HealthDay News — Improved steps to manage pain and stress in pediatric emergency medical care are recommended, according to a clinical report from the American Academy of Pediatrics (AAP).

“A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction,” Joel A. Fein, MD, MPH, and colleagues from the AAP’s Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine, reported in Pediatrics.

After examining pediatric pain management policies in all U.S. emergency medical services (EMS) agencies, Fien and colleagues came up with the following guidelines for management of a child’s distress  in the ED during illness or after injury.

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They identified several barriers to successful pain management in pediatric emergencies, including complexity in patient assessment, communication difficulties, lack of staff and concerns about adverse effects from medications.

The researchers recommended that training and education in pediatric pain assessment and management should be provided to all members of the EMS for children, and that pain should be assessed based on the child’s age and level of development using one of the following tools: numerical scales; the FACES pain scale, in which the child identifies which facial expression most resembles his or her degree of discomfort; or a neonatal pain scoring tool.

Anxiety can be relieved by incorporation of child life specialists and others trained in non-pharmacological stress reduction. The presence of family may be viable and useful during painful procedures in the acute care setting. Pain assessments should occur from EMS admission through discharge.

Analgesic and anesthetic administration should be as painless or pain free as possible, with policies in place to guide the administration of medications, such as ibuprofen, acetaminophen, or oral oxycodone, as well as for the use of topical anesthetics for any likely painful procedure, such as placement of an intravenous line, lumbar puncture or suturing lacerations.

Pain prophylaxis should be given to neonates and young infants with topical anesthetics, and also by the method of having the infant suck sucrose solution from a pacifier immediately before a procedure.

The guidelines clarify that pain medication should not be withheld from patients with abdominal pain, as it does not interfere with the ability to assess patients. Patients undergoing painful or stressful procedures in the emergency room should be given sedation or dissociative anesthesia. As part of the systematic approach to pain management, emergency departments should include sedation competencies in recredentialing procedures and develop protocol, policies and quality improvement programs.

“The most important part of providing safe sedation for children is the establishment of appropriate sedation systems and sedation training programs with credentialing guidelines for sedation providers that specifically address the core competencies required for the care of pediatric patients,” the researchers wrote.

Procedures that require sedation should involve a risk stratification step, in which children are assessed prior to sediation, including examination of the airway and consideration of any pre-existing conditions. Other recommendations include creating specific discharge criteria, so that no children are sent home during a time period when adverse events could still occur. Discharged patients should receive written follow-up care instructions for the child’s parents or caregivers.

ERs should consider employing specialists that are skilled in dealing with kids in stressful situations to help evaluate and treat children with disabilities that may have difficulty communicating pain, anxiety and fear, and therefore exhibit poorly controlled behavior or have trouble cooperating with health-care providers.

Regular quality control assessments to review pediatric pain management processes and outcomes with ED staff and transport personelle should be conducted.

“Multiple modalities are now available that allow pain and anxiety control for all age groups. Future research should concentrate on pharmacologic, nonpharmacologic, and device-related technology that can assist in reducing the pain and distress associated with medical procedures,” the researchers concluded.


  1. Fein J et al. Pediatrics 2012; 130: e1391-e1405.