American Society of Regional Anesthesia and Pain Medicine August 2017 - 23

Addressing Procedural Pain in Pediatric Patients
Hospitalized children are exposed
to many potentially painful
procedures. These painful events
can lead to increased distress
and long-lasting fear months after
the event.1 Painful experiences in
early childhood can "prime" kids
to be more sensitive to painful
stimuli later in their admission or
even be at risk for chronic pain
syndromes later in life as adults.2
In the preoperative setting, a child
may already have had multiple
painful procedures prior to
arriving to the operating room and
have immense anxiety, fear, and
distress, leading to a greater pain
response postoperatively.3 Thus, it
is prudent to develop a system to
improve coping and address pain
early in a child's hospital course
for any procedure they may have.

child and family member, and the family member's use of coping
strategies.7 Therefore, prior to the procedure, family members
must be evaluated and given the proper support for participation.8,9
It is important to note that with the improved patient and family
satisfaction associated with their involvement, there is no detriment
to procedural performance.10-12

Neil Patel, MD
Assistant Professor
Department of Anesthesiology,
Perioperative Care and Pain
Medicine
NYU Langone Medical Center
New York, NY
Section Editor: Andrea Nicol, MD

Procedural pain management in pediatric patients can be a
difficult task but one that is highly valued by patients and families.
Unlike the perioperative setting where analgesia is addressed
by anesthesiologists, procedures without sedation are done by a
variety of medical specialties and providers within the hospital.
These individual groups may also perform procedures in different
manners and there may even be intradepartmental variability.
At Hassenfeld Children's Hospital of New York at NYU Langone,
in partnership with the Sala Institute for Child and Family Care,
we have made it a priority to address issues related to pediatric
procedural pain. After a review of practices at major children's
hospitals, we found a similar situation at Children's Minnesota and
their subsequent development of the Children's Comfort Promise.4
We hope to develop as robust of a program for pediatric procedural
pain management at our institution. We have adopted the four
practices used by Minnesota and added a fifth: partnership with
patients and family, positioning for comfort, distraction, numbing,
and sucrose/breastfeeding.
PARTNERSHIP WITH PATIENTS AND FAMILY
A key component of pediatric pain management is the involvement
of both the patient and family. Appropriate goals, expectations,
and coping strategies should be developed prior to the procedure.
By creating a partnership, a sense of control is returned to the
family and satisfaction improves.5,6 Defining a specific task for
family members allows everyone to harmoniously work towards
the same goal. There are times, however, that family presence
may not be beneficial and its effectiveness likely depends on
how anxious the family member is, the interactions between the

POSITIONING FOR COMFORT
A safe and simple technique to enhance patient and family comfort
and satisfaction is holding and positioning. Common practice in
starting IVs or blood draws in children is with a patient supine
in their bed possibly with parental presence. Practitioners often
believe that this is the safest position for the child, one they are
most comfortable with, and more likely to get good results with
minimal attempts. A major concern for staff who regularly start IVs
or draw blood on patients is the fear that if a child is held upright
by a family member they may not be secure and the limbs may
not be stable for IV access. This has, however, been shown not to
be the case.13 Although nurses in the study done by Stephens et
al did report concern and dissatisfaction over positioning, there
was no significant difference in the number of IV attempts needed.
Overall, upright patient positioning for IV access has been shown to
decrease IV distress in children and improve satisfaction in family/
caregivers without negatively affecting success rate.14 A properly
executed position of comfort encourages a familiar and supportive
embrace with caregiver and child, safely and comfortably
immobilizing the extremities not involved in the procedure, and
isolating out that extremity that is needed.
DISTRACTION
Distraction during potentially painful or distressing procedures
is a low-cost, easily implemented intervention proven to have
benefits in children's perceived distress.15 Distractions should be
age appropriate and engaging to the child. When possible, children
should be allowed and encouraged to self-select their distraction
method. This may increase the likelihood of effective distraction
and also create a sense of "mastery," where the child then feels
empowered in their coping.16
NUMBING
Adequate analgesia can reduce the pain associated with the
procedure and the anxiety surrounding future procedures. Numbing
can take many forms, with the most common intervention being
topical lidocaine solution; however, injected local anesthetic, local
anesthetic administered through a needleless system, cold packs,
and vibrating devices can also be used. Barriers to the use of
numbing strategies include provider beliefs that procedures are
just as painful as administration of injectable lidocaine, the use
of topical analgesia decreases procedure success rate, and the
time required to obtain effective analgesia is too long.17 Although
subjectively providers may feel procedural success is hindered
by topical analgesics, there is data to show otherwise. Taddio et

American Society of Regional Anesthesia and Pain Medicine
2017

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