INTRODUCTION

Pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage, or described in terms of such damage. The
International Association for the Study of Pain further states that, Pain is always
subjective. Each individual learns the application of the word through experiences
related to injury in early life. This definition emphasizes the individuality of each
persons pain response and the importance of pain experiences, especially those in
early life, in shaping that response.
Pain is based on the perception of the patient, which may be influenced by
a myriad of interrelated factors, including the patients emotional and psychologic
state, level of anxiety, previous pain experience, understanding of the procedure,
and medical condition and environmental factors, including the setting and person
performing the procedure. (KELLY)
Common routine and emergency childhood painful medical procedures,
such as immunizations, blood tests, sircumcision, dental care, and laceration
repair, along with minor everyday pain experiences, such as falls, bumps, and
cuts, compose the majority of the typical childs pain events. Thus, a childs
experience during painful medical procedures likely plays a significant role in
shaping that individuals pain response to future events. (KELLY)
Besides the negative experience of pain itself, growing evidence supports
the occurrence of long-term negative effects from inadequately treated pediatric
pain, especially in infants. Significant short term adverse outcomes have also been
demonstrated, including hypoxemia, altered metabolic stress responses, and even
mortality. (kelly)
Studies have shown the individual pain response is influenced by age,
gender, and culture. Younger patients had more pain before and after the
procedure than older patients, but no difference was found in pain intensity during
the procedure. (Michelle)
Procedures, many of which produce pain, are common occurrences in
health care today to providing diagnostic information, treatment, or palliation.
Any procedure causing actual or potential tissue damage has the potential to cause

pain(medscape). Management of procedural pain in childhood is important

because childrens perception of pain is influenced by their early pain experiences
and can impact their future response to painful events or procedures (Melanie).

CONTENT
2.1.

Pain Perception
Pain arises due to stimulation by substances algesic on pain receptors that are

often found in the superficial layers of the skin and in some tissues in the body,
such as the joint surface, periosteum, skeletal, muscle and dental pulp. Pain
receptors are the ends free afferent nerve fibers A delta and C. These receptors
activated by the stimuli of high intensity, for example in the form of thermal
mechanical, electrical, stimulation or chemical stimuli.
Algesic substances

will activate pain receptors

ion K, H,

lactic acid,

histamine, serotonin, bradykinin and prostaglandins. Furthermore, after the pain

receptors are activated by substances such algesik, pain impulses transmitted to
the central nervous through multiple channels. The series processes of tissue
damage until felt the perception of pain is an electro-physiological process called
nociception
There is a clear process that occurs following a process of electrophysiological nociception :
1. Transduction: a process pain stimuli are translated or converted into an
electrical activity in nerve endings.
2. ttransmission: a channeling process following the sensory nerve impulses
through the transduction process. This impulse is supplied by nerve fibers
A delta and C fibers as the first of peripheral neurons to the spinal cord.
3. Modulation: is the process of interaction between the system and the
endogenous analgesic with pain impulses that enter the dorsal horn of the
spinal cord. Endogenous analgesic system includes enkephalins,
endorphins, serotonin and noradrenaline which has the effect of pressing
pain impulses in the spinal cord dorsal horn. Thus dorsal horn described as
pain gate that could be closed or open to channel pain impulses. The
process of closing or opening the door of pain played by endogenous
analgesic.

4. Perception: is the end of complex process interaction that starts from the
process of transduction, transmission, and modulation which produces a
subjective feeling known as pain perception.

Figure 1. Pain Perception (buku cok)

The development of pain pathways begins early in foetal life, with reflex
responses to somatic stimuli being present from around 8 weeks gestation. At 26
weeks gestation, a clear flexion withdrawal response to noxious stimuli can be
elicited. Furthermore, coordinated facial movements in response to heel prick are
seen in premature infants of 26-31 weeks gestational age. (the royal australaisan)
Complex synaptic connections in the dorsal horn of the spinal cord,
descending inhibitory pain pathways, and cortical connections do not develop
until the early neonatal period. Therefore, responses to any sensory input,
including pain, may be amplified in neonates compared to adults. (the royal
australaisan)

2.2.

Procedural Pain
Pain is subjective. Pain is an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such

damage. Pain response is individual and is learned through social learning and
experience. Kelly
Pain is based on the perception of the patient, which may be influenced by a
myriad of interrelated factors, including the patients emotional and psychologic
state, level of anxiety, previous pain experience, understanding of the procedure,
and medical condition and environmental factors, including the setting and person
performing the procedure. Kelly
Procedures, many of which produce pain, are common occurrences in health
care today to providing diagnostic information, treatment, or palliation. Any
procedure causing actual or potential tissue damage has the potential to cause
pain. Therefore, potentially painful procedures can range from simple procedures
to more invasive procedures, such as lumbar punctures, fracture reductions, or
biopsies, and can occur in a variety of settings, from the hospital or same day
surgery center to an ambulatory clinic, physician/dentist office, or home care
environment. Medscape
Common routine and emergency childhood painful medical procedures, such
as immunizations, blood tests, sircumcision, dental care, and laceration repair,
along with minor everyday pain experiences, such as falls, bumps, and cuts,
compose the majority of the typical childs pain events. Thus, a childs experience
during painful medical procedures likely plays a significant role in shaping that
individuals pain response to future events. (KELLY)
Studies have shown the individual pain response is influenced by age, gender,
and culture. In a study of 412 adults undergoing wound care, younger patients had
more pain before and after the procedure than older patients, but no difference
was found in pain intensity during the procedure. michelle
Neonates, infants, young children, and critically ill patients are at higher risk
for increased pain owing to their inability to communicate effectively. In infants,
pain steals the energy that should be directed toward growth and development and

disrupts sleep, feeding, and bonding. Pain in those early days of life can cause
structural and physiologic changes that can lead to lifelong abnormal responses to
noxious and even nonnoxious stimuli causing a lowered pain threshold and central
sensitization. In the sentinel study by Taddio, Katz, Ilersich, and Koren (1997),
circumcised infants exhibited a stronger pain response to subsequent routine
immunization than did those who were uncircumcised. Furthermore, cognitive
and psychosocial development of preverbal children may be adversely affected by
early painful experiences, despite the individual having no conscious memory of
the event. These effects in response to pain are believed to occur because of the
close proximity between the areas that process pain, emotion, and attention in the
brain.medscape
2.3.

Pediatric Procedural Pain Management

Routine medical care involving blood sampling and other painful diagnostic

and therapeutic procedures can cause great distress for children and their families.
When such procedures are essential, it is important that they should be achieved
with as little pain as possible. For many children who have chronic illness, these
procedures often need to be repeated, and this can generate very high levels of
anxiety and distress if their previous experience has been poor. (buku pediatric)
2.3.1 Procedural Pain In The Neonate
Premature neonates are able to perceive pain, but the response to both pain
and analgesia is dependent on developmental age. Because of this, pain
assessment in this age-group is particularly difficult, and the low sensitivity of
many pain measurement tools can complicate the interpretation of evidence.
Clinically, neonates appear to be sensitive to the adverse effects of many drugs,
including analgesics. however, reductions in the response to pain have been
observed following nontraditional analgesia such as sucrose and physical and
environmental measures, for example, suckling or tactile stimulation, which are
currently not known to have potentially harmful effects. A number of documents
including reviews, guideline, and policy statements have been published recently
on the subject of procedural pain management in the neonate. On the basis of the

currently available evidence, the following measures can be generally

recommended for the management of procedural pain in the neonate:

Breast-feeding should be encouraged during the procedure.

Nonpharmacological measures including non-nutritive sucking, kangaroo

care, swaddling/facilitated tucking, tactile stimulation, and heel massage can
be used for brief procedures.

2.3.1.1 Blood sampling in the neonate (includes peripheral venous, arterial,

and percutaneous central venous cannulation)
Venepuncture is the preferred method of blood sampling when a
significant volume of blood is required. It has been shown to be less painful in
neonates and less likely to require resampling. (the royal australian)Where an
indwelling arterial catheter is not available, then venepuncture (VP) or heel prick
blood sampling (HPBS) is used. HPBS requires appropriate training and is used to
collect small blood samples such as blood glucose, bilirubin newborn screening
tests, and capillary blood gases. VP also requires training but is technically more
difficult and is used to collect larger blood samples. The principles and techniques
of pain relief are applicable to other invasive procedures such as peripheral
arterial line insertion and percutaneous central venous catheters (i.e., long line).
Recomendation mangement of procedural pain blood sampling in the neonate :PA
+ RA

Administration of15-50% sucrose is effective in neonates and may be

effective up to 2 months of age.

Nonpharmacological measures including tactile stimulation, breast-feeding,

non-nutritive sucking, kangaroocare, and massage of the heel can be used
for heel prick blood sampling.

Venepuncture (by a trained practitioner) is preferred to heel lance for larger

samples as it is less painful.

Topical local anesthetics alone are insufficient for heel lance pain.

Topical local anesthetics can be used for venipuncture pain.

Using the whole plantar surface of the heel reduces the pain of heel prick
blood sampling.

Remifentanil and sucrose decreased central venous catheter pain.

Topical tetracaine plus morphine is superior to topical analgesia alone for

central venous catheter pain in ventilated infants.
A large number of studies have demonstrated that sucrose before VP or HPBS

reduces the behavioral pain scores measured by a range of validated assessments.

The dose of sucrose differed across these studies. Relieving the pain of HPBS has
been challenging with pharmacological methods. However, nonpharmacological
methods including breast-feeding, non-nutritive sucking, kangaroo care, and
premassage of the heel before and during HPBS have consistently demonstrated
reduced behavioral pain scores and physiological markers. VP appears to be less
painful than HPBS so is the preferred option whenever practical. Topical local
anesthesia (LA) can reduce the pain of VP and insertion of central venous
catheters. However, topical LA is not effective for HPBS. Morphine with topical
LA was more effective than LA alone for central venous line placement in
ventilated neonates. In addition, low-dose remifentanil combined with sucrose
reduced the pain of insertion of central venous catheters. HPBS pain can be
reduced with procedure modification such as using an automated spring-loaded
device, avoiding squeezing the heel, and using a wider area of the plantar surface
of the heel. PA
2.3.1.2 Ocular Examination For Retinopathy Of Prematurity
Preterm infants at risk of retinopathy of prematurity (ROP) should have
regular ocular examination. An eyelid speculum is inserted to hold the eye open,
and the retina is examined by indirect fundoscopy through a dilated pupil. In
addition, a small proportion will require laser ablation of significant disease.
Recomendation of procedural pain management in ocular examination :

Sucrose may contribute to pain response reduction in examination for

retinopathy.

Infants undergoing examination for retinopathy should receive local

anesthetic drops in combination with other measures if an eyelid speculum is
used.

Swaddling, developmental care, non-nutritive sucking, and pacifier should be

considered for neonates undergoing examination for retinopathy

Laser treatment should be with general anesthesia if timely treatment is

needed.
A combined analgesic approach using LA, a pacifier, swaddling, and the

addition of a sweet solution is likely to be most effective for ROP screening

examination pain. Oral sucrose prior to the screen reduced the behavioral pain
scores in small groups of infants. Laser treatment is painful, and appropriate painrelieving strategies should be employed. Laser treatment may be more rapidly
available if sedation, analgesia, ventilation, and muscle relaxation are possible on
the neonatal unit.(buku pediatri )
2.3.1.3 Lumbar Puncture (LP) In The Neonate
Sampling of cerebrospinal fluid is often regarded as a minor procedure in
infants; nevertheless, it is associated with pain that can be reduced by suitable
analgesia.Topical local anesthesia is effective in reducing lumbar puncture pain.
There have been few studies directly investigating LP pain in the neonate.
Topical local anesthetic has been found to be effective. Indirect evidence suggests
that subcutaneous infiltration of LA would also be effective, but it has not been
consistently shown to be superior to placebo in the neonate, in contrast to
positive effects in older children and adults.
2.3.1.4 Urine Sampling In The Neonate
Urine sampling can be important to detect urinary tract infection in
neonates and must be collected avoiding sample contamination. Direct
catheterization of the urethra or catheterization of the bladder by the percutaneous
suprapubic route is often preferred because some types of urine collection bags
have a high rate of contamination, and clean catch specimens can be difficult or
time-consuming to collect.

Transurethral catheterization with local anesthetic gel is preferred as it is

less painful than suprapubic catheterization with topical local anesthesia. Sucrose
also reduces the pain response to urethral catheterization.
Transurethral catheterization appeared to be less painful. Sucrose analgesia
immediately before bladder catheterization in neonates and infants up to 3 months
old was not effective at abolishing pain responses.
2.1.3.5 Nasogastric Tube Placement
Nasogastric tube (NGT) insertion is a painful and distressing procedure.
Neonates who have not fully established enteral feeding or who have not
developed a coordinated suck will require NGT feeds. In addition, the NGT is
replaced to prevent nosocomial infection and when displaced.
Sucrose can reduce the pain response from NGT insertion. Sucrose (0.5 ml
of 24%) given 2 min before NGT insertion reduced the behavioral pain score and
physiological responses in a small number of stable preterm infants.
2.1.3.6 Immunization And Intramuscular Injection
There are two indications for IM injections: routine immunization and
administration of vitamin K. In any other situation, an alternative route of
administration should be used. PA It is always preferable to avoid the
intramuscular route of administration when an alternative route exists e.g. oral or
intravenous.RA Swaddling, breast-feeding or pacifier, and sucrose should be
considered in neonates undergoing vaccination to reduce procedural pain.
2.3.2 Procedural Pain Management In Infants And Older Children
Painful procedures are often identified as the most feared and distressing
component of medical care for children and their families. When managing
procedural pain in infants, older children, and adolescents, special emphasis
should be given not only to proven analgesic strategies but also to reduction in
anticipatory and procedural anxiety by suitable preparatory measures. Families,
play therapists, nursing staff, and other team members play key roles in reducing
anxiety by suitable preparation. The personality, previous experience, and

analgesic preferences of the child will influence management strategies.

Analgesia/sedation with 50% nitrous oxide/oxygen by supervised selfadministration should be considered where indicated, especially in children older
than 6 years who can cooperate.
2.3.2.1 Blood Sampling And Intravenous Cannulation In Children
For most children, venepuncture or intravenous cannulation may be a one
off event, but children with chronic illness are likely to require multiple
procedures, and this can be very distressing for the child, the family, and the
medical team. When managing such pain in infants, older children, and
adolescents, special emphasis should be given not only to proven analgesic
strategies but also to reduction in anticipatory anxiety by suitable preparatory
measures. Venepuncture or intravenous cannulation may be technically difficult
practitioners should not continue to try multiple cannulation sites unless the
procedure is urgent or a more experienced practitioner is not available. In
nonurgent cases, consider whether the test can be rescheduled, and enlist the help
of a more experienced practitioner.
Topical local anesthesia should be used for intravenous cannulation.
Psychological strategies also needed to reduce pain and anxiety. Topical LA, such
as EMLA or AMETOP (amethocaine), has an established place in the
management of venous cannulation. Recent evidence suggests that amethocaine
has an advantage over EMLA for cannulation. Amethocaine has a faster onset of
action.
Newer preparations such as liposomal encapsulated LA or newer LA
delivery systems may offer advantages in some situations. Buffered injected LA,
for example, lidocaine + bicarbonate 10:1, administered with a fine 30-g needle
subcutaneously prior to cannulation is faster in onset and may be as acceptable
and effective as topical preparations.
Nitrous oxide (5070%) inhalation has been used in children older than 6
years who can self-administer during venepuncture in some circumstances. 50%
nitrous oxide and EMLA have been shown to be equally effective for
venepuncture with further improvements in pain reduction using a combination of

the two. The efficacy of vapocoolant topical spray has not been clearly
established. Vapocoolant spray was not effective in reducing pain in one study of
intravenous cannulation but did show a modest reduction in pain. Psychological
approaches such as distraction should be offered to all children as it is easy to
administer. Hypnosis can also be very effective for children requiring repeated
interventions.
2.3.2.2 Lumbar Puncture In Children
Lumbar puncture (LP) is necessary in acutely ill children in whom
meningitis is suspected. These children are likely to be unwell and anxious, and
they may also undergo other painful procedures such as venipuncture as part of
diagnosis and treatment.
Positioning of the child is very important for success, and it is helpful to
have assistance from trained staff with experience of correct positioning. Children
who require multiple LPs may cope better with the addition of sedation.
Following is recomendation of procedural pain management in lumbar puncture :

Behavioral techniques of pain management should be used to reduce LP pain.

Topical LA and LA infiltration are effective for LP pain and do not decrease
success rates.

50% nitrous oxide/oxygen should be offered to children willing and able to

cooperate.
Few studies have directly examined the efficacy of analgesics in awake

children undergoing lumbar puncture. Most commonly, local anesthesia is

combined with sedative agents, such as midazolam, or biobehavioral techniques,
such as distraction or other cognitive behavioral interventions, is effective for LP
pain, and may also be used in combination with LA (either topical or infiltration)
and other strategies. Ketamine analgesia/sedation or general anesthesia is
sometimes used in emergency departments and oncology units with appropriate
facilities. whereas children requiring multiple LPs should be offered sedation or
GA.
2.3.2.3 Bladder Catheterization And Related Urine Sampling Procedures

Urine specimens are usually obtained by clean catch or midstream

specimen (MSU). Urine may be obtained from young infants by means of
suprapubic aspirate (SPA). Sampling by urethral catheterization appears to be less
painful than SPA. Bladder catheterization may be required for radiological or
other investigation of the renal tract, for example, micturating cystourethrogram
(MCUG) also known as voiding cystourethrogram (VCUG). Consider whether
MCUG is really necessary. It is a distressing procedure for the child and other less
invasive techniques, such as dynamic renal scanning may provide the same
information. Bladder catheterization may also be required in children who develop
urinary retention, particularly those receiving epidural analgesia postoperatively.
Very ill patients in ICU may also require catheterization to monitor urine output.
Lubricant containing local anesthesia should be applied to the urethral
mucosa prior to bladder catheterization. Recommendations Psychological
preparation and psychological and behavioral interventions should be used during
bladder catheterization and invasive investigations of the renal tract.
Bladder catheterization has been shown to cause significant pain and
distress, but analgesia is not part of routine care in many institutions. More
complex interventions, which include bladder catheterizations such as MCUG or
VCUG, have also been shown to cause significant distress, which can be reduced
by psychological preparation and behavioral pain management techniques such as
distraction or hypnosis. Local anesthetics incorporated into lubricant gels are
frequently used in adults to reduce the pain and discomfort of catheterization, but
this has not been well studied in children. However, in younger children (mean
age 2 years), application of lidocaine gel to the genital mucosa for only 23 min
before the procedure and its subsequent use as a lubricant did not decrease pain.
Techniques combining adequate preparation, local anesthesia, and behavioral
interventions are likely to be more effective.
2.3.2.4 Nasogastric Tube Insertion
NGT insertion is a painful and distressing procedure frequently performed
with little attention to pain-relieving strategies. Infants who are unwell and unable
to feed, particularly those with respiratory problems such as bronchiolitis, may

need to be tube fed for a short period. NGT is often maintained in the
postoperative period and may need to be re-inserted if they become displaced.
Older children may also be fed via NGT, for example, in patients with cystic
fibrosis who sometimes require supplementary feeding on multiple occasions.
Clearly, it is particularly important to optimize pain management in those patients
who are likely to need repeated NGT placement.
Topical local anesthetics such as lubricant gel containing lidocaine,
applied prior to placement, are likely to reduce the pain and discomfort of NGT
insertion.
NGT insertion has been little studied in children. In the adult, topical local
anesthesia and lubricants have been shown to reduce pain and facilitate placement
.10% nebulized lidocaine is also effective in adults but may also slightly increase
the incidence of epistaxis.
2.3.2.5 Immunization And Intramuscular Injection
Immunization schedules result in increasing numbers of intramuscular
injections being administered to infants and children. At 2 and 3 months, infants
are offered diphtheria, tetanus, pertussis, hemophilus (Hib), and polio
immunization

as

one vaccination,

with a separate

meningococcal

or

pneumococcal vaccine. All 3 are given at 4 months. Children receive further

immunizations at 1 year and 15 months, again at preschool, and finally at school
leaving. Intramuscular administration of asparaginase to children with leukemia,
and long-acting penicillin therapy are other examples. The pain of these injections
is widely acknowledged and contributes to anxiety in patients and their
parents/carers, particularly regarding vaccinations. There is now evidence that
such pain may be reduced by a number of strategies. Knowledge that practitioners
have considered the use of these strategies may help parents in their decisions
about immunization. It is important that treatable pain is not a barrier to the
childhood immunization program.
Intramuscular injections should be avoided in children as part of routine
care.

If

intramuscular

injection

isunavoidable,

pharmacological

and

nonpharmacological strategies should be employed to reduce pain. Following are

recomendation

management

of

procedural

pain

in

immunization

and

intramuscular injection :

Psychological strategies such as distraction should be used for infants and

children undergoing vaccination.

Consider additional procedure modifications such as vaccine formulation,

order of vaccines (least painful first) needle size, depth of injection (25 mm
25 gauge needle), or the use of vapocoolant spay.

Swaddling, breast-feeding or pacifier, and sucrose should be considered in

infants undergoing vaccination.
There are two phases of immunization pain: the initial pain of the needle

piercing the skin and injection of a volume of vaccine into the muscle or
subcutaneous tissue, followed by a later phase of soreness and swelling at the
vaccination site because of subsequent inflammatory reaction. Children typically
dread

needle-related

pain;

the

use

of

either

nonpharmacological

or

pharmacological pain reduction strategies may reduce subsequent negative recall.

The optimal dose of sucrose has not yet been determined, and its effectiveness in
infants from 1 month is uncertain (137).
Topical local anesthesia (EMLA, Ametop) is clearly capable of reducing
components of vaccination pain in both infants and older children, but the efficacy
and the balance of effectiveness against cost are difficult to determine from the
studies presently available. Lidocaine local anesthesia added to asparaginase or
benzyl penicillin injection reduced the pain requires further investigation.
2.3.2.6 Repair Of Lacerations In Children
Traumatic lacerations of the skin and scalp are common presentations in
the emergency department. Acceptable, safe, and effective repair is often a
considerable challenge. For minor lacerations without general anesthesia or
sedation, a combination of pharmacological and nonpharmacological techniques is
likely to be most effective. For extensive wounds or children who are very
anxious consider sedation or general anesthesia. Following are recomendation
management of procedural pain in reapair of lacerations :

For repair of simple low-tension lacerations, tissue adhesives should be

considered as they are less painful, quick to use, and have a similar cosmetic
outcome to sutures or adhesive skin closures.

Topical anesthetic preparations, for example, LAT (lidocaine, adrenaline,

tetracaine) if available, can be used in preference to injected LA, as they are
less painful to apply. Buffering injected lidocaine with sodium bicarbonate
should be considered.

HAT should be considered for scalp lacerations. It is less painful than

suturing, does not require shaving, and produces a similar outcome.

If injected lidocaine is used, pretreatment of the wound with a topical

anesthetic preparation, for example, lidocaine, adrenaline, tetracaine (LAT)
gel, reduces the pain of subsequent injection.

50% nitrous oxide reduces pain and anxiety during laceration repair.
There are a number of alternatives to simple wound suture in the awake

patient. Tissue dhesives in simple low-tension wounds and the hair apposition
technique (HAT) in scalp lacerations are less painful alternatives. A number of
topical local anesthetic mixtures are available. They can give equivalent analgesia
to infiltrated local anesthetic and are less painful to apply although a recent
systematic review in adults and children concluded that there was insufficient
evidence to unreservedly recommend topical LA in preference to injected LA.
Nitrous oxide has been shown to be effective in reducing pain, anxiety, and
distress in cooperative children. Psychological techniques such as distraction and
relaxation are also likely to be useful.
2.3.2.7 Dressing Changes In The Burned Child
Children with burns often require repeated, often extremely painful,
dressing changes. Children with severe burns are normally cared for in a specialist
unit, but some children will be seen in Emergency Departments. Initial dressing
changes are likely to be performed under general anesthesia, and if children
remain very distressed, this option may be favored for subsequent procedures.
Sedation is sometimes used to supplement analgesia for burns dressings. In the
early stages of burn pain management, children may require continuous infusion

of potent opioids such as morphine, and additional analgesia will be required prior
to dressing changes.
Both pharmacological and nonpharmacological techniquesshould be used
in the management of painful dressing changes. Potent opioid analgesia given by
oral, transmucosal, or nasal routes according to patient preference and availability
of suitable preparations should be considered for dressing changes in burned
children. Nonpharmacological therapies such as distraction and relaxation should
be considered as part of pain management for dressing changes in burned
children.
The evidence base for managing burn pain in children is small and
incomplete. Opioids are used extensively and should be given as necessary by
intravenous or other routes. There is evidence for distraction with children using a
variety of devices, such as helmet Visual Reality devices or hand-held multimodal
devices where the child is an active participant in the game they are playing being
more effective than standard distraction when burns dressings are being changed.
Nitrous oxide is used extensively for single painful procedure in children who are
able to cooperate; multiple or frequent administration may lead to bone marrow
toxicity.

Prevention and treatment of procedural pain should be multidimensional,

including

environmental

methods,

nonpharmacologic

interventions,

and

pharmacologic interventions. EDs are typically chaotic, noisy, and frightening for
young children. Health care workers often feel rushed. They may justify holding
the child down and quickly performing the procedure. Creating a distresslowering environment requires a change in the culture of the ED and the
commitment of all staff, including physicians, nurses, technicians, and
phlebotomists. Multidisciplinary pain management teams that promote pain

management education, formulate and implement protocols, identify and remove

barriers to effective pain management, carry out quality improvement exercises,
and work to keep prevention and treatment of pain a high priority should be
created. This approach will be much more successful than expecting individual
health care providers to spontaneously learn new pain-management techniques
and implement them on their own. kelly
1.3.1 Nonpharmacologic Interventions
Emphasis has been placed on pharmacologic procedural sedation and
analgesia, but environmental and nonpharmacologic therapies contribute greatly
to distress reduction. Environmental methods to reduce pain and distress include :
(kelly)
1. Provide information and prepare the parent and child.

Give step-by-step information of what will occur during the procedure.

Give sensory information about what the child will see, hear, and feel.

Use age-appropriate language and terminology and avoid medical jargon.

Avoid high-anxiety words such as pain, hurt, cut, shot.

Use words such as poking, freezing, squeezing instead.

Do not insinuate that the procedure will definitely hurt.

Be aware of possible misinterpretations of words and phrases such as

dye or put to sleep.

Address childrens concerns (eg, taking all my blood).

Consider using books describing the procedure the child can read with the
parent.

Give information before and during the procedure.

Be honest.

2. Parental involvement

Ask the parents how much distress they expect from the child.

Allow parents to remain present.

Do not ask the parent to help restrain the child.

Instruct the parent not to threaten the child (eg, with additional shots).

Instruct the parent on coping-promoting behaviors (eg,distraction) and to

avoid distress-promoting behaviors

3. Health care worker behavior

Be calm, confident, and in control.

Avoid reassurance, apology, criticism.

Avoid conversation with other health care workers and parents that may be
distressing (eg, describing possible adverse events) in front of the child.

Teach students how to perform the procedure outside the room to

minimize discussion in front of the child.

4. Health care setting

Maintain a quiet, calm environment.

Avoid stressors such as beeping monitors.

Avoid long delays between informing the child of the procedure and
performing it.

Avoid situations in which children can see or hear procedures performed

on other children.

5. Procedural details

Allow comfort items such as favorite stuffed animals or blankets.

For venipunctures and intravenous cannulation in thumb-sucking children,

avoid the arm of the preferred thumb.

Do not force the child to lie down if he or she does not want to and is not
required to.

Consider giving the child a job (eg, holding a gauze).

Give the child choices to increase the perception of control (eg, right arm
or left).

For long procedures (eg, burn dressing changes), allow the child time
outs of a predetermined number and

Allow the child to count down from 10 to 1 before a brief procedure.

Use automatic lancets for finger sticks.


6.

Venipuncture, when feasible, may be less painful than heel lance.

Hospitalized children

Use a treatment room; keep the patients room/bed as a safe place.

Give hospitalized children a predictable safe time when procedures will

not occur and a predictable time for procedures.

Plan ahead and draw all blood samples at once if possible.

Do not give pain medications by a painful route (intramuscular).

Simple nonpharmacologic techniques can be taught to children as tricks

to use and to parents for coaching their children (Table 3). Children are more
likely to use coping techniques if coached by an adult. Parents are ideal coaches
because they know what is likely to interest their child, and although they wish to
remain present for the procedure, they may not know how to help their children.
Added benefits include reduction of parents anxiety by giving them an assigned
role and teaching parents techniques that they can use for other painful events.
Table 3. Nonpharmacologic interventions to reduce pain and distress with
procedures.
Technique

Description

Distraction

Infant: pacifier, bubbles, toys

Toddler: bubbles, songs, pop-up books, party
blower, kaleidoscope, toys
School-age: videos, video games, search for objects
in pictures, stories, jokes, counting,
nonprocedural conversation
Adolescent: music by headphones, video games,
nonprocedural conversation, focusing on objects

Deep breathing

Have the child breathe rhythmically with slow deep

breaths.

Blowing

Have the child blow out imaginary candles or take

a deep breath and blow away the pain.

Party blowers have been used successfully.
Suggestion

Help the child put on a magic glove that does

not allow pain, or apply magic invisible cream,
or turn off a pain switch.

Superhero imagery

Have the child imagine that he or she is a superhero

and the procedure is a special mission.

Guided imagery

Help the child imagine a favorite place or activity,

concentrating on all the associated sensations.

Thought-stopping and

Teach the child to think or say Stop! when

positive

feeling pain and then to think or say, I can handle

self-statements

this, or similar positive self-statements.

Rewards

Let the child know that rewards such as stickers,

decorative bandages, small trophies, certificates,
or prizes are available. Make behavior such as
cooperation a goal, but give all children the reward.

Spot pressure or counter

Rub the surrounding skin or provide spot pressure

irritation

to the surrounding skin.

Sweet solution or pacifier or

Useful for infants for minor procedures. Give 2 mL

Breastfeeding

of 30% sucrose or 30% glucose immediately

before or during the procedure. Allow sucking on
pacifier or breastfeeding during the procedure.

Cognitive behavior therapy

Preparation with dolls or other materials, role

playing, role modeling, practicing desirable
behavior,
desensitization (slow introduction to subparts of
procedure), hypnosis, guided imagery,
progressive muscle relaxation, memory alteration

1.3.2 Pharmacologic Interventions

Topical and local anesthesia, combined with environmental and simple

nonpharmacologic techniques, may be sufficient forminor procedures. Eutectic
mixture of local anesthetics cream is effective in reducing the pain and distress of
skin punctures. Cost and the long time to onset of effect, 40 to 60 minutes, have
precluded widespread use. A new nonprescription topical anesthetic, 4%
liposomal lidocaine, has an onset of effect of 20 to 30 minutes Iontophoresis of
lidocaine is effective and has an onset of effect of 10 minutes but requires an
initial investment in the equipment. Vapocoolant sprays, ethyl chloride and
fluoromethane, produce immediate brief (seconds) anesthesia but may not be
tolerated well by young children. Although effective, rapid-onset topical
anesthetics exist, they are underused for minor procedures. Adult health care
workers who underestimate the negative effect of minor procedures for a child
may wrongly conclude that the costs outweigh the benefits. kelly
Topical lidocaine-epinephrine-tetracaine gel is effective for laceration
repair and does not have the adverse event risks of tetracaine-adrenalin-cocaine
solution. Injected local anesthetics may be required for additional anesthesia.
Methods to decrease pain and distress from injection of local anesthetics include
keeping needles out of sight of the child (especially the large-gauge needle used to
draw up the anesthetic), buffering lidocaine with sodium bicarbonate in a 9:1
ratio, warming the local anesthetic, using a small-gauge needle (27 to 30 gauge),
injecting slowly, injecting from wound edges rather than through intact skin, and
counterirritating surrounding skin during the injection. Mixing bupivacaine with
lidocaine or using lidocaine with epinephrine (except where contraindicated)
increases the duration of anesthesia. kelly
Long noninvasive procedures in which motion control is important, such
as diagnostic imaging, and more invasive painful procedures, such as fracture
reduction or abscess drainage, may require procedural sedation and analgesia.
kelly