medical play,” Fichmeller said. The nitrous oxide is mixed with oxygen and delivered via a child-sized mask that goes around the child’s nose and mouth: “We take it out and touch it and play with it. We do this with children as young as 18 months, just to recognize that this equipment isn’t scary. We talk about how they are going to breathe in and out to help their body stay calm and relaxed.” 

Some young patients don’t respond well to nitrous, Feeder said. “A few older kids told me they didn’t really like the way it made them feel. That’s the way they expressed their experience. But the majority of our kids who use nitrous literally sing through their procedures, no matter how big they are. It just puts them in a more relaxed state.”

That was the case for Ava. After a few deep breaths of the nitrous oxide/oxygen combination, her anxiety level dropped dramatically, her mother said.

“When she finally had her blood drawn, she was playing games,” Jay said. “It was such a good experience.”

When the procedure was completed, recovery from the nitrous oxide was almost instantaneous, Jay said. 

“As soon as they switched the nitrous oxide off and started running 100 percent oxygen, she was normal and good to go in a matter of minutes. The rest of the day, she kept saying, ‘I want my blood drawn again.’ The fear had disappeared.” 

Tough enough?

Does offering children an easy way to escape their anxieties about common medical procedures create a generation unable to face up to life’s hard realities?

Feeder said that she believes that helping kids ease their fears actually makes them more able to face tough times later on. 

“For kids who have a really hard time emotionally with medical procedures, nitrous is a great option,” Feeder said.  “We need to get kids to a point where they can cope without using nitrous, but teaching them that pain is part of life is an old-school mentality. A lot of us grew up with that attitude: I don’t think it actually made us stronger. We want to teach kids that doctor’s offices and hospitals aren’t scary, that they can trust health care professionals to help them feel better.”

Feeder and Fichmeller share the conviction that helping children build a positive association with medicine will only help them grow into mentally healthy adults.

“We want to do everything we can to provide the best possible experience for infants, toddlers and younger kids so they are able to build off that experience in the medical setting for their future medical interactions,” Feeder said. “It’s hard to undo trauma, but simple things like comfort holds, numbing cream and nitrous oxide can really help to reduce or eliminate trauma in the first place.”

Micky Jay said she thinks some people are just born anxious and pain sensitive. 

“Ava has always been this way,” she sighed. “A finger prick really hurts her feelings. I have an older daughter who never balked about medical procedures, but Ava is different.”

Though Ava has already had some negative experiences at the doctor’s office during her young life, her mother is hoping that positive experiences going forward might erase the some of those fears and anxieties.

“I grew up on a farm,” Jay said. “I’m all about tough love, but Ava has so much anxiety. This treatment helps her deal with it, so I’m OK with that. She needs to go back to the doctor soon: She keeps talking about it, but she never brings up blood draws or shots. I think that the nitrous helped build up her self-confidence. Now she knows she can do it. And if she has a few more good experiences like that one, she might not need to use nitrous again.”