relief of pain and anxiety in pediatric patients in - pediatrics

CLINICAL REPORT

Relief of Pain and Anxiety in Pediatric Patients inEmergency Medical Systems

abstractControl of pain and stress for children is a vital component of emergencymedical care. Timely administration of analgesia affects the entire emer-gency medical experience and can have a lasting effect on a child’s andfamily’s reaction to current and future medical care. A systematic approachto pain management and anxiolysis, including staff education and protocoldevelopment, can provide comfort to children in the emergency setting andimprove staff and family satisfaction. Pediatrics 2012;130:e1391–e1405

BACKGROUND

A systematic approach to pain management is required to ensure relief ofpain and anxiety for childrenwho enter into the emergencymedical system,which includes all emergency medical services (EMS) agencies, interfacilitycritical care transport teams, and the emergency department (ED).1

The administration of appropriate analgesia in children varies by age aswell as by training of the ED team (which includes physicians, nurses,physician assistants, and nurse practitioners), however, and still lagsbehind analgesia provided for adults in similar situations.2 Furthermore,neonates are at highest risk of receiving inadequate analgesia.3,4

Encouragingly, improvements in the recognition and treatment of pain inchildren have led to changes in the approach to pain management foracutely ill and injured pediatric patients.5 Studies have shown an increasein opiate use in children with fractures.6–8 Recent advances in the ap-proach and support for pediatric analgesia and sedation, as well as newproducts and devices, have improved the overall climate of the ED forpatients and families in search of the “ouchless” ED.5,9 Increased parentaleducation regarding pain and sedation, physician comfort and desire toenhance patient satisfaction, and a quest to satisfy accreditation regu-lations have appropriately driven this effort. System-wide approaches forpain management awareness and strategies work best if they are woveninto the fabric of the emergency medical system through education andprotocol development. The purpose of this report was to provide in-formation to optimize the comfort and minimize the distress of childrenand families as they are cared for in the emergency setting.

STATEMENT OF THE PROBLEM

Barriers to adequate pain control for children in the ED and in out-of-hospital emergency care settings include difficulty in assessing pain in

Joel A. Fein, MD, MPH, William T. Zempsky, MD, MPH,Joseph P. Cravero, MD, and THE COMMITTEE ON PEDIATRICEMERGENCY MEDICINE AND SECTION ON ANESTHESIOLOGYAND PAIN MEDICINE

KEY WORDSpain, stress, anxiety, analgesia, opiates, topical anesthesia

ABBREVIATIONSED—emergency departmentEMS—emergency medical servicesIV—intravenousNPO—nil per os

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-2536

doi:10.1542/peds.2012-2536

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

PEDIATRICS Volume 130, Number 5, November 2012 e1391

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician inRendering Pediatric Care

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young patients, unfamiliarity with newproducts and techniques, fear of medi-cation adverse effects, staffing limita-tions, and time constraints.10–15 Children’spain is underestimated because of theunderuse of appropriate assessmenttools and the failure to account for thewide range of children’s developmentalstages. Analgesic agents typically usedfor pain in other settings might not beused in the ED because of concernsregarding masking of symptoms andprevention of appropriate diagnosesas well as misconceptions or per-sonal biases by physicians or parentsagainst using stigmatized medicationslike opiates. Topical anesthetics may beunderused because of concerns re-garding delay in definitive treatment,cost, or lack of availability. In additionto the child’s developmental level, cul-ture, ethnicity, and race affect painmanagement from both a patient andphysician perspective. It is clear thatcultural differences can contribute tohow an individual or family manifestsbehavioral distress and anxiety16–19;however, no predictable patterns haveemerged with regard to a consistentpain experience within ethnic groups.20

Studies have noted that Hispanicand black individuals with long-bonefractures were less likely to receiveanalgesics than were non-Hispanicwhite individuals.21–23 A review ofthe National Hospital AmbulatoryMedical Care Survey from 1992 to1997 demonstrated that among pa-tients with fractures, black childrencovered by Medicaid were least likelyto receive parenteral sedation andanalgesia.24 Opioid prescribing forpainful conditions has increased for allpatients, but white patients continue tobe more likely to receive an opioidprescription than black, Hispanic, orAsian patients.25

Although few physicians still believethat children do not feel pain the sameway adults do and that pain has no

untoward consequences,15 there is agrowing recognition of how evenminor painful procedures, such asneedle sticks, can affect a child’slonger-term emotional well-being.26

Inadequate sedation and pain con-trol can worsen a child’s reaction tosubsequent, possibly even nonpainfulprocedures. Neonates who undergoprocedures with inadequate analge-sia have long-standing alterations intheir response to and perceptions ofpainful experiences.27–32 Inadequatepain control as well as invalidationof the child’s pain during oncologyprocedures leads to significantly in-creased pain scores for subsequentpainful procedures.33,34 Posttrau-matic stress symptoms can occurafter procedures or stressful medi-cal experiences that are not accom-panied by appropriate pain controlor sedation, and this can lead toadverse reactions to subsequentprocedures.35–37

In the ED, children often present witha constellation of symptoms but no finaldiagnosis; they are usually unknownto the treating physician, have awide range of medical or surgicalproblems, and are unlikely to be fastingon arrival.11 These factors make theirassessment and the selection of ap-propriate analgesic intervention morecomplicated. As well, the emergencysetting can be a busy, fast-paced envi-ronment in which heightened patientand parental anxiety increases the per-ception of pain and makes its treatmentmore difficult.12

Optimal pain management requiresa thorough understanding of painassessment and management strate-gies.12,13 Education in pain man-agement is a recent emphasis forhospitals as well as regulatory agen-cies, such as The Joint Commission:“Each and every patient has a right tothe assessment and management ofpain.”38,39

NEW INFORMATION

Setting the Stage for Relief of Painand Anxiety

Physicians can begin to address painand anxiety as soon as a child comesin contact with the EMS system.Prehospital EMS providers typicallyreceive relatively little pain manage-ment instruction.40,41 The developmentof pain assessment and managementprotocols specifically for prehospitalEMS providers, along with educationalinitiatives, can improve pain manage-ment in the field.40,42–44 Several adultstudies and 1 pediatric trial showthat analgesics, such as opiates andtramadol hydrochloride, can be usedin prehospital protocols to decreasepain scores without causing respi-ratory depression.45–48 Alternative de-livery systems, such as transmucosalmedications or inhaled nitrous oxide,could offer pain control without re-quiring intravenous (IV) access, pro-viding advantages in the field as wellas in the hospital setting.49–53 SomeEMS systems have implemented a“toolbox” of distraction equipment onunits as an adjunct to providing painrelief in the anxious, uncomfortablechild.

Assessment and Management ofPain, Stress, and Anxiety in the ED

The Environment

It is clear that there is a relationshipbetween anxiety and perceived painin children and adults.54 The creationof an appropriate environment isessential to minimize the pain anddistress of a child’s ED visit.12 Ideally,each child should be placed in a pri-vate room. Even in a general ED, therecan be a dedicated pediatric area thatprovides a child-friendly, calming en-vironment.11 Colorful walls, pictureson the ceiling, and a collection of toysand games will minimize fear inducedby this strange setting.12

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Stress management and emotionalsupport are essential to providing acomfortable environment for the childand have been shown to reduce anxietyin older children as well as parentalperception of pain in younger chil-dren.55 Adequate preparation has beenshown to decrease anxiety and in-crease a child’s coping before a minorprocedure or surgery.56–58 Distractioncan range from simple techniques,such as a bubble blower or pinwheelused by the child during a painful in-jection, to techniques that requiremore time and training, such as hyp-nosis.59–61 Structural changes, such asoutfitting each procedure room withequipment that can provide videos andmusic, and distraction stations equip-ped with bubble columns, light wands,and imagery projectors, can be helpfulin engendering a feeling of safety andcomfort in young children.62–67 A childlife specialist based in the ED has theability to (1) decrease anxiety and painperception using developmentally ap-propriate education and preparationto patients and families; (2) teachthe child and staff simple distractiontechniques, deep breathing, progres-sive relaxation, or guided imagery; (3)help the child to develop and executecoping plans during difficult events inthe ED; (4) educate the child about theED environment and his or her di-agnosis; and (5) support family in-volvement in the child’s care.68–70 Thechild life specialist has an importantrole. He or she is one of a few profes-sionals in the emergency setting whois not in a position to cause emotionalor physical pain to the child71,72; how-ever, nurses, physicians, and ancillarystaff also share in this responsibilityand can learn from and teach eachother these techniques. Optimally, thetreatment plan for each child shouldbe communicated to the entire medicalcare team with specific regard to theenvironmental and behavioral man-agement of anxiety in the emergency

medical setting. This includes teachingchildren what to expect during a pro-cedure or during their visit, showingthem specific medical supplies theywill be using, offering them choiceswhen appropriate, giving them a roleor a job during a procedure or hospitalvisit, and using distractions. Creatinga relaxing environment can help achild to feel more comfortable and lessstressed.

Allowing (but not requiring) familypresence during painful proceduresalso may be of benefit. Although thereis no evidence that family presence de-creases pain, their presence for pro-cedures can decrease child distress.73–76

Family presence does not usually in-crease anxiety of the child or decreasethe procedure success rate of experi-enced physicians; however, it is im-portant to monitor parental responsesto limit the adverse effects on all par-ties.73,74,77 In addition, involving theparent as a coach for the child duringthe procedure is useful in reducinganxiety and distress.78–82

Pain Assessment in the ED

The Joint Commission standards in-clude mandatory pain assessments forall hospital patients.39 Pain is, by na-ture, a subjective experience and isinfluenced by social, psychological,and experiential factors. For example,patients who experience chronic painmay not report the same pain level orexhibit the same facial cues and vo-calizations as those who are new tothe pain experience. Pain assessment,which is obviously the first step towardappropriate treatment, can, therefore,be more complex than just obtaininga single pain score; it is also essentialto pay attention to changes in painscores in response to treatment. Thecurrent clinical standard for pain as-sessment is a self-report scale. Simplenumerical scales, such as verballygrading pain from 0 to 10, are often

used in adults; although there is evi-dence that this technique may be ac-curate in older children with moderateto severe pain, it may be less accuratefor those with abdominal pain.83,84

Several well-validated scales exist forchildren as young as 3 years to reporttheir own pain level.85–88 The revisedFACES pain scale, the Wong-Baker Facesscale, and the 10-cm Visual AnalogScale have been used successfully inmany EDs caring for children.86,88–92

Other dimensions can be added to thevisual analog scale, such as height,width, and color, and are valid methodsfor assessment of acute pain in chil-dren.93 For those who are unable touse self-report scales, behavioralscales can be combined with an eval-uation of the patient’s history andphysical findings to assess the level ofa child’s pain.94–96 Pain in a neonate canbe evaluated using the Neonatal InfantPain Scale,97 and pain in infants, youngchildren, and those with cognitive im-pairment can be assessed using theFLACC (face, legs, activity, crying andconsolability) scale.98–104 It must benoted that few, if any, scales have beenvalidated in the prehospital setting.

Pain Management in the ED

Pain assessment should occur rou-tinely at the triage desk along with vitalsigns; however, reassessment duringthe ED stay is imperative to determinetreatment effect.12,13,105 In addition,physicians should take into accountthe possibility that combining multipleminor procedures may produce asmuch stress and discomfort as a sin-gle major procedure.106

Controlling Pain Related to NeedleSticks and Other Minor Procedures

Patients with less acute conditions alsomay require analgesia.107 Protocolsshould be developed to facilitate thedelivery of appropriate medications,such as acetaminophen, ibuprofen, ororal opiates, to these patients (Table 1).




Topical anesthetics can be placedproactively to control the pain associ-ated with placement of IV cathetersand other minor procedures. For ex-ample, in 1 inner-city pediatric ED, 90%of patients requiring IV access did notundergo this procedure until at least60 minutes after triage.108 A predictionmodel was developed whereby thepatient’s chief complaint and medicalhistory, combined with an experiencedtriage nurse assessment, determinedwith some accuracy which patientshad a high probability of requiring IVaccess.109 These findings could beadapted to develop topical anestheticprotocols for painful procedures inother EDs, taking into account theirpatient volume, acuity, and flow char-acteristics (Table 2). Some topical an-esthetics have been developed thatproduce anesthesia more rapidly thaneutectic mixture of local anesthetics(EMLA; AstraZeneca, Wilmington, DE).A topical liposomal 4% lidocaine cream(LMX4; Ferndale Laboratories, Ferndale,MI) provides anesthesia in approxi-mately 30 minutes.110,111 Heat-activatedsystems have shortened the time re-quired to as low as 10 to 20 minutes

for IV insertion pain relief.112 Topicalanesthetics also have been reportedto improve procedural success rates,likely because of decreased movementleading to better accuracy.113,114 Whenthe procedure cannot be delayed orneeds to take place in the prehospitalsetting, other techniques can be used;intradermal lidocaine injection as well

as intradermal saline with benzyl al-cohol preservative decreases the painof venous cannulation without affectingprocedural success rate.115–119 Needle-free injection systems using eitherpowder or liquid jet injection reducethe onset time even more.106,120–123

Vapocoolant sprays that have immedi-ate onset of action have been found tobe effective in reducing venipuncturepain in adults; however, they are lesseffective in children, likely because oftheir intolerance of the unpleasant coldfeeling resulting from the requiredadministration time.124,125 Recent inno-vations include a vibrating device that,when applied to the proximal extremityover a cold pack, may decrease thepain of venipuncture and immuniza-tions by taking advantage of the “gate”theory of pain. However, further studyis required to determine the compar-ative efficacy of this technique.

Similar protocols should be developedfor topical anesthetic placement forlaceration repair at triage (Table 3).Laceration repair should be completedwith an emphasis on minimizing painand anxiety. Several topical anesthetic/vasoconstrictor combinations, such aslidocaine, epinephrine, and tetracaine,which can be made by the in-hospitalpharmacy as a liquid or gel prepara-tion, provide excellent wound anesthe-sia in 20 to 30 minutes.126,127 EMLAcream also provides topical anesthesiafor laceration repair, although it is notapproved by the US Food and DrugAdministration for this purpose.128,129

Tissue adhesives, such as octyl cyano-acrylate, provide essentially painlessclosure for low-tension wounds.130,131

Steri-Strips (3M, St Paul, MN) providesimilar painless closure and are lessexpensive than currently available tis-sue adhesives.132 Absorbable suturesshould be considered for facial woundsthat must be sutured to avoid thepain and anxiety produced by sutureremoval.133,134

TABLE 1 Triage Oral AnalgesicAdministration Guidelines

PurposeTo provide analgesic therapy to patients

presenting to triage with a complaint of painProcedure1. Assess pain score using a validated tool2. Immediately triage to a treatment room all

patients with severe pain as assessed bytriage nurse and consideration of pain score

3. For those not requiring immediate evaluationwith pain score >3 (0–10 scale) or chiefcomplaint consistent with pain, consideradministration of oral analgesic

4. Assess recent analgesic useContraindications1. Allergy to analgesic (consider alternative)

Medications1. Ibuprofen (avoid if the patient has aspirin

allergy, anticipated surgery, bleedingdisorder, hemorrhage, or renal disease)

2. Acetaminophen (avoid if the patient hashepatic disease or dysfunction)

3. Oral oxycodone

TABLE 2 Guidelines for Use of TopicalLidocaine in the ED

Topical anesthetics should be considered in anypatient who has a high likelihood of undergoinga non-emergent invasive procedure on intactskin in the ED. These include the following:• Intravenous line placement or venipuncture• Lumbar puncture• Abscess drainage• Joint aspiration

Discussion with parents should bring up thefollowing issues:• Topical lidocaine does not provide completepain relief

• Some patients may require a procedurebefore topical lidocaine reaches its fulleffectiveness (see below)

• Discuss with the parents how they feel thepatient will tolerate the topical lidocaineapplication, in terms of anticipation of theprocedure as well as sensory integrationdisorders

Contraindications:• Emergent need for IV access• Allergy to amide anesthetics• Nonintact skin• EMLA only: Recent sulfonamide antibiotic use(trimethoprim-sulfamethoxazole,erythromycin-sulfisoxazole); congenital oridiopathic methemoglobinemia

The topical anesthetic dose should be lower forpatients <12 mo old or weighing <10 kg

Placement of topical lidocaine:• Intravenous line placementTopical lidocaine should be placed in at least2 sites over veins amenable to placementof an IV line, preferably judged by thenurse placing the IV line.

Care should be taken to avoid mucousmembrane contact or ingestion

• Lumbar puncturePlacement of topical lidocaine for lumbarpuncture should be considered as soon asthe decision is made to perform a lumbarpuncture; accurate placement mayrequire consultation with the clinicianperforming the procedure

Liposomal topical lidocaine reaches fulleffectiveness in 30 min, heated topicallidocaine in 20 min, EMLA reaches fulleffectiveness in 60 min.


Lidocaine can be used alone in urgentsituations or after topical anestheticshave been applied. Lidocaine can beinjected in an almost painless man-ner.115 This technique includes buff-ering the anesthetic with bicarbonate,warming the lidocaine before injec-tion, and injecting slowly with a small-gauge needle.135–139 Lidocaine buff-ered with bicarbonate made in ad-vance can be stocked in the ED andwill remain stable for up to 30 days.140,141

The pain of intramuscular injection canbe reduced using the shortest needlelength possible to reach the intra-muscular tissue, and applying concur-rent manual pressure to the injectionsite.142–145

Neonatal Pain Managementin the ED

Simple changes in practice can mini-mize painful stimuli for infants. Pro-tocols for topical anesthetic placementshould include neonates. Topical an-esthetics for procedures ranging fromcircumcision to venipuncture are safein newborn infants and even preterminfants, with appropriate dosing andshort administration times.146–148

Recent studies have suggested meth-ods by which neonatal distress duringpainful procedures can be minimized.Sucrose has been found to decreasethe response to noxious stimuli, suchas heel sticks and injections, in neo-nates and has even been demon-strated to reduce subsequent cryingepisodes during routine care, such asdiaper changes.149–161 This effect seemsto be strongest in the newborn infantand decreases gradually over the first6 months of life. Nursing protocols thatallow for the use of sucrose beforepainful procedures are in place atmany hospitals (Table 4). A 12% to 25%sucrose solution that is made by thepharmacy or is available commerciallycan be used (Sweet-Ease, Children’sMedical Ventures, Norwell, MA). The useof a pacifier alone or in conjunctionwith sucrose also has been shown tohave analgesic effects in neonates un-dergoing routine venipuncture.162 Skin-to-skin contact of an infant with his orher mother and breastfeeding duringa procedure decrease pain behaviorsassociated with painful stimuli.163,164

Available evidence supports the use oflocal and topical anesthetic for lumbarpuncture in neonates.165,166 Protocolscan allow for the timely placement oftopical anesthetic, or injected buff-ered lidocaine can be used at the siteof needle insertion before the pro-cedure. Concerns over the increaseddifficulty of lumbar puncture after lo-cal anesthetic use have proved to beunfounded, and one study even dem-onstrated improved success with theuse of topical anesthetic.113,165,167

Pain can be decreased in neonates bythe elimination of heel sticks and in-tramuscular injections. Venipunctureseems to be less painful than heellancing for obtaining blood for diag-nostic testing.168 When the intra-muscular route is necessary, topicalanesthetic should be used.169 Use of dis-traction techniques discussed previously,

ice, and less painful injection techniquescan also be efficacious.170–173 The use oflidocaine as the diluent for ceftriaxonecan decrease the pain of intramuscularinjection.174

Does the Appropriate Use ofAnalgesics Make Evaluation MoreDifficult?

There is no evidence that pain man-agement masks symptoms or cloudsmental status, preventing adequate as-sessment and diagnosis. For patientswith abdominal pain, several adult stud-ies have shown that pain medicationssuch as morphine can be used withoutaffecting diagnostic accuracy.175–179 Pedi-atric studies have demonstrated similarfindings.179,180 Clinical experience sug-gests that the use of pain medicationmakes children more comfortable andmakes the examination of the patient’sabdomen and diagnostic testing (suchas ultrasonography) easier, thus aidingin diagnosis. In the child who has suf-fered multisystem trauma, small ti-trated doses of opiates can be used toprovide pain relief without affecting theclinical examination or the ability toperform neurologic assessments.181,182

The development of pain protocols canimprove the management of children

TABLE 3 Guidelines for Use of LET (a TopicalAnesthetic for Open Wounds)

Eligibility• LET can be applied to simple lacerations andmay be applied to complex or deeperlacerations that may require supplementalsubcutaneous anesthetic administration.

Contraindications• Allergy to amide anesthetics• Gross contamination of wound

Procedure• LET should be placed according to standardED procedure; time of placement should bedocumented on triage sheet

• Dose: 3 mL for children >17 kg; 0.175 mL/kgin children <17 kga

(1) Place LET on open wound and cover withocclusive dressing or place cotton ballsoaked with LET solution into wound

(2) Allow LET to soak into wound for 10–20min or until wound edges appearblanched.

LET, lidocaine, epinephrine, and tetracaine.a Based on maximum dose of 5 mg/kg of lidocaine.

TABLE 4 Guidelines for Use of Sucrose inthe ED

Indications• Use as an adjunct for limiting the painassociated with procedures such as heelsticks, venipuncture, IV line insertion, arterialpuncture, insertion of a Foley catheter, andlumbar puncture in neonates and infantsyounger than 6 mo

Procedure1. Administer 2 mL of 25% sucrose solution by

syringe into the infant’s mouth (1 mL in eachcheek) or allow infant to suck solution froma nipple (pacifier) no more than 2 min beforethe start of the painful procedure

2. Sucrose seems to be more effective whengiven in combination with a pacifier;nonnutritive suck also contributes to calmingthe infant and decreasing pain-eliciteddistress

Contraindications: None




who suffer major trauma.183 Regionalanesthesia should also be consideredfor patients who have injuries that areamenable to these techniques.184,185

Additional studies evaluating thesepractices in pediatric patients arenecessary but should not delay thedevelopment of protocols for the useof analgesics in patients with acuteabdominal pain and multisystem traumain the ED and even the prehospitalsetting.

Analgesia in the ED and EMS Setting

Optimal pain management requires ex-peditious pain assessment and rapidadministration of systemic opioid painmedication to patients in severe pain.This may occur through various routesof administration, including trans-mucosal or IV routes. The IV routeallows for rapid relief of pain and drugtitration; the intramuscular route isless preferred, because it does notallow for medication titration and ispainful at the time of delivery and fordays afterward. Adjunctive pain medi-cations, such as nonsteroidal antiin-flammatory drugs, can be usedjudiciously in children with pain; anti-platelet activity and gastrointestinaltract and renal toxicity are rare butrecognized adverse effects. Oral opiatesand nonsteroidal antiinflammatorydrugs are appropriate for mild tomoderate pain if the patient has nocontraindications to receiving oral medi-cations. Alternative routes of medicationadministration, including oral, intra-nasal, transdermal, and inhaled routes,should be used when appropriate andmay offer rapid relief of pain.186 Studiesof transmucosal, aerosolized, and in-haled fentanyl show analgesic actioncommensurate with IV opioids.187–189

Transmucosal administration may beappropriate and useful in the pre-hospital setting as well.190 Intranasaldelivery, despite demonstrating morerapid onset of action, also may be lesstolerated because of burning of the

nasal mucosa during administra-tion.54,191 Drug delivery into thecentral nervous system is greatly en-hanced with the use of an atomizerthat distributes the medication moreevenly to the mucous membranes.192–194

Because adverse events are stillpossible when this mode of opiateadministration is used, care should betaken when using adjunctive medi-cations, such as benzodiazepines. Inaddition, if there is no IV access, it isprudent to prepare for alternativemethods of administration for reversalagents. Pain medication should beprovided in the ED as well as on dis-charge, even for those with mild tomoderate pain. Patients and familiesshould get specific instructions re-garding dose and duration of use.Clear, written instructions should beprovided for families regarding theafter care of children who have re-ceived procedural sedation. Pain med-ication should be recommended on anaround-the-clock basis for anyone inwhom moderate pain is anticipated.

The use of sedative hypnotic medicationmay be required to reduce pain anddistress for children undergoing pro-cedures in the ED. Unfortunately, painand anxiety are often difficult to dif-ferentiate in infants and toddlers andeven in school-aged children. Althoughmany procedures can be performedrelatively painlessly with the use of atopical or local anesthetic, this does notobviate the use of pharmacologic agentsto decrease the anxiety and stress inchildren undergoing procedures in theED, especially when the child needsto remain still to ensure the successof the procedure. When the procedureis expected to be painful, the agentsused should have analgesic propertiesas well. Emergency physicians are in-creasingly using short-acting medi-cations such as propofol, alone orin combination with ketamine, forprocedural sedation in children.195,196

Published reports involving adult pa-tients and recently published experi-ences with children demonstrate that,when applied using careful protocolsand in a setting of experienced se-dation teams, propofol, either aloneor in combination with ketamine,can be used safely and effectivelyfor sedation in children.195,197–205

Benzodiazepines, particularly rapidlyeffective but relatively short-actingones, such as midazolam, are alsohelpful in the prehospital and ED set-tings. Nitrous oxide is a potent an-algesic that does not require venousaccess and is available in someEDs.49–53 Nitrous oxide should beused in conjunction with appropri-ate sedation guidelines and avoidedin patients with pneumothorax, bowelobstruction, intracranial injury, andcardiovascular compromise.52,53 Nitrousoxide has many potential applications,including anxiolysis for proceduressuch as IV catheter insertion and lac-eration repair, pain control for burndébridement, and fracture and dislo-cation reduction; care should be takenif opiates are used concurrently so asnot to reduce respiratory drive.206 Themost important part of providing safesedation for children is the establish-ment of appropriate sedation systemsand sedation training programs withcredentialing guidelines for sedationproviders that specifically address thecore competencies required for thecare of pediatric patients.207,208

Pain Considerations for Children WithDevelopmental Disabilities

Children with developmental disabi-lities, particularly those with severeneurologic involvement, provide addi-tional challenges to parents and EMSand ED personnel in management ofacute pain and its associated anxiety.For many children, previous painfulexperiences in similar settings add tostress of the acute incident. Learningabout the child’s anticipated response


and previous experiences from parents,primary care physicians, and special-ists informs the emergency physicianand staff of useful supportive tech-nique.209–211 Parental understandingand awareness of subtle indirect behav-iors or emotional shifts are often crit-ical adjuncts in the assessment processof the child’s sense of comfort and well-being. Child life specialists, as pre-viously mentioned, are knowledgeableof distinct coping strategies to assistchildren with developmental dis-abilities and children who are moresensitive to sights and sounds. Mythsof pain insensitivity or indifferencemust be actively avoided.212–214 Painmodulation can vary widely, related toneurotransmitter function differenceswithin the brain or along the injuredspinal cord, thereby altering the per-ception and response to pain in childrenwith previous injuries.213–215 Cognitiveimpairments can affect both under-standing and coping mechanisms,making self-report particularly chal-lenging in young people with motor and/or cognitive differences. Maladaptivebehaviors, heightened anxiety, and un-common coping styles can add furthercomplexity to the assessment process.The Non-communicating Children’s PainChecklist–Revised offers a validated vi-sual method for staff members to as-sess and reassess children 3 to 18years of age.216–218 In addition, the In-dividual Numeric Rating Scale has beenshown to be effective in children withdevelopmental disabilities. In general,the approaches to medication use forpain and anxiety should hold true forchildren with developmental disabil-ities; some children, however, showaltered sensitivity to medications andmay be taking medications that interactwith common pain medications.219

Sedation Policies and Protocolsin the ED

Physicians, physician assistants, andnurse practitioners who administer

sedation and analgesia should haveproven training and skills and ongoingeducation in the management ofpediatric airways and resuscitation,especially in the use of face maskventilation and laryngeal mask air-ways. Emergency physicians and othernonanesthesiologist physicians withappropriate training have demon-strated the ability to safely and ef-fectively provide moderate and deepsedation and dissociative anesthesia,allowing for the timely performance ofprocedures and rapid relief of painand anxiety.202,207,208,220,221 A recentlarge prospective study of 131 751elective pediatric sedation encountersdemonstrated no differences in seri-ous adverse outcomes (ie, death, ICUadmissions, aspiration events) be-tween those performed by anesthesi-ologists and those performed by otherpediatric medical subspecialists prac-ticing in highly organized sedationsystems.222 Although the reported in-cidence of serious complications islow, it is imperative to develop ongo-ing policies that establish informedconsent and close monitoring of thesepatients. A critical component of anysedation protocol is to require atrained observer to be solely respon-sible for monitoring the patient whilethe procedure is being performed.223,224

Techniques such as noninvasive end-tidal carbon dioxide monitoring allow formore consistent detection of bradypnea,hypopnea, and apnea in sedated chil-dren and are being recognized in-creasingly as an essential part of thesedation armamentarium225,226; how-ever, this is not a replacement for directvisualization of respiratory effort. Cur-rent guidelines from the AmericanAcademy of Pediatrics, American Soci-ety of Anesthesiologists, and AmericanCollege of Emergency Physicians rec-ommend a structured evaluation ofchildren that allows risk stratificationbefore beginning sedation, thereby re-ducing the risk of complications in the

pediatric age group.223,227–235 This eval-uation should include issues such aspreexisting medical conditions, fo-cused airway examination, and con-sideration of nil per os (NPO) status.NPO guidelines for children receivingsedation in the ED are controversial.Many children who have received pro-cedural sedation for emergencies havenot fasted in accordance with publishedguidelines for elective procedures, andthis variation was not associated withadverse outcomes.236–239 Current dataare insufficient to determine the lengthof time that constitutes safety withregard to NPO status.237–243 Recentlypublished guidelines recommend thatthe physician consider the urgency ofthe procedure, targeted depth of seda-tion, risk level of the patient, and timingof most recent solid food intake todetermine the safety profile for eachpatient.244

Discharge criteria also are criticallyimportant for children undergoingsedation in the ED. Patients who re-ceive sedatives with long half-lives,such as chloral hydrate or pentobar-bital, are at particular risk of adverseevents after discharge, either duringtransportation or in their homes afterthe procedure.224 Strict adherence tocriteria that require a child to be“back to baseline” in terms of con-sciousness, or adaptation of newer“maintenance of wakefulness” crite-ria, are critical to optimize safetysurrounding the sedation process.245

Quality Improvement Programs

Any ED that provides treatment ofchildren should have a quality im-provement program that reviews, atregular intervals, sedation and painmanagement practices in pediatricpatients. Transport team and pre-hospital EMS providers are essentialpartners in this ongoing review andshould consider establishing internalreview policies as well. Many hospitalsuse a multidisciplinary committee to




help interpret the data emanating fromthese reviews and then suggest system-wide protocol and educational initia-tives. Indicators that should be evalu-ated include the use of validated painscores; appropriate analgesics forspecific disease states (whether severeor mild to moderate pain); topical an-esthetics and other non-noxious routesof analgesia and sedation; monitoringfor adverse outcomes; and the use ofdischarge instructions that outlinethe indications, dose, and duration ofanalgesic to be used.246–248 Dischargeinstruction also should include anypossible adverse effects of sedative/analgesic medications used in the ED.Adverse events that lead to respiratorydepression or other life-threateningconditions should be fully reviewedby a committee charged with under-standing if systemic care issues orprovider-specific issues were rootcauses of these outcomes.

Implementation

A systematic approach to pain man-agement in the EMS requires an im-plementation strategy, promoted andadvocated by leadership, that includesthe following: (1) a comprehensiveevaluation of current pain and distressmanagement practices; (2) an edu-cational and credentialing programregarding pain assessment and man-agement techniques for all clinicalstaff, preferably overseen by a hospital-wide sedation committee249; (3) de-velopment of protocols to allow theuniversal and efficient applicationof pain management strategies andmedications; and (4) a quality improve-ment process to evaluate the ongoingsuccess of the program.11,13 EMSagencies should establish policies andprotocols that make available perti-nent provider education and ensurequality improvement processes are inplace for pediatric pain managementprotocols appropriate for their practicesetting.

CONCLUSIONS

Management of a child’s distressduring illness or after an injury is animportant yet complex aspect of emer-gency medical care for children. Physi-cians and prehospital EMS providersshould be aware of all the availableanalgesic and sedative options. Ade-quate pain assessment is essential forpain relief and should begin on entryinto the EMS and continue throughdischarge of the child from the ED.Multiple modalities are now availablethat allow pain and anxiety controlfor all age groups. Future researchshould concentrate on pharmacologic,nonpharmacologic, and device-relatedtechnology that can assist in reducingthe pain and distress associated withmedical procedures.

SUMMARY OF KEY POINTS

1. Training and education in pediatricpain assessment and managementshould be provided to all partici-pants in the EMS for children;EMS medical directors should for-mally include pediatric pain manage-ment measures within the protocolsprovided to EMS providers.

2. Incorporation of child life specialistsand others trained in nonpharmaco-logic stress reduction can alleviatethe anxiety and perceived pain re-lated to pediatric procedures.

3. Family presence during painfulprocedures can be a viable anduseful practice in the acute caresetting.

4. Pain assessment for childrenshould begin at admission to EMS,including prehospital management,and continue until discharge fromthe ED. When discharged, patientsshould receive detailed instructionsregarding analgesic administration.

5. Administration of analgesics andanesthetics should be painless oras pain free as possible.

6. Neonates and young infants shouldreceive adequate pain prophylaxisfor procedures and pain relief asappropriate.

7. Administration of pain medicationhas been demonstrated to pre-serve the ability to assess patientswith abdominal pain and shouldnot be withheld.

8. Sedation or dissociative anesthe-sia should be provided appro-priately for patients undergoingpainful or stressful proceduresin the ED.

9. Pain management and sedation, in-cluding deep sedation and dissocia-tive anesthesia, are fully within themonitoring and management cap-abilities of appropriately trainedemergency medicine and pediatricemergency medicine physicians.Each emergency department thatprovides sedation and analgesiato children should include sedationcompetencies in recredentialingprocedures and develop protocols,policies, and quality improvementprograms as part of the systematicapproach to pain management inthe EMS.

LEAD AUTHORSJoel A. Fein, MD, MPHWilliam T. Zempsky, MD, MPHJoseph P. Cravero, MD

COMMITTEE ON PEDIATRICEMERGENCY MEDICINE, 2011–2012Kathy N. Shaw, MD, MSCE, ChairpersonAlice D. Ackerman, MD, MBAThomas H. Chun, MD, MPHGregory P. Conners, MD, MPH, MBANanette C. Dudley, MDJoel A. Fein, MD, MPHSusan M. Fuchs, MDBrian R. Moore, MDSteven M. Selbst, MDJoseph L. Wright, MD, MPH

FORMER COMMITTEE MEMBERSLaura S. Fitzmaurice, MDKaren S. Frush, MDPatricia J. O’MalleyLoren G. Yamamoto, MD, MPH, MBA


LIAISONSIsabel A. Barata, MD – American College ofEmergency PhysiciansKim Bullock, MD – American Academy of FamilyPhysiciansToni K. Gross, MD, MPH – National Association ofEMS PhysiciansElizabeth Edgerton, MD, MPH – Maternal andChild Health BureauTamar Magarik Haro – AAP Department ofFederal AffairsJaclynn S. Haymon, MPA, RN – EMSC NationalResource CenterCynthia Wright Johnson, MSN, RNC – NationalAssociation of State EMS OfficialsLou E. Romig, MD – National Association ofEmergency Medical TechniciansSally K. Snow, RN, BSN – Emergency NursesAssociation

David W. Tuggle, MD – American College ofSurgeons

FORMER LIAISONSMark Hostetler, MD – American College ofEmergency PhysiciansDan Kavanaugh, MSW – Maternal and ChildHealth BureauCindy Pellegrini – AAP Department of FederalAffairsTina Turgel, BSN, RN-C – Maternal and ChildHealth Bureau

STAFFSue Tellez

SECTION ON ANESTHESIOLOGY ANDPAIN MEDICINE EXECUTIVECOMMITTEE, 2011–2012Carolyn F. Bannister, MD, ChairpersonJoseph D. Tobias, MD, Chairperson-ElectCorrie T. M. Anderson, MDKenneth R. Goldschneider, MDJeffrey L. Koh, MDDavid M. Polaner, MDConstance S. Houck, MD, Immediate PastChairperson

LIAISONSMark A. Singleton, MD – American Society ofAnesthesiologistsJeffrey L. Galinkin, MD – AAP Committee on Drugs

STAFFJennifer G. Riefe

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DOI: 10.1542/peds.2012-2536 originally published online October 29, 2012; 2012;130;e1391Pediatrics

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DOI: 10.1542/peds.2012-2536 originally published online October 29, 2012; 2012;130;e1391Pediatrics

AND PAIN MEDICINEANESTHESIOLOGYPEDIATRIC EMERGENCY MEDICINE AND SECTION ON

Joel A. Fein, William T. Zempsky, Joseph P. Cravero and THE COMMITTEE ONRelief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems

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ISSN: 1073-0397. 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it


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