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Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics

revised

  • 114(5):1348

A statement of reaffirmation for this policy was published at

  • 136(5):e1418
From the American Academy of PediatricsClinical Report

Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems

Joel A. Fein, William T. Zempsky, Joseph P. Cravero and THE COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE AND SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE
Pediatrics November 2012, 130 (5) e1391-e1405; DOI: https://doi.org/10.1542/peds.2012-2536
Joel A. Fein
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William T. Zempsky
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Joseph P. Cravero
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Abstract

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child’s and family’s reaction to current and future medical care. 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.

KEY WORDS
  • pain
  • stress
  • anxiety
  • analgesia
  • opiates
  • topical anesthesia
  • Abbreviations:
    ED —
    emergency department
    EMS —
    emergency medical services
    IV —
    intravenous
    NPO —
    nil per os
  • Background

    A systematic approach to pain management is required to ensure relief of pain and anxiety for children who enter into the emergency medical system, which includes all emergency medical services (EMS) agencies, interfacility critical care transport teams, and the emergency department (ED).1 The administration of appropriate analgesia in children varies by age as well as by training of the ED team (which includes physicians, nurses, physician assistants, and nurse practitioners), however, and still lags behind 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 in children have led to changes in the approach to pain management for acutely ill and injured pediatric patients.5 Studies have shown an increase in opiate use in children with fractures.6–8 Recent advances in the approach and support for pediatric analgesia and sedation, as well as new products and devices, have improved the overall climate of the ED for patients and families in search of the “ouchless” ED.5,9 Increased parental education regarding pain and sedation, physician comfort and desire to enhance patient satisfaction, and a quest to satisfy accreditation regulations have appropriately driven this effort. System-wide approaches for pain management awareness and strategies work best if they are woven into the fabric of the emergency medical system through education and protocol development. The purpose of this report was to provide information to optimize the comfort and minimize the distress of children and 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 young patients, unfamiliarity with new products and techniques, fear of medication adverse effects, staffing limitations, and time constraints.10–15 Children’s pain is underestimated because of the underuse of appropriate assessment tools and the failure to account for the wide range of children’s developmental stages. Analgesic agents typically used for pain in other settings might not be used in the ED because of concerns regarding masking of symptoms and prevention of appropriate diagnoses as well as misconceptions or personal biases by physicians or parents against using stigmatized medications like opiates. Topical anesthetics may be underused because of concerns regarding delay in definitive treatment, cost, or lack of availability. In addition to the child’s developmental level, culture, ethnicity, and race affect pain management from both a patient and physician perspective. It is clear that cultural differences can contribute to how an individual or family manifests behavioral distress and anxiety16–19; however, no predictable patterns have emerged with regard to a consistent pain experience within ethnic groups.20 Studies have noted that Hispanic and black individuals with long-bone fractures were less likely to receive analgesics than were non-Hispanic white individuals.21–23 A review of the National Hospital Ambulatory Medical Care Survey from 1992 to 1997 demonstrated that among patients with fractures, black children covered by Medicaid were least likely to receive parenteral sedation and analgesia.24 Opioid prescribing for painful conditions has increased for all patients, but white patients continue to be more likely to receive an opioid prescription than black, Hispanic, or Asian patients.25

    Although few physicians still believe that children do not feel pain the same way adults do and that pain has no untoward consequences,15 there is a growing recognition of how even minor painful procedures, such as needle sticks, can affect a child’s longer-term emotional well-being.26 Inadequate sedation and pain control can worsen a child’s reaction to subsequent, possibly even nonpainful procedures. Neonates who undergo procedures with inadequate analgesia have long-standing alterations in their response to and perceptions of painful experiences.27–32 Inadequate pain control as well as invalidation of the child’s pain during oncology procedures leads to significantly increased pain scores for subsequent painful procedures.33,34 Posttraumatic stress symptoms can occur after procedures or stressful medical experiences that are not accompanied by appropriate pain control or sedation, and this can lead to adverse reactions to subsequent procedures.35–37

    In the ED, children often present with a constellation of symptoms but no final diagnosis; they are usually unknown to the treating physician, have a wide range of medical or surgical problems, and are unlikely to be fasting on arrival.11 These factors make their assessment and the selection of appropriate analgesic intervention more complicated. As well, the emergency setting can be a busy, fast-paced environment in which heightened patient and parental anxiety increases the perception of pain and makes its treatment more difficult.12

    Optimal pain management requires a thorough understanding of pain assessment and management strategies.12,13 Education in pain management is a recent emphasis for hospitals as well as regulatory agencies, such as The Joint Commission: “Each and every patient has a right to the assessment and management of pain.”38,39

    New Information

    Setting the Stage for Relief of Pain and Anxiety

    Physicians can begin to address pain and anxiety as soon as a child comes in contact with the EMS system. Prehospital EMS providers typically receive relatively little pain management instruction.40,41 The development of pain assessment and management protocols specifically for prehospital EMS providers, along with educational initiatives, can improve pain management in the field.40,42–44 Several adult studies and 1 pediatric trial show that analgesics, such as opiates and tramadol hydrochloride, can be used in prehospital protocols to decrease pain scores without causing respiratory depression.45–48 Alternative delivery systems, such as transmucosal medications or inhaled nitrous oxide, could offer pain control without requiring intravenous (IV) access, providing advantages in the field as well as in the hospital setting.49–53 Some EMS systems have implemented a “toolbox” of distraction equipment on units as an adjunct to providing pain relief in the anxious, uncomfortable child.

    Assessment and Management of Pain, Stress, and Anxiety in the ED

    The Environment

    It is clear that there is a relationship between anxiety and perceived pain in children and adults.54 The creation of an appropriate environment is essential to minimize the pain and distress of a child’s ED visit.12 Ideally, each child should be placed in a private room. Even in a general ED, there can be a dedicated pediatric area that provides a child-friendly, calming environment.11 Colorful walls, pictures on the ceiling, and a collection of toys and games will minimize fear induced by this strange setting.12

    Stress management and emotional support are essential to providing a comfortable environment for the child and have been shown to reduce anxiety in older children as well as parental perception of pain in younger children.55 Adequate preparation has been shown to decrease anxiety and increase a child’s coping before a minor procedure or surgery.56–58 Distraction can range from simple techniques, such as a bubble blower or pinwheel used by the child during a painful injection, to techniques that require more time and training, such as hypnosis.59–61 Structural changes, such as outfitting each procedure room with equipment that can provide videos and music, and distraction stations equipped with bubble columns, light wands, and imagery projectors, can be helpful in engendering a feeling of safety and comfort in young children.62–67 A child life specialist based in the ED has the ability to (1) decrease anxiety and pain perception using developmentally appropriate education and preparation to patients and families; (2) teach the child and staff simple distraction techniques, deep breathing, progressive relaxation, or guided imagery; (3) help the child to develop and execute coping plans during difficult events in the ED; (4) educate the child about the ED environment and his or her diagnosis; and (5) support family involvement in the child’s care.68–70 The child life specialist has an important role. He or she is one of a few professionals in the emergency setting who is not in a position to cause emotional or physical pain to the child71,72; however, nurses, physicians, and ancillary staff also share in this responsibility and can learn from and teach each other these techniques. Optimally, the treatment plan for each child should be communicated to the entire medical care team with specific regard to the environmental and behavioral management of anxiety in the emergency medical setting. This includes teaching children what to expect during a procedure or during their visit, showing them specific medical supplies they will be using, offering them choices when appropriate, giving them a role or a job during a procedure or hospital visit, and using distractions. Creating a relaxing environment can help a child to feel more comfortable and less stressed.

    Allowing (but not requiring) family presence during painful procedures also may be of benefit. Although there is no evidence that family presence decreases pain, their presence for procedures can decrease child distress.73–76 Family presence does not usually increase anxiety of the child or decrease the procedure success rate of experienced physicians; however, it is important to monitor parental responses to limit the adverse effects on all parties.73,74,77 In addition, involving the parent as a coach for the child during the procedure is useful in reducing anxiety and distress.78–82

    Pain Assessment in the ED

    The Joint Commission standards include mandatory pain assessments for all hospital patients.39 Pain is, by nature, a subjective experience and is influenced by social, psychological, and experiential factors. For example, patients who experience chronic pain may not report the same pain level or exhibit the same facial cues and vocalizations as those who are new to the pain experience. Pain assessment, which is obviously the first step toward appropriate treatment, can, therefore, be more complex than just obtaining a single pain score; it is also essential to pay attention to changes in pain scores in response to treatment. The current clinical standard for pain assessment is a self-report scale. Simple numerical scales, such as verbally grading pain from 0 to 10, are often used in adults; although there is evidence that this technique may be accurate in older children with moderate to severe pain, it may be less accurate for those with abdominal pain.83,84 Several well-validated scales exist for children as young as 3 years to report their own pain level.85–88 The revised FACES pain scale, the Wong-Baker Faces scale, and the 10-cm Visual Analog Scale have been used successfully in many EDs caring for children.86,88–92 Other dimensions can be added to the visual analog scale, such as height, width, and color, and are valid methods for assessment of acute pain in children.93 For those who are unable to use self-report scales, behavioral scales can be combined with an evaluation of the patient’s history and physical findings to assess the level of a child’s pain.94–96 Pain in a neonate can be evaluated using the Neonatal Infant Pain Scale,97 and pain in infants, young children, and those with cognitive impairment can be assessed using the FLACC (face, legs, activity, crying and consolability) scale.98–104 It must be noted that few, if any, scales have been validated in the prehospital setting.

    Pain Management in the ED

    Pain assessment should occur routinely at the triage desk along with vital signs; however, reassessment during the ED stay is imperative to determine treatment effect.12,13,105 In addition, physicians should take into account the possibility that combining multiple minor procedures may produce as much stress and discomfort as a single major procedure.106

    Controlling Pain Related to Needle Sticks and Other Minor Procedures

    Patients with less acute conditions also may require analgesia.107 Protocols should be developed to facilitate the delivery of appropriate medications, such as acetaminophen, ibuprofen, or oral opiates, to these patients (Table 1). Topical anesthetics can be placed proactively to control the pain associated with placement of IV catheters and other minor procedures. For example, in 1 inner-city pediatric ED, 90% of patients requiring IV access did not undergo this procedure until at least 60 minutes after triage.108 A prediction model was developed whereby the patient’s chief complaint and medical history, combined with an experienced triage nurse assessment, determined with some accuracy which patients had a high probability of requiring IV access.109 These findings could be adapted to develop topical anesthetic protocols for painful procedures in other EDs, taking into account their patient volume, acuity, and flow characteristics (Table 2). Some topical anesthetics have been developed that produce anesthesia more rapidly than eutectic mixture of local anesthetics (EMLA; AstraZeneca, Wilmington, DE). A topical liposomal 4% lidocaine cream (LMX4; Ferndale Laboratories, Ferndale, MI) provides anesthesia in approximately 30 minutes.110,111 Heat-activated systems have shortened the time required to as low as 10 to 20 minutes for IV insertion pain relief.112 Topical anesthetics also have been reported to improve procedural success rates, likely because of decreased movement leading to better accuracy.113,114 When the procedure cannot be delayed or needs to take place in the prehospital setting, other techniques can be used; intradermal lidocaine injection as well as intradermal saline with benzyl alcohol preservative decreases the pain of venous cannulation without affecting procedural success rate.115–119 Needle-free injection systems using either powder or liquid jet injection reduce the onset time even more.106,120–123 Vapocoolant sprays that have immediate onset of action have been found to be effective in reducing venipuncture pain in adults; however, they are less effective in children, likely because of their intolerance of the unpleasant cold feeling resulting from the required administration time.124,125 Recent innovations include a vibrating device that, when applied to the proximal extremity over a cold pack, may decrease the pain of venipuncture and immunizations by taking advantage of the “gate” theory of pain. However, further study is required to determine the comparative efficacy of this technique.

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    TABLE 1

    Triage Oral Analgesic Administration Guidelines

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    TABLE 2

    Guidelines for Use of Topical Lidocaine in the ED

    Similar protocols should be developed for topical anesthetic placement for laceration repair at triage (Table 3). Laceration repair should be completed with an emphasis on minimizing pain and anxiety. Several topical anesthetic/vasoconstrictor combinations, such as lidocaine, epinephrine, and tetracaine, which can be made by the in-hospital pharmacy as a liquid or gel preparation, provide excellent wound anesthesia in 20 to 30 minutes.126,127 EMLA cream also provides topical anesthesia for laceration repair, although it is not approved by the US Food and Drug Administration for this purpose.128,129 Tissue adhesives, such as octyl cyanoacrylate, provide essentially painless closure for low-tension wounds.130,131 Steri-Strips (3M, St Paul, MN) provide similar painless closure and are less expensive than currently available tissue adhesives.132 Absorbable sutures should be considered for facial wounds that must be sutured to avoid the pain and anxiety produced by suture removal.133,134

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    TABLE 3

    Guidelines for Use of LET (a Topical Anesthetic for Open Wounds)

    Lidocaine can be used alone in urgent situations or after topical anesthetics have been applied. Lidocaine can be injected in an almost painless manner.115 This technique includes buffering the anesthetic with bicarbonate, warming the lidocaine before injection, and injecting slowly with a small-gauge needle.135–139 Lidocaine buffered with bicarbonate made in advance can be stocked in the ED and will remain stable for up to 30 days.140,141

    The pain of intramuscular injection can be reduced using the shortest needle length possible to reach the intramuscular tissue, and applying concurrent manual pressure to the injection site.142–145

    Neonatal Pain Management in the ED

    Simple changes in practice can minimize painful stimuli for infants. Protocols for topical anesthetic placement should include neonates. Topical anesthetics for procedures ranging from circumcision to venipuncture are safe in newborn infants and even preterm infants, with appropriate dosing and short administration times.146–148

    Recent studies have suggested methods by which neonatal distress during painful procedures can be minimized. Sucrose has been found to decrease the response to noxious stimuli, such as heel sticks and injections, in neonates and has even been demonstrated to reduce subsequent crying episodes during routine care, such as diaper changes.149–161 This effect seems to be strongest in the newborn infant and decreases gradually over the first 6 months of life. Nursing protocols that allow for the use of sucrose before painful procedures are in place at many hospitals (Table 4). A 12% to 25% sucrose solution that is made by the pharmacy or is available commercially can be used (Sweet-Ease, Children’s Medical Ventures, Norwell, MA). The use of a pacifier alone or in conjunction with sucrose also has been shown to have analgesic effects in neonates undergoing routine venipuncture.162 Skin-to-skin contact of an infant with his or her mother and breastfeeding during a procedure decrease pain behaviors associated with painful stimuli.163,164

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    TABLE 4

    Guidelines for Use of Sucrose in the ED

    Available evidence supports the use of local and topical anesthetic for lumbar puncture in neonates.165,166 Protocols can allow for the timely placement of topical anesthetic, or injected buffered lidocaine can be used at the site of needle insertion before the procedure. Concerns over the increased difficulty of lumbar puncture after local anesthetic use have proved to be unfounded, and one study even demonstrated improved success with the use of topical anesthetic.113,165,167

    Pain can be decreased in neonates by the elimination of heel sticks and intramuscular injections. Venipuncture seems to be less painful than heel lancing for obtaining blood for diagnostic testing.168 When the intramuscular route is necessary, topical anesthetic should be used.169 Use of distraction techniques discussed previously, ice, and less painful injection techniques can also be efficacious.170–173 The use of lidocaine as the diluent for ceftriaxone can decrease the pain of intramuscular injection.174

    Does the Appropriate Use of Analgesics Make Evaluation More Difficult?

    There is no evidence that pain management masks symptoms or clouds mental status, preventing adequate assessment and diagnosis. For patients with abdominal pain, several adult studies have shown that pain medications such as morphine can be used without affecting diagnostic accuracy.175–179 Pediatric studies have demonstrated similar findings.179,180 Clinical experience suggests that the use of pain medication makes children more comfortable and makes the examination of the patient’s abdomen and diagnostic testing (such as ultrasonography) easier, thus aiding in diagnosis. In the child who has suffered multisystem trauma, small titrated doses of opiates can be used to provide pain relief without affecting the clinical examination or the ability to perform neurologic assessments.181,182 The development of pain protocols can improve the management of children who suffer major trauma.183 Regional anesthesia should also be considered for patients who have injuries that are amenable to these techniques.184,185 Additional studies evaluating these practices in pediatric patients are necessary but should not delay the development of protocols for the use of analgesics in patients with acute abdominal pain and multisystem trauma in the ED and even the prehospital setting.

    Analgesia in the ED and EMS Setting

    Optimal pain management requires expeditious pain assessment and rapid administration of systemic opioid pain medication to patients in severe pain. This may occur through various routes of administration, including transmucosal or IV routes. The IV route allows for rapid relief of pain and drug titration; the intramuscular route is less preferred, because it does not allow for medication titration and is painful at the time of delivery and for days afterward. Adjunctive pain medications, such as nonsteroidal antiinflammatory drugs, can be used judiciously in children with pain; antiplatelet activity and gastrointestinal tract and renal toxicity are rare but recognized adverse effects. Oral opiates and nonsteroidal antiinflammatory drugs are appropriate for mild to moderate pain if the patient has no contraindications to receiving oral medications. Alternative routes of medication administration, including oral, intranasal, transdermal, and inhaled routes, should be used when appropriate and may offer rapid relief of pain.186 Studies of transmucosal, aerosolized, and inhaled fentanyl show analgesic action commensurate with IV opioids.187–189 Transmucosal administration may be appropriate and useful in the prehospital setting as well.190 Intranasal delivery, despite demonstrating more rapid onset of action, also may be less tolerated because of burning of the nasal mucosa during administration.54,191 Drug delivery into the central nervous system is greatly enhanced with the use of an atomizer that distributes the medication more evenly to the mucous membranes.192–194 Because adverse events are still possible when this mode of opiate administration is used, care should be taken when using adjunctive medications, such as benzodiazepines. In addition, if there is no IV access, it is prudent to prepare for alternative methods of administration for reversal agents. Pain medication should be provided in the ED as well as on discharge, even for those with mild to moderate pain. Patients and families should get specific instructions regarding dose and duration of use. Clear, written instructions should be provided for families regarding the after care of children who have received procedural sedation. Pain medication should be recommended on an around-the-clock basis for anyone in whom moderate pain is anticipated.

    The use of sedative hypnotic medication may be required to reduce pain and distress for children undergoing procedures in the ED. Unfortunately, pain and anxiety are often difficult to differentiate in infants and toddlers and even in school-aged children. Although many procedures can be performed relatively painlessly with the use of a topical or local anesthetic, this does not obviate the use of pharmacologic agents to decrease the anxiety and stress in children undergoing procedures in the ED, especially when the child needs to remain still to ensure the success of the procedure. When the procedure is expected to be painful, the agents used should have analgesic properties as well. Emergency physicians are increasingly using short-acting medications such as propofol, alone or in combination with ketamine, for procedural sedation in children.195,196 Published reports involving adult patients and recently published experiences with children demonstrate that, when applied using careful protocols and in a setting of experienced sedation teams, propofol, either alone or in combination with ketamine, can be used safely and effectively for sedation in children.195,197–205 Benzodiazepines, particularly rapidly effective but relatively short-acting ones, such as midazolam, are also helpful in the prehospital and ED settings. Nitrous oxide is a potent analgesic that does not require venous access and is available in some EDs.49–53 Nitrous oxide should be used in conjunction with appropriate sedation guidelines and avoided in patients with pneumothorax, bowel obstruction, intracranial injury, and cardiovascular compromise.52,53 Nitrous oxide has many potential applications, including anxiolysis for procedures such as IV catheter insertion and laceration repair, pain control for burn débridement, and fracture and dislocation reduction; care should be taken if opiates are used concurrently so as not to reduce respiratory drive.206 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.207,208

    Pain Considerations for Children With Developmental Disabilities

    Children with developmental disabilities, particularly those with severe neurologic involvement, provide additional challenges to parents and EMS and ED personnel in management of acute pain and its associated anxiety. For many children, previous painful experiences in similar settings add to stress of the acute incident. Learning about the child’s anticipated response and previous experiences from parents, primary care physicians, and specialists informs the emergency physician and staff of useful supportive technique.209–211 Parental understanding and awareness of subtle indirect behaviors or emotional shifts are often critical adjuncts in the assessment process of the child’s sense of comfort and well-being. Child life specialists, as previously mentioned, are knowledgeable of distinct coping strategies to assist children with developmental disabilities and children who are more sensitive to sights and sounds. Myths of pain insensitivity or indifference must be actively avoided.212–214 Pain modulation can vary widely, related to neurotransmitter function differences within the brain or along the injured spinal cord, thereby altering the perception and response to pain in children with previous injuries.213–215 Cognitive impairments can affect both understanding and coping mechanisms, making self-report particularly challenging in young people with motor and/or cognitive differences. Maladaptive behaviors, heightened anxiety, and uncommon coping styles can add further complexity to the assessment process. The Non-communicating Children’s Pain Checklist–Revised offers a validated visual method for staff members to assess and reassess children 3 to 18 years of age.216–218 In addition, the Individual Numeric Rating Scale has been shown to be effective in children with developmental disabilities. In general, the approaches to medication use for pain and anxiety should hold true for children with developmental disabilities; some children, however, show altered sensitivity to medications and may be taking medications that interact with common pain medications.219

    Sedation Policies and Protocols in the ED

    Physicians, physician assistants, and nurse practitioners who administer sedation and analgesia should have proven training and skills and ongoing education in the management of pediatric airways and resuscitation, especially in the use of face mask ventilation and laryngeal mask airways. Emergency physicians and other nonanesthesiologist physicians with appropriate training have demonstrated the ability to safely and effectively provide moderate and deep sedation and dissociative anesthesia, allowing for the timely performance of procedures and rapid relief of pain and anxiety.202,207,208,220,221 A recent large prospective study of 131 751 elective pediatric sedation encounters demonstrated no differences in serious adverse outcomes (ie, death, ICU admissions, aspiration events) between those performed by anesthesiologists and those performed by other pediatric medical subspecialists practicing in highly organized sedation systems.222 Although the reported incidence of serious complications is low, it is imperative to develop ongoing policies that establish informed consent and close monitoring of these patients. A critical component of any sedation protocol is to require a trained observer to be solely responsible for monitoring the patient while the procedure is being performed.223,224 Techniques such as noninvasive end-tidal carbon dioxide monitoring allow for more consistent detection of bradypnea, hypopnea, and apnea in sedated children and are being recognized increasingly as an essential part of the sedation armamentarium225,226; however, this is not a replacement for direct visualization of respiratory effort. Current guidelines from the American Academy of Pediatrics, American Society of Anesthesiologists, and American College of Emergency Physicians recommend a structured evaluation of children that allows risk stratification before beginning sedation, thereby reducing the risk of complications in the pediatric age group.223,227–235 This evaluation should include issues such as preexisting medical conditions, focused airway examination, and consideration of nil per os (NPO) status. NPO guidelines for children receiving sedation in the ED are controversial. Many children who have received procedural sedation for emergencies have not fasted in accordance with published guidelines for elective procedures, and this variation was not associated with adverse outcomes.236–239 Current data are insufficient to determine the length of time that constitutes safety with regard to NPO status.237–243 Recently published guidelines recommend that the physician consider the urgency of the procedure, targeted depth of sedation, risk level of the patient, and timing of most recent solid food intake to determine the safety profile for each patient.244

    Discharge criteria also are critically important for children undergoing sedation in the ED. Patients who receive sedatives with long half-lives, such as chloral hydrate or pentobarbital, are at particular risk of adverse events after discharge, either during transportation or in their homes after the procedure.224 Strict adherence to criteria that require a child to be “back to baseline” in terms of consciousness, or adaptation of newer “maintenance of wakefulness” criteria, are critical to optimize safety surrounding the sedation process.245

    Quality Improvement Programs

    Any ED that provides treatment of children should have a quality improvement program that reviews, at regular intervals, sedation and pain management practices in pediatric patients. Transport team and prehospital EMS providers are essential partners in this ongoing review and should consider establishing internal review policies as well. Many hospitals use a multidisciplinary committee to help interpret the data emanating from these reviews and then suggest system-wide protocol and educational initiatives. Indicators that should be evaluated include the use of validated pain scores; appropriate analgesics for specific disease states (whether severe or mild to moderate pain); topical anesthetics and other non-noxious routes of analgesia and sedation; monitoring for adverse outcomes; and the use of discharge instructions that outline the indications, dose, and duration of analgesic to be used.246–248 Discharge instruction also should include any possible adverse effects of sedative/analgesic medications used in the ED. Adverse events that lead to respiratory depression or other life-threatening conditions should be fully reviewed by a committee charged with understanding if systemic care issues or provider-specific issues were root causes of these outcomes.

    Implementation

    A systematic approach to pain management in the EMS requires an implementation strategy, promoted and advocated by leadership, that includes the following: (1) a comprehensive evaluation of current pain and distress management practices; (2) an educational and credentialing program regarding pain assessment and management techniques for all clinical staff, preferably overseen by a hospital-wide sedation committee249; (3) development of protocols to allow the universal and efficient application of pain management strategies and medications; and (4) a quality improvement process to evaluate the ongoing success of the program.11,13 EMS agencies should establish policies and protocols that make available pertinent provider education and ensure quality improvement processes are in place for pediatric pain management protocols appropriate for their practice setting.

    Conclusions

    Management of a child’s distress during illness or after an injury is an important yet complex aspect of emergency medical care for children. Physicians and prehospital EMS providers should be aware of all the available analgesic and sedative options. Adequate pain assessment is essential for pain relief and should begin on entry into the EMS and continue through discharge of the child from the ED. 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.

    Summary of Key Points

    1. Training and education in pediatric pain assessment and management should be provided to all participants in the EMS for children; EMS medical directors should formally include pediatric pain management measures within the protocols provided to EMS providers.

    2. Incorporation of child life specialists and others trained in nonpharmacologic stress reduction can alleviate the anxiety and perceived pain related to pediatric procedures.

    3. Family presence during painful procedures can be a viable and useful practice in the acute care setting.

    4. Pain assessment for children should begin at admission to EMS, including prehospital management, and continue until discharge from the ED. When discharged, patients should receive detailed instructions regarding analgesic administration.

    5. Administration of analgesics and anesthetics should be painless or as pain free as possible.

    6. Neonates and young infants should receive adequate pain prophylaxis for procedures and pain relief as appropriate.

    7. Administration of pain medication has been demonstrated to preserve the ability to assess patients with abdominal pain and should not be withheld.

    8. Sedation or dissociative anesthesia should be provided appropriately for patients undergoing painful or stressful procedures in the ED.

    9. Pain management and sedation, including deep sedation and dissociative anesthesia, are fully within the monitoring and management capabilities of appropriately trained emergency medicine and pediatric emergency medicine physicians. Each emergency department that provides sedation and analgesia to children should include sedation competencies in recredentialing procedures and develop protocols, policies, and quality improvement programs as part of the systematic approach to pain management in the EMS.

    Lead Authors

    Joel A. Fein, MD, MPH

    William T. Zempsky, MD, MPH

    Joseph P. Cravero, MD

    Committee on Pediatric Emergency Medicine, 2011–2012

    Kathy N. Shaw, MD, MSCE, Chairperson

    Alice D. Ackerman, MD, MBA

    Thomas H. Chun, MD, MPH

    Gregory P. Conners, MD, MPH, MBA

    Nanette C. Dudley, MD

    Joel A. Fein, MD, MPH

    Susan M. Fuchs, MD

    Brian R. Moore, MD

    Steven M. Selbst, MD

    Joseph L. Wright, MD, MPH

    Former Committee Members

    Laura S. Fitzmaurice, MD

    Karen S. Frush, MD

    Patricia J. O’Malley

    Loren G. Yamamoto, MD, MPH, MBA

    Liaisons

    Isabel A. Barata, MD – American College of Emergency Physicians

    Kim Bullock, MD – American Academy of Family Physicians

    Toni K. Gross, MD, MPH – National Association of EMS Physicians

    Elizabeth Edgerton, MD, MPH – Maternal and Child Health Bureau

    Tamar Magarik Haro – AAP Department of Federal Affairs

    Jaclynn S. Haymon, MPA, RN – EMSC National Resource Center

    Cynthia Wright Johnson, MSN, RNC – National Association of State EMS Officials

    Lou E. Romig, MD – National Association of Emergency Medical Technicians

    Sally K. Snow, RN, BSN – Emergency Nurses Association

    David W. Tuggle, MD – American College of Surgeons

    Former Liaisons

    Mark Hostetler, MD – American College of Emergency Physicians

    Dan Kavanaugh, MSW – Maternal and Child Health Bureau

    Cindy Pellegrini – AAP Department of Federal Affairs

    Tina Turgel, BSN, RN-C – Maternal and Child Health Bureau

    Staff

    Sue Tellez

    Section on Anesthesiology and Pain Medicine Executive Committee, 2011–2012

    Carolyn F. Bannister, MD, Chairperson

    Joseph D. Tobias, MD, Chairperson-Elect

    Corrie T. M. Anderson, MD

    Kenneth R. Goldschneider, MD

    Jeffrey L. Koh, MD

    David M. Polaner, MD

    Constance S. Houck, MD, Immediate Past Chairperson

    Liaisons

    Mark A. Singleton, MD – American Society of Anesthesiologists

    Jeffrey L. Galinkin, MD – AAP Committee on Drugs

    Staff

    Jennifer G. Riefe

    Footnotes

    • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    • The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

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

    References

    1. ↵
      1. Augarten A,
      2. Zaslansky R,
      3. Matok Pharm I,
      4. et al
      . The impact of educational intervention programs on pain management in a pediatric emergency department. Biomed Pharmacother. 2006;60(7):299–302pmid:16842965
      OpenUrlCrossRefPubMed
    2. ↵
      1. Probst BD,
      2. Lyons E,
      3. Leonard D,
      4. Esposito TJ
      . Factors affecting emergency department assessment and management of pain in children. Pediatr Emerg Care. 2005;21(5):298–305pmid:15874811
      OpenUrlCrossRefPubMed
    3. ↵
      1. Batton DG,
      2. Barrington KJ,
      3. Wallman C,
      4. American Academy of Pediatrics, Committee on Fetus and Newborn,,
      5. Section on Surgery, Section of Anesthesiology and Pain Medicine,
      6. Canadian Paediatric Society Fetus and Newborn Committee
      . Prevention and management of pain in the neonate: an update. Pediatrics. 2006;118(5):2231–2241pmid:17079598
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. Lewis LM,
      2. Lasater LC,
      3. Brooks CB
      . Are emergency physicians too stingy with analgesics? South Med J. 1994;87(1):7–9pmid:8284721
      OpenUrlCrossRefPubMed
    5. ↵
      1. Bhargava R,
      2. Young KD
      . Procedural pain management patterns in academic pediatric emergency departments. Acad Emerg Med. 2007;14(5):479–482pmid:17363765
      OpenUrlCrossRefPubMed
    6. ↵
      1. Selbst SM,
      2. Clark M
      . Analgesic use in the emergency department. Ann Emerg Med. 1990;19(9):1010–1013pmid:2393166
      OpenUrlCrossRefPubMed
      1. Petrack EM,
      2. Christopher NC,
      3. Kriwinsky J
      . Pain management in the emergency department: patterns of analgesic utilization. Pediatrics. 1997;99(5):711–714pmid:9113948
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Alexander J,
      2. Manno M
      . Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med. 2003;41(5):617–622pmid:12712027
      OpenUrlCrossRefPubMed
    8. ↵
      1. Schechter NL,
      2. Blankson V,
      3. Pachter LM,
      4. Sullivan CM,
      5. Costa L
      . The ouchless place: no pain, children’s gain. Pediatrics. 1997;99(6):890–894pmid:9164787
      OpenUrlFREE Full Text
    9. ↵
      1. McGrath PJ,
      2. Frager G
      . Psychological barriers to optimal pain management in infants and children. Clin J Pain. 1996;12(2):135–141pmid:8776553
      OpenUrlCrossRefPubMed
    10. ↵
      1. Craig KD,
      2. Lilley CM,
      3. Gilbert CA
      . Social barriers to optimal pain management in infants and children. Clin J Pain. 1996;12(3):232–242pmid:8866164
      OpenUrlCrossRefPubMed
    11. ↵
      1. Zempsky W
      . Developing the painless emergency department: a systematic approach to change. Clin Pediatr Emerg Med. 2000;1(4):253–259
      OpenUrlCrossRef
    12. ↵
      1. Ducharme J
      . Acute pain and pain control: state of the art. Ann Emerg Med. 2000;35(6):592–603pmid:10828773
      OpenUrlPubMed
      1. Kelly A-M
      . A process approach to improving pain management in the emergency department: development and evaluation. J Accid Emerg Med. 2000;17(3):185–187pmid:10819380
      OpenUrlAbstract/FREE Full Text
    13. ↵
      1. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health,
      2. Task Force on Pain in Infants, Children, and Adolescents
      . The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793–797pmid:11533354
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Lipton JA,
      2. Marbach JJ
      . Ethnicity and the pain experience. Soc Sci Med. 1984;19(12):1279–1298pmid:6531706
      OpenUrlCrossRefPubMed
      1. Wolff B
      . Ethnocultural factors influencing pain and illness behavior. Clin J Pain. 1985;1(1):23–30
      OpenUrlCrossRef
    15. Martinelli A. Pain and ethnicity: how people of different cultures experience pain. AORN J. 1987;46(2):273–274, 276, 278
    16. ↵
      1. Bernstein B,
      2. Pachter L
      . Cultural considerations in children’s pain. In: Schechter N, Berde C, Yaster M, eds. Pain in Infants, Children, and Adolescents. Philadelphia: Lippincott, Williams and Wilkins; 2003:142–156
    17. ↵
      1. Jones M,
      2. Qazi M,
      3. Young KD
      . Ethnic differences in parent preference to be present for painful medical procedures. Pediatrics. 2005;116(2). Available at: www.pediatrics.org/cgi/content/full/116/2/e191pmid:16061573
      OpenUrlAbstract/FREE Full Text
    18. ↵
      1. Anderson KO,
      2. Green CR,
      3. Payne R
      . Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187–1204pmid:19944378
      OpenUrlCrossRefPubMed
      1. Todd KH,
      2. Samaroo N,
      3. Hoffman JR
      . Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537–1539pmid:8445817
      OpenUrlCrossRefPubMed
    19. ↵
      1. Todd KH,
      2. Deaton C,
      3. D’Adamo AP,
      4. Goe L
      . Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11–16pmid:10613935
      OpenUrlCrossRefPubMed
    20. ↵
      1. Hostetler MA,
      2. Auinger P,
      3. Szilagyi PG
      . Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997. Am J Emerg Med. 2002;20(3):139–143pmid:11992329
      OpenUrlCrossRefPubMed
    21. ↵
      1. Pletcher MJ,
      2. Kertesz SG,
      3. Kohn MA,
      4. Gonzales R
      . Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299(1):70–78pmid:18167408
      OpenUrlCrossRefPubMed
    22. ↵
      1. Young KD
      . Pediatric procedural pain. Ann Emerg Med. 2005;45(2):160–171pmid:15671974
      OpenUrlCrossRefPubMed
    23. ↵
      1. Kennedy RM,
      2. Luhmann J,
      3. Zempsky WT
      . Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008;122(suppl 3):S130–S133pmid:18978006
      OpenUrlAbstract/FREE Full Text
      1. Walco GA
      . Needle pain in children: contextual factors. Pediatrics. 2008;122(suppl 3):S125–S129pmid:18978005
      OpenUrlAbstract/FREE Full Text
      1. Taddio A,
      2. Katz J,
      3. Ilersich AL,
      4. Koren G
      . Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349(9052):599–603pmid:9057731
      OpenUrlCrossRefPubMed
      1. Taddio A,
      2. Goldbach M,
      3. Ipp M,
      4. Stevens B,
      5. Koren G
      . Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet. 1995;345(8945):291–292pmid:7837863
      OpenUrlCrossRefPubMed
      1. Grunau RE,
      2. Whitfield MF,
      3. Petrie J
      . Children’s judgements about pain at age 8-10 years: do extremely low birthweight (< or = 1000 g) children differ from full birthweight peers? J Child Psychol Psychiatry. 1998;39(4):587–594pmid:9599786
      OpenUrlCrossRefPubMed
    24. ↵
      1. Johnston CC,
      2. Stevens BJ
      . Experience in a neonatal intensive care unit affects pain response. Pediatrics. 1996;98(5):925–930pmid:8909487
      OpenUrlAbstract/FREE Full Text
    25. ↵
      1. Cline RJW,
      2. Harper FWK,
      3. Penner LA,
      4. Peterson AM,
      5. Taub JW,
      6. Albrecht TL
      . Parent communication and child pain and distress during painful pediatric cancer treatments. Soc Sci Med. 2006;63(4):883–898pmid:16647174
      OpenUrlCrossRefPubMed
    26. ↵
      1. Weisman SJ,
      2. Bernstein B,
      3. Schechter NL
      . Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998;152(2):147–149pmid:9491040
      OpenUrlCrossRefPubMed
    27. ↵
      Blount R, Zempsky W, Jaaniste T, et al. Management of pediatric pain and distress due to medical procedures. In: Roberts M, Steele R, eds. Handbook of Pediatric Psychology. 4th ed. New York, NY: Gilford Press; 2009:171–188
      1. Wintgens A,
      2. Boileau B,
      3. Robaey P
      . Posttraumatic stress symptoms and medical procedures in children. Can J Psychiatry. 1997;42(6):611–616pmid:9288423
      OpenUrlPubMed
    28. ↵
      1. Kain ZN,
      2. Mayes LC,
      3. Wang SM,
      4. Hofstadter MB
      . Postoperative behavioral outcomes in children: effects of sedative premedication. Anesthesiology. 1999;90(3):758–765pmid:10078677
      OpenUrlCrossRefPubMed
    29. ↵
      1. Twycross A
      . Education about pain: a neglected area? Nurse Educ Today. 2000;20(3):244–253pmid:10820579
      OpenUrlCrossRefPubMed
    30. ↵
      1. Joint Commission on Accreditation of Healthcare Organizations
      . Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2001
    31. ↵
      1. Ricard-Hibon A,
      2. Chollet C,
      3. Saada S,
      4. Loridant B,
      5. Marty J
      . A quality control program for acute pain management in out-of-hospital critical care medicine. Ann Emerg Med. 1999;34(6):738–744pmid:10577403
      OpenUrlCrossRefPubMed
    32. ↵
      1. Dieckmann R,
      2. Brownstein D,
      3. Gausche-Hill M
      , eds. Pediatric Education for Prehospital Professionals. Sudbury, MA: Jones and Bartlett; 2000
    33. ↵
      1. Rogovik AL,
      2. Goldman RD
      . Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries. Am J Emerg Med. 2007;25(4):400–405pmid:17499657
      OpenUrlCrossRefPubMed
      1. Jennings PA,
      2. Cameron P,
      3. Bernard S
      . Measuring acute pain in the prehospital setting. Emerg Med J. 2009;26(8):552–555pmid:19625547
      OpenUrlAbstract/FREE Full Text
    34. ↵
      1. Baskett PJF
      . Acute pain management in the field. Ann Emerg Med. 1999;34(6):784–785pmid:10577410
      OpenUrlCrossRefPubMed
    35. ↵
      1. Ward ME,
      2. Radburn J,
      3. Morant S
      . Evaluation of intravenous tramadol for use in the prehospital situation by ambulance paramedics. Prehosp Disaster Med. 1997;12(2):158–162pmid:10187002
      OpenUrlPubMed
      1. Vergnion M,
      2. Degesves S,
      3. Garcet L,
      4. Magotteaux V
      . Tramadol, an alternative to morphine for treating posttraumatic pain in the prehospital situation. Anesth Analg. 2001;92(6):1543–1546pmid:11375843
      OpenUrlCrossRefPubMed
      1. Bruns BM,
      2. Dieckmann R,
      3. Shagoury C,
      4. Dingerson A,
      5. Swartzell C
      . Safety of pre-hospital therapy with morphine sulfate. Am J Emerg Med. 1992;10(1):53–57pmid:1736917
      OpenUrlCrossRefPubMed
    36. ↵
      1. DeVellis P,
      2. Thomas SH,
      3. Wedel SK,
      4. Stein JP,
      5. Vinci RJ
      . Prehospital fentanyl analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care. 1998;14(5):321–323pmid:9814395
      OpenUrlPubMed
    37. ↵
      1. National Association of Emergency Medical Services Physicians
      . Use of nitrous oxide:oxygen mixtures in prehospital emergency care. Prehosp Disaster Med. 1990;5(3):273–274pmid:10149681
      OpenUrlPubMed
      1. Baskett PJ
      . Nitrous oxide in pre-hospital care. Acta Anaesthesiol Scand. 1994;38(8):775–776pmid:7887097
      OpenUrlPubMed
      1. Burton JH,
      2. Auble TE,
      3. Fuchs SM
      . Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children. Acad Emerg Med. 1998;5(2):112–117pmid:9492130
      OpenUrlPubMed
    38. ↵
      1. Luhmann JD,
      2. Kennedy RM,
      3. Jaffe DM,
      4. McAllister JD
      . Continuous-flow delivery of nitrous oxide and oxygen: a safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients. Pediatr Emerg Care. 1999;15(6):388–392pmid:10608322
      OpenUrlPubMed
    39. ↵
      1. Luhmann JD,
      2. Kennedy RM,
      3. Porter FL,
      4. Miller JP,
      5. Jaffe DM
      . A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair. Ann Emerg Med. 2001;37(1):20–27pmid:11145766
      OpenUrlCrossRefPubMed
    40. ↵
      1. Koppal R,
      2. Ardash E,
      3. Uday A,
      4. Anilkumar G
      . Comparison of the midazolam transnasal atomizer and oral midazolam for sedative premedication in paediatric cases. J Clin Diagn Res. 2011;5(5):932–934
      OpenUrl
    41. ↵
      1. Sinha M,
      2. Christopher NC,
      3. Fenn R,
      4. Reeves L
      . Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics. 2006;117(4):1162–1168pmid:16585311
      OpenUrlAbstract/FREE Full Text
    42. ↵
      1. Kolk AM,
      2. van Hoof R,
      3. Fiedeldij Dop MJ
      . Preparing children for venipuncture. The effect of an integrated intervention on distress before and during venipuncture. Child Care Health Dev. 2000;26(3):251–260pmid:10921442
      OpenUrlCrossRefPubMed
      1. Lewis Claar R,
      2. Walker LS,
      3. Barnard JA
      . Children’s knowledge, anticipatory anxiety, procedural distress, and recall of esophagogastroduodenoscopy. J Pediatr Gastroenterol Nutr. 2002;34(1):68–72pmid:11753168
      OpenUrlCrossRefPubMed
    43. ↵
      1. Kain ZN,
      2. Caldwell-Andrews AA
      . Preoperative psychological preparation of the child for surgery: an update. Anesthesiol Clin North America. 2005;23(4):597–614, viipmid:16310653
      OpenUrlCrossRefPubMed
    44. ↵
      1. Katz ER,
      2. Kellerman J,
      3. Ellenberg L
      . Hypnosis in the reduction of acute pain and distress in children with cancer. J Pediatr Psychol. 1987;12(3):379–394pmid:3479547
      OpenUrlAbstract/FREE Full Text
      1. Rogovik AL,
      2. Goldman RD
      . Hypnosis for treatment of pain in children. Can Fam Physician. 2007;53(5):823–825pmid:17872743
      OpenUrlAbstract/FREE Full Text
    45. ↵
      Butler LD, Symons BK, Henderson SL, Shortliffe LD, Spiegel D. Hypnosis reduces distress and duration of an invasive medical procedure for children. Pediatrics. 2005;115(1). Available at: www.pediatrics.org/cgi/content/full/115/1/e77
    46. ↵
      1. Klassen JA,
      2. Liang Y,
      3. Tjosvold L,
      4. Klassen TP,
      5. Hartling L
      . Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials. Ambul Pediatr. 2008;8(2):117–128pmid:18355741
      OpenUrlCrossRefPubMed
      1. French GM,
      2. Painter EC,
      3. Coury DL
      . Blowing away shot pain: a technique for pain management during immunization. Pediatrics. 1994;93(3):384–388pmid:8115196
      OpenUrlAbstract/FREE Full Text
      1. Fowler-Kerry S,
      2. Lander JR
      . Management of injection pain in children. Pain. 1987;30(2):169–175pmid:3670868
      OpenUrlCrossRefPubMed
      1. Megel ME,
      2. Houser CW,
      3. Gleaves LS
      . Children’s responses to immunizations: lullabies as a distraction. Issues Compr Pediatr Nurs. 1998;21(3):129–145pmid:10531890
      OpenUrlCrossRefPubMed
      1. Fratianne RB,
      2. Prensner JD,
      3. Huston MJ,
      4. Super DM,
      5. Yowler CJ,
      6. Standley JM
      . The effect of music-based imagery and musical alternate engagement on the burn debridement process. J Burn Care Rehabil. 2001;22(1):47–53pmid:11227684
      OpenUrlCrossRefPubMed
    47. ↵
      1. Favara-Scacco C,
      2. Smirne G,
      3. Schilirò G,
      4. Di Cataldo A
      . Art therapy as support for children with leukemia during painful procedures. Med Pediatr Oncol. 2001;36(4):474–480pmid:11260571
      OpenUrlCrossRefPubMed
    48. ↵
      1. Krebel MS,
      2. Clayton C,
      3. Graham C
      . Child life programs in the pediatric emergency department. Pediatr Emerg Care. 1996;12(1):13–15pmid:8677171
      OpenUrlPubMed
      1. Alcock DS,
      2. Feldman W,
      3. Goodman JT,
      4. McGrath PJ,
      5. Park JM
      . Evaluation of child life intervention in emergency department suturing. Pediatr Emerg Care. 1985;1(3):111–115pmid:3842878
      OpenUrlPubMed
    49. ↵
      1. American Academy of Pediatrics, Committee on Hospital Care
      . Child life services. Pediatrics. 2000;106(5):1156–1159pmid:11061794
      OpenUrlAbstract/FREE Full Text
    50. ↵
      1. Rothenberg MB
      . The unique role of the child life worker in children’s health care settings. Child Health Care. 1982;10(4):121–124pmid:10262134
      OpenUrlCrossRefPubMed
    51. ↵
      1. Rae WA,
      2. Worchel FF,
      3. Upchurch J,
      4. Sanner JH,
      5. Daniel CA
      . The psychosocial impact of play on hospitalized children. J Pediatr Psychol. 1989;14(4):617–627pmid:2607397
      OpenUrlAbstract/FREE Full Text
    52. ↵
      1. Bauchner H,
      2. Waring C,
      3. Vinci R
      . Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics. 1991;87(4):544–548pmid:2011433
      OpenUrlAbstract/FREE Full Text
    53. ↵
      1. Wolfram RW,
      2. Turner ED,
      3. Philput C
      . Effects of parental presence during young children’s venipuncture. Pediatr Emerg Care. 1997;13(5):325–328pmid:9368244
      OpenUrlCrossRefPubMed
      1. Boudreaux ED,
      2. Francis JL,
      3. Loyacano T
      . Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research. Ann Emerg Med. 2002;40(2):193–205pmid:12140499
      OpenUrlCrossRefPubMed
    54. ↵
      1. Emergency Nurses Association
      . Emergency Nurses Association Position Statement: Family Presence at the Bedside During Invasive Procedures and Resuscitation in the Emergency Department. Des Plaines, IL: Emergency Nurses Association; 2010
    55. ↵
      1. Smith RW,
      2. Shah V,
      3. Goldman RD,
      4. Taddio A
      . Caregivers’ responses to pain in their children in the emergency department. Arch Pediatr Adolesc Med. 2007;161(6):578–582pmid:17548763
      OpenUrlCrossRefPubMed
    56. ↵
      1. Cohen LL
      . Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics. 2008;122(suppl 3):S134–S139pmid:18978007
      OpenUrlAbstract/FREE Full Text
      1. Crenshaw DA
      . An interpersonal neurobiological-informed treatment model for childhood traumatic grief. Omega (Westport). 2006-2007;54(4):319–335pmid:18186426
      OpenUrlPubMed
      1. Kleiber C,
      2. Craft-Rosenberg M,
      3. Harper DC
      . Parents as distraction coaches during i.v. insertion: a randomized study. J Pain Symptom Manage. 2001;22(4):851–861pmid:11576802
      OpenUrlCrossRefPubMed
      1. Dingeman RS,
      2. Mitchell EA,
      3. Meyer EC,
      4. Curley MAQ
      . Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature. Pediatrics. 2007;120(4):842–854pmid:17908772
      OpenUrlAbstract/FREE Full Text
    57. ↵
      1. Moreland P
      . Family presence during invasive procedures and resuscitation in the emergency department: a review of the literature. J Emerg Nurs. 2005;31(1):58–72, quiz 119pmid:15682130
      OpenUrlCrossRefPubMed
    58. ↵
      1. Bailey B,
      2. Bergeron S,
      3. Gravel J,
      4. Daoust R
      . Comparison of four pain scales in children with acute abdominal pain in a pediatric emergency department. Ann Emerg Med. 2007;50(4):379–383, 383.e1–383.e2pmid:17588706
      OpenUrlCrossRefPubMed
    59. ↵
      1. von Baeyer CL,
      2. Spagrud LJ,
      3. McCormick JC,
      4. Choo E,
      5. Neville K,
      6. Connelly MA
      . Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children’s self-reports of pain intensity. Pain. 2009;143(3):223–227pmid:19359097
      OpenUrlCrossRefPubMed
    60. ↵
      1. Cohen LL,
      2. Lemanek K,
      3. Blount RL,
      4. et al
      . Evidence-based assessment of pediatric pain. J Pediatr Psychol. 2008;33(9):939–955, discussion 956–957pmid:18024983
      OpenUrlAbstract/FREE Full Text
    61. ↵
      Jacob E. Pain assessment and management in children. In: Wong D, Hockenberry MJ, Wilson D, eds. Wong’s Nursing Care of Infants and Children. 9th ed. St. Louis, MO: Mosby; 2011:179–202.
      1. Beyer JE,
      2. Aradine CR
      . Content validity of an instrument to measure young children’s perceptions of the intensity of their pain. J Pediatr Nurs. 1986;1(6):386–395pmid:3641907
      OpenUrlPubMed
    62. ↵
      1. Scott J,
      2. Huskisson EC
      . Graphic representation of pain. Pain. 1976;2(2):175–184pmid:1026900
      OpenUrlCrossRefPubMed
      1. Hicks CL,
      2. von Baeyer CL,
      3. Spafford PA,
      4. van Korlaar I,
      5. Goodenough B
      . The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93(2):173–183pmid:11427329
      OpenUrlCrossRefPubMed
      1. Belville RG,
      2. Seupaul RA
      . Pain measurement in pediatric emergency care: a review of the faces pain scale-revised. Pediatr Emerg Care. 2005;21(2):90–93pmid:15699816
      OpenUrlCrossRefPubMed
      1. Stinson JN,
      2. Kavanagh T,
      3. Yamada J,
      4. Gill N,
      5. Stevens B
      . Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006;125(1-2):143–157pmid:16777328
      OpenUrlCrossRefPubMed
    63. ↵
      1. McGrath PJ,
      2. Walco GA,
      3. Turk DC,
      4. et al.,
      5. PedIMMPACT
      . Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain. 2008;9(9):771–783pmid:18562251
      OpenUrlCrossRefPubMed
    64. ↵
      1. Bulloch B,
      2. Tenenbein M
      . Validation of 2 pain scales for use in the pediatric emergency department. Pediatrics. 2002;110(3):e33pmid:12205283
      OpenUrlAbstract/FREE Full Text
    65. ↵
      1. McGrath P,
      2. Johnson G,
      3. Goodman J,
      4. Schillinger J,
      5. Dunn J,
      6. Chapman J
      . CHEOPS: a behavioral scale for rating postoperative pain in children. Adv Pain Res Ther. 1985;9:395–402
      OpenUrl
      1. Grunau RVE,
      2. Craig KD
      . Pain expression in neonates: facial action and cry. Pain. 1987;28(3):395–410pmid:3574966
      OpenUrlCrossRefPubMed
    66. ↵
      1. McGrath P
      . Behavioral measures of pain. In: Finley G, McGrath P, eds. Measurement of Pain in Infants and Children. Seattle, WA: IASP Press; 1998:83–102
    67. ↵
      1. Lawrence J,
      2. Alcock D,
      3. McGrath P,
      4. Kay J,
      5. MacMurray SB,
      6. Dulberg C
      . The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66pmid:8413140
      OpenUrlPubMed
    68. ↵
      1. Merkel SI,
      2. Voepel-Lewis T,
      3. Shayevitz JR,
      4. Malviya S
      . The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293–297pmid:9220806
      OpenUrlPubMed
      1. Malviya S,
      2. Voepel-Lewis T,
      3. Tait AR,
      4. Merkel S,
      5. Tremper K,
      6. Naughton N
      . Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). Br J Anaesth. 2002;88(2):241–245pmid:11878656
      OpenUrlAbstract/FREE Full Text
      1. Merkel S,
      2. Voepel-Lewis T,
      3. Malviya S
      . Pain assessment in infants and young children: the FLACC scale. Am J Nurs. 2002;102(10):55–58pmid:12394307
      OpenUrlPubMed
      1. Munro HM,
      2. Walton SR,
      3. Malviya S,
      4. et al
      . Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents. Can J Anaesth. 2002;49(5):461–466pmid:11983659
      OpenUrlCrossRefPubMed
      1. Riegger LQ,
      2. Voepel-Lewis T,
      3. Kulik TJ,
      4. et al
      . Albumin versus crystalloid prime solution for cardiopulmonary bypass in young children. Crit Care Med. 2002;30(12):2649–2654pmid:12483054
      OpenUrlCrossRefPubMed
      1. Tait AR,
      2. Voepel-Lewis T,
      3. Robinson A,
      4. Malviya S
      . Priorities for disclosure of the elements of informed consent for research: a comparison between parents and investigators. Paediatr Anaesth. 2002;12(4):332–336pmid:11982841
      OpenUrlCrossRefPubMed
    69. ↵
      1. Voepel-Lewis T,
      2. Merkel S,
      3. Tait AR,
      4. Trzcinka A,
      5. Malviya S
      . The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002;95(5):1224–1229pmid:12401598
      OpenUrlCrossRefPubMed
    70. ↵
      1. Drendel AL,
      2. Brousseau DC,
      3. Gorelick MH
      . Pain assessment for pediatric patients in the emergency department. Pediatrics. 2006;117(5):1511–1518pmid:16651304
      OpenUrlAbstract/FREE Full Text
    71. ↵
      1. Sacchetti A,
      2. Baren J,
      3. Carraccio C
      . Total procedural requirements as indication for emergency department sedation. Pediatr Emerg Care. 2010;26(3):209–211pmid:20216283
      OpenUrlCrossRefPubMed
    72. ↵
      1. Michaelewski T,
      2. Zempsky W,
      3. Schechter N
      . Pain in low-severity emergency department visits: frequency and management [abstract]. Ann Emerg Med. 2001;38:S21
      OpenUrl
    73. ↵
      1. Fein JA,
      2. Callahan JM,
      3. Boardman CR
      . Intravenous catheterization in the ED: is there a role for topical anesthesia? Am J Emerg Med. 1999;17(6):624–625pmid:10530554
      OpenUrlCrossRefPubMed
    74. ↵
      1. Fein JA,
      2. Callahan JM,
      3. Boardman CR,
      4. Gorelick MH
      . Predicting the need for topical anesthetic in the pediatric emergency department. Pediatrics. 1999;104(2):e19pmid:10429137
      OpenUrlAbstract/FREE Full Text
    75. ↵
      1. Kleiber C,
      2. Sorenson M,
      3. Whiteside K,
      4. Gronstal BA,
      5. Tannous R
      . Topical anesthetics for intravenous insertion in children: a randomized equivalency study. Pediatrics. 2002;110(4):758–761pmid:12359791
      OpenUrlAbstract/FREE Full Text
    76. ↵
      1. Eichenfield LF,
      2. Funk A,
      3. Fallon-Friedlander S,
      4. Cunningham BB
      . A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics. 2002;109(6):1093–1099pmid:12042548
      OpenUrlAbstract/FREE Full Text
    77. ↵
      1. Curry SE,
      2. Finkel JC
      . Use of the Synera patch for local anesthesia before vascular access procedures: a randomized, double-blind, placebo-controlled study. Pain Med. 2007;8(6):497–502pmid:17716323
      OpenUrlCrossRefPubMed
    78. ↵
      1. Baxter AL,
      2. Fisher RG,
      3. Burke BL,
      4. Goldblatt SS,
      5. Isaacman DJ,
      6. Lawson ML
      . Local anesthetic and stylet styles: factors associated with resident lumbar puncture success. Pediatrics. 2006;117(3):876–881pmid:16510670
      OpenUrlAbstract/FREE Full Text
    79. ↵
      1. Taddio A,
      2. Soin HK,
      3. Schuh S,
      4. Koren G,
      5. Scolnik D
      . Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial. CMAJ. 2005;172(13):1691–1695pmid:15967972
      OpenUrlAbstract/FREE Full Text
    80. ↵
      1. Klein EJ,
      2. Shugerman RP,
      3. Leigh-Taylor K,
      4. Schneider C,
      5. Portscheller D,
      6. Koepsell T
      . Buffered lidocaine: analgesia for intravenous line placement in children. Pediatrics. 1995;95(5):709–712pmid:7724308
      OpenUrlAbstract/FREE Full Text
      1. Sacchetti AD,
      2. Carraccio C
      . Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age. Acad Emerg Med. 1996;3(11):1016–1019pmid:8922007
      OpenUrlPubMed
      1. Fein JA,
      2. Boardman CR,
      3. Stevenson S,
      4. Selbst SM
      . Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children. Pediatr Emerg Care. 1998;14(2):119–122pmid:9583393
      OpenUrlPubMed
      1. Luhmann J,
      2. Hurt S,
      3. Shootman M,
      4. Kennedy R
      . A comparison of buffered lidocaine versus ELA-Max before peripheral intravenous catheter insertions in children. Pediatrics. 2004;113(3 pt 1). Available at: www.pediatrics.org/cgi/content/full/113/3/e217pmid:14993579
      OpenUrlPubMed
    81. ↵
      1. Brown D
      . Local anesthesia for vein cannulation: a comparison of two solutions. J Infus Nurs. 2004;27(2):85–88pmid:15085035
      OpenUrlCrossRefPubMed
    82. ↵
      1. Zempsky WT,
      2. Robbins B,
      3. Richards PT,
      4. Leong MS,
      5. Schechter NL
      . A novel needle-free powder lidocaine delivery system for rapid local analgesia. J Pediatr. 2008;152(3):405–411pmid:18280850
      OpenUrlCrossRefPubMed
      1. Zempsky WT,
      2. Bean-Lijewski J,
      3. Kauffman RE,
      4. et al
      . Needle-free powder lidocaine delivery system provides rapid effective analgesia for venipuncture or cannulation pain in children: randomized, double-blind Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial. Pediatrics. 2008;121(5):979–987pmid:18450903
      OpenUrlAbstract/FREE Full Text
      1. Lysakowski C,
      2. Dumont L,
      3. Tramèr MR,
      4. Tassonyi E
      . A needle-free jet-injection system with lidocaine for peripheral intravenous cannula insertion: a randomized controlled trial with cost-effectiveness analysis. Anesth Analg. 2003;96(1):215–219pmid:12505955
      OpenUrlCrossRefPubMed
    83. ↵
      1. Jimenez N,
      2. Bradford H,
      3. Seidel KD,
      4. Sousa M,
      5. Lynn AM
      . A comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient. Anesth Analg. 2006;102(2):411–414pmid:16428534
      OpenUrlCrossRefPubMed
    84. ↵
      1. Cohen Reis E,
      2. Holubkov R
      . Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children. Pediatrics. 1997;100(6):E5pmid:9374583
      OpenUrlCrossRefPubMed
    85. ↵
      Ramsook C, Kozinetz C, Moro-Sutherland D. The efficacy of ethyl chloride as a local anesthetic for venipuncture in an emergency room setting. Paper presented at: 39th Annual Meeting of the Ambulatory Pediatric Association; May 3, 1999; San Francisco, CA
    86. ↵
      1. Schilling CG,
      2. Bank DE,
      3. Borchert BA,
      4. Klatzko MD,
      5. Uden DL
      . Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Ann Emerg Med. 1995;25(2):203–208pmid:7832348
      OpenUrlCrossRefPubMed
    87. ↵
      1. Ernst AA,
      2. Marvez E,
      3. Nick TG,
      4. Chin E,
      5. Wood E,
      6. Gonzaba WT
      . Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics. 1995;95(2):255–258pmid:7838644
      OpenUrlAbstract/FREE Full Text
    88. ↵
      1. Zempsky WT,
      2. Karasic RB
      . EMLA versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med. 1997;30(2):163–166pmid:9250639
      OpenUrlCrossRefPubMed
    89. ↵
      1. Singer AJ,
      2. Stark MJ
      . LET versus EMLA for pretreating lacerations: a randomized trial. Acad Emerg Med. 2001;8(3):223–230pmid:11229943
      OpenUrlCrossRefPubMed
    90. ↵
      1. Simon HK,
      2. McLario DJ,
      3. Bruns TB,
      4. Zempsky WT,
      5. Wood RJ,
      6. Sullivan KM
      . Long-term appearance of lacerations repaired using a tissue adhesive. Pediatrics. 1997;99(2):193–195pmid:9024445
      OpenUrlAbstract/FREE Full Text
    91. ↵
      1. Quinn J,
      2. Wells G,
      3. Sutcliffe T,
      4. et al
      . A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA. 1997;277(19):1527–1530pmid:9153366
      OpenUrlCrossRefPubMed
    92. ↵
      1. Zempsky WT,
      2. Parrotti D,
      3. Grem C,
      4. Nichols J
      . Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care. 2004;20(8):519–524pmid:15295247
      OpenUrlCrossRefPubMed
    93. ↵
      1. Holger JS,
      2. Wandersee SC,
      3. Hale DB
      . Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med. 2004;22(4):254–257pmid:15258862
      OpenUrlCrossRefPubMed
    94. ↵
      1. Karounis H,
      2. Gouin S,
      3. Eisman H,
      4. Chalut D,
      5. Pelletier H,
      6. Williams B
      . A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004;11(7):730–735pmid:15231459
      OpenUrlCrossRefPubMed
    95. ↵
      1. Bartfield JM,
      2. Gennis P,
      3. Barbera J,
      4. Breuer B,
      5. Gallagher EJ
      . Buffered versus plain lidocaine as a local anesthetic for simple laceration repair. Ann Emerg Med. 1990;19(12):1387–1389pmid:2240750
      OpenUrlCrossRefPubMed
      1. Davidson JA,
      2. Boom SJ
      . Warming lignocaine to reduce pain associated with injection. BMJ. 1992;305(6854):617–618pmid:1393074
      OpenUrlAbstract/FREE Full Text
      1. Krause RS,
      2. Moscati R,
      3. Filice M,
      4. Lerner EB,
      5. Hughes D
      . The effect of injection speed on the pain of lidocaine infiltration. Acad Emerg Med. 1997;4(11):1032–1035pmid:9383487
      OpenUrlPubMed
      1. Scarfone RJ,
      2. Jasani M,
      3. Gracely EJ
      . Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med. 1998;31(1):36–40pmid:9437339
      OpenUrlCrossRefPubMed
    96. ↵
      1. Bartfield JM,
      2. Sokaris SJ,
      3. Raccio-Robak N
      . Local anesthesia for lacerations: pain of infiltration inside vs outside the wound. Acad Emerg Med. 1998;5(2):100–104pmid:9492127
      OpenUrlPubMed
    97. ↵
      1. Bartfield JM,
      2. Homer PJ,
      3. Ford DT,
      4. Sternklar P
      . Buffered lidocaine as a local anesthetic: an investigation of shelf life. Ann Emerg Med. 1992;21(1):16–19pmid:1539881
      OpenUrlCrossRefPubMed
    98. ↵
      1. Meyer G,
      2. Henneman PL,
      3. Fu P
      . Buffered lidocaine. Ann Emerg Med. 1991;20(2):218–219pmid:1996811
      OpenUrlPubMed
    99. ↵
      1. Cook IF,
      2. Murtagh J
      . Needle length required for intramuscular vaccination of infants and toddlers. An ultrasonographic study. Aust Fam Physician. 2002;31(3):295–297pmid:11926163
      OpenUrlPubMed
      1. Groswasser J,
      2. Kahn A,
      3. Bouche B,
      4. Hanquinet S,
      5. Perlmuter N,
      6. Hessel L
      . Needle length and injection technique for efficient intramuscular vaccine delivery in infants and children evaluated through an ultrasonographic determination of subcutaneous and muscle layer thickness. Pediatrics. 1997;100(3 pt 1):400–403pmid:9282716
      OpenUrlFREE Full Text
      1. Barnhill BJ,
      2. Holbert MD,
      3. Jackson NM,
      4. Erickson RS
      . Using pressure to decrease the pain of intramuscular injections. J Pain Symptom Manage. 1996;12(1):52–58pmid:8718917
      OpenUrlCrossRefPubMed
    100. ↵
      1. Chung JW,
      2. Ng WM,
      3. Wong TK
      . An experimental study on the use of manual pressure to reduce pain in intramuscular injections. J Clin Nurs. 2002;11(4):457–461pmid:12100641
      OpenUrlCrossRefPubMed
    101. ↵
      1. Taddio A,
      2. Ohlsson A,
      3. Einarson TR,
      4. Stevens B,
      5. Koren G
      . A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics. 1998;101(2). Available at: www.pediatrics.org/cgi/content/full/101/2/e1pmid:9445511
      OpenUrlAbstract/FREE Full Text
      1. Essink-Tebbes CM,
      2. Wuis EW,
      3. Liem KD,
      4. van Dongen RT,
      5. Hekster YA
      . Safety of lidocaine-prilocaine cream application four times a day in premature neonates: a pilot study. Eur J Pediatr. 1999;158(5):421–423pmid:10333129
      OpenUrlCrossRefPubMed
    102. ↵
      1. Brisman M,
      2. Ljung BM,
      3. Otterbom I,
      4. Larsson LE,
      5. Andréasson SE
      . Methaemoglobin formation after the use of EMLA cream in term neonates. Acta Paediatr. 1998;87(11):1191–1194pmid:9846923
      OpenUrlCrossRefPubMed
    103. ↵
      1. Taddio A,
      2. Shah V,
      3. Katz J
      . Reduced infant response to a routine care procedure after sucrose analgesia. Pediatrics. 2009;123(3). Available at: www.pediatrics.org/cgi/content/full/123/3/e425pmid:19254979
      OpenUrlAbstract/FREE Full Text
      1. Hatfield LA,
      2. Gusic ME,
      3. Dyer A-M,
      4. Polomano RC
      . Analgesic properties of oral sucrose during routine immunizations at 2 and 4 months of age. Pediatrics. 2008;121(2). Available at: www.pediatrics.org/cgi/content/full/121/2/e327pmid:18245406
      OpenUrlAbstract/FREE Full Text
      1. Blass E,
      2. Fitzgerald E,
      3. Kehoe P
      . Interactions between sucrose, pain and isolation distress. Pharmacol Biochem Behav. 1987;26(3):483–489pmid:3575365
      OpenUrlCrossRefPubMed
      1. Barr RG,
      2. Young SN,
      3. Wright JH,
      4. et al
      . “Sucrose analgesia” and diphtheria-tetanus-pertussis immunizations at 2 and 4 months. J Dev Behav Pediatr. 1995;16(4):220–225pmid:7593655
      OpenUrlPubMed
      1. Lewindon PJ,
      2. Harkness L,
      3. Lewindon N
      . Randomised controlled trial of sucrose by mouth for the relief of infant crying after immunisation. Arch Dis Child. 1998;78(5):453–456pmid:9659093
      OpenUrlAbstract/FREE Full Text
      1. Stevens B,
      2. Taddio A,
      3. Ohlsson A,
      4. Einarson T
      . The efficacy of sucrose for relieving procedural pain in neonates—a systematic review and meta-analysis. Acta Paediatr. 1997;86(8):837–842pmid:9307163
      OpenUrlPubMed
      1. Harrison D,
      2. Bueno M,
      3. Yamada J,
      4. Adams-Webber T,
      5. Stevens B
      . Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics. 2010;126(5):894–902pmid:20937658
      OpenUrlAbstract/FREE Full Text
      1. Harrison D,
      2. Stevens B,
      3. Bueno M,
      4. et al
      . Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child. 2010;95(6):406–413pmid:20463370
      OpenUrlAbstract/FREE Full Text
    104. Harrison D, Yamada J, Stevens B. Strategies for the prevention and management of neonatal and infant pain. Curr Pain Headache Rep. 2010;14(2):113–123
    105. Stevens B, Johnston C, Taddio A, Gibbins S, Yamada J. The premature infant pain profile: evaluation 13 years after development. Clin J Pain. 2010;26(9):813–830
      1. Stevens B,
      2. McGrath P,
      3. Ballantyne M,
      4. et al
      . Influence of risk of neurological impairment and procedure invasiveness on health professionals’ management of procedural pain in neonates. Eur J Pain. 2010;14(7):735–741pmid:20047845
      OpenUrlCrossRefPubMed
      1. Stevens B,
      2. Yamada J,
      3. Ohlsson A
      . Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2010;(1):CD001069pmid:20091512
      OpenUrlPubMed
    106. ↵
      1. Yamada J,
      2. Stevens B,
      3. Sidani S,
      4. Watt-Watson J,
      5. de Silva N
      . Content validity of a process evaluation checklist to measure intervention implementation fidelity of the EPIC intervention. Worldviews Evid Based Nurs. 2010;7(3):158–164pmid:20180940
      OpenUrlCrossRefPubMed
    107. ↵
      1. Carbajal R,
      2. Chauvet X,
      3. Couderc S,
      4. Olivier-Martin M
      . Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates. BMJ. 1999;319(7222):1393–1397pmid:10574854
      OpenUrlAbstract/FREE Full Text
    108. ↵
      1. Gray L,
      2. Miller LW,
      3. Philipp BL,
      4. Blass EM
      . Breastfeeding is analgesic in healthy newborns. Pediatrics. 2002;109(4):590–593pmid:11927701
      OpenUrlAbstract/FREE Full Text
    109. ↵
      1. Gray L,
      2. Watt L,
      3. Blass EM
      . Skin-to-skin contact is analgesic in healthy newborns. Pediatrics. 2000;105(1). Available at: www.pediatrics.org/cgi/content/full/e14pmid:10617751
      OpenUrlAbstract/FREE Full Text
    110. ↵
      1. Pinheiro JM,
      2. Furdon S,
      3. Ochoa LF
      . Role of local anesthesia during lumbar puncture in neonates. Pediatrics. 1993;91(2):379–382pmid:8424014
      OpenUrlAbstract/FREE Full Text
    111. ↵
      1. Kaur G,
      2. Gupta P,
      3. Kumar A
      . A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med. 2003;157(11):1065–1070pmid:14609894
      OpenUrlCrossRefPubMed
    112. ↵
      1. Carraccio C,
      2. Feinberg P,
      3. Hart LS,
      4. Quinn M,
      5. King J,
      6. Lichenstein R
      . Lidocaine for lumbar punctures. A help not a hindrance. Arch Pediatr Adolesc Med. 1996;150(10):1044–1046pmid:8859136
      OpenUrlCrossRefPubMed
    113. ↵
      1. Larsson BA,
      2. Tannfeldt G,
      3. Lagercrantz H,
      4. Olsson GL
      . Venipuncture is more effective and less painful than heel lancing for blood tests in neonates. Pediatrics. 1998;101(5):882–886pmid:9565419
      OpenUrlAbstract/FREE Full Text
    114. ↵
      1. Uhari M
      . A eutectic mixture of lidocaine and prilocaine for alleviating vaccination pain in infants. Pediatrics. 1993;92(5):719–721pmid:8414863
      OpenUrlAbstract/FREE Full Text
    115. ↵
      1. Ipp MM,
      2. Gold R,
      3. Goldbach M,
      4. et al
      . Adverse reactions to diphtheria, tetanus, pertussis-polio vaccination at 18 months of age: effect of injection site and needle length. Pediatrics. 1989;83(5):679–682pmid:2717284
      OpenUrlAbstract/FREE Full Text
      1. Holmes HS
      . Options for painless local anesthesia. Postgrad Med. 1991;89(3):71–72pmid:1994360
      OpenUrlPubMed
      1. Keen MF
      . Comparison of intramuscular injection techniques to reduce site discomfort and lesions. Nurs Res. 1986;35(4):207–210pmid:3636818
      OpenUrlPubMed
    116. ↵
      1. Main KM,
      2. Jørgensen JT,
      3. Hertel NT,
      4. Jensen S,
      5. Jakobsen L
      . Automatic needle insertion diminishes pain during growth hormone injection. Acta Paediatr. 1995;84(3):331–334pmid:7780258
      OpenUrlPubMed
    117. ↵
      1. Schichor A,
      2. Bernstein B,
      3. Weinerman H,
      4. Fitzgerald J,
      5. Yordan E,
      6. Schechter N
      . Lidocaine as a diluent for ceftriaxone in the treatment of gonorrhea. Does it reduce the pain of the injection? Arch Pediatr Adolesc Med. 1994;148(1):72–75pmid:8143016
      OpenUrlCrossRefPubMed
    118. ↵
      1. LoVecchio F,
      2. Oster N,
      3. Sturmann K,
      4. Nelson LS,
      5. Flashner S,
      6. Finger R
      . The use of analgesics in patients with acute abdominal pain. J Emerg Med. 1997;15(6):775–779pmid:9404792
      OpenUrlCrossRefPubMed
      1. Pace S,
      2. Burke TF
      . Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996;3(12):1086–1092pmid:8959160
      OpenUrlPubMed
      1. Attard AR,
      2. Corlett MJ,
      3. Kidner NJ,
      4. Leslie AP,
      5. Fraser IA
      . Safety of early pain relief for acute abdominal pain. BMJ. 1992;305(6853):554–556pmid:1393034
      OpenUrlAbstract/FREE Full Text
      1. Green R,
      2. Bulloch B,
      3. Kabani A,
      4. Hancock BJ,
      5. Tenenbein M
      . Early analgesia for children with acute abdominal pain. Pediatrics. 2005;116(4):978–983pmid:16199711
      OpenUrlAbstract/FREE Full Text
    119. ↵
      1. Kim MK,
      2. Strait RT,
      3. Sato TT,
      4. Hennes HM
      . A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med. 2002;9(4):281–287pmid:11927450
      OpenUrlCrossRefPubMed
    120. ↵
      1. Bailey B,
      2. Bergeron S,
      3. Gravel J,
      4. Bussières J-F,
      5. Bensoussan A
      . Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial. Ann Emerg Med. 2007;50(4):371–378pmid:17597256
      OpenUrlCrossRefPubMed
    121. ↵
      1. Hedderich R,
      2. Ness TJ
      . Analgesia for trauma and burns. Crit Care Clin. 1999;15(1):167–184pmid:9929793
      OpenUrlCrossRefPubMed
    122. ↵
      1. Joseph MH,
      2. Brill J,
      3. Zeltzer LK
      . Pediatric pain relief in trauma. Pediatr Rev. 1999;20(3):75–83, quiz 84pmid:10073069
      OpenUrlFREE Full Text
    123. ↵
      1. Zohar ZRN,
      2. Eitan AMD,
      3. Halperin PMD,
      4. et al
      . Pain relief in major trauma patients: an Israeli perspective. J Trauma. 2001;51(4):767–772pmid:11586173
      OpenUrlPubMed
    124. ↵
      1. Fletcher AK,
      2. Rigby AS,
      3. Heyes FLP
      . Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003;41(2):227–233pmid:12548273
      OpenUrlCrossRefPubMed
    125. ↵
      1. Blasier RD,
      2. White R
      . Intravenous regional anesthesia for management of children’s extremity fractures in the emergency department. Pediatr Emerg Care. 1996;12(6):404–406pmid:8989785
      OpenUrlCrossRefPubMed
    126. ↵
      1. Wolfe TR,
      2. Braude DA
      . Intranasal medication delivery for children: a brief review and update. Pediatrics. 2010;126(3):532–537pmid:20696726
      OpenUrlAbstract/FREE Full Text
    127. ↵
      1. Borland M,
      2. Jacobs I,
      3. King B,
      4. O’Brien D
      . A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007;49(3):335–340pmid:17067720
      OpenUrlCrossRefPubMed
      1. Miner JR,
      2. Kletti C,
      3. Herold M,
      4. Hubbard D,
      5. Biros MH
      . Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med. 2007;14(10):895–898pmid:17898251
      OpenUrlCrossRefPubMed
    128. ↵
      1. Furyk JS,
      2. Grabowski WJ,
      3. Black LH
      . Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas. 2009;21(3):203–209pmid:19527280
      OpenUrlCrossRefPubMed
    129. ↵
      1. Theroux MC,
      2. West DW,
      3. Corddry DH,
      4. et al
      . Efficacy of intranasal midazolam in facilitating suturing of lacerations in preschool children in the emergency department. Pediatrics. 1993;91(3):624–627pmid:8441570
      OpenUrlAbstract/FREE Full Text
    130. ↵
      1. Kogan A,
      2. Katz J,
      3. Efrat R,
      4. Eidelman LA
      . Premedication with midazolam in young children: a comparison of four routes of administration. Paediatr Anaesth. 2002;12(8):685–689pmid:12472704
      OpenUrlCrossRefPubMed
    131. ↵
      1. Henry RJ,
      2. Ruano N,
      3. Casto D,
      4. Wolf RH
      . A pharmacokinetic study of midazolam in dogs: nasal drop vs. atomizer administration. Pediatr Dent. 1998;20(5):321–326pmid:9803431
      OpenUrlPubMed
      1. Klein EJ,
      2. Brown JC,
      3. Kobayashi A,
      4. Osincup D,
      5. Seidel K
      . A randomized clinical trial comparing oral, aerosolized intranasal, and aerosolized buccal midazolam. Ann Emerg Med. 2011;58(4):323–329pmid:21689865
      OpenUrlCrossRefPubMed
    132. ↵
      Primosch R, Bender F. Factors associated with administration route when using midazolam for pediatric conscious sedation. ASDC J Dent Child. 2001;68(4):233–238, 228
    133. ↵
      1. Bassett KE,
      2. Anderson JL,
      3. Pribble CG,
      4. Guenther E
      . Propofol for procedural sedation in children in the emergency department. Ann Emerg Med. 2003;42(6):773–782pmid:14634602
      OpenUrlCrossRefPubMed
    134. ↵
      Miner JR, Burton JH. Clinical practice advisory: emergency department procedural sedation with propofol. Ann Emerg Med. 2007;50(2):182–187, 187.e1
    135. ↵
      1. Hohl CM,
      2. Sadatsafavi M,
      3. Nosyk B,
      4. Anis AH
      . Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review. Acad Emerg Med. 2008;15(1):1–8pmid:18211306
      OpenUrlCrossRefPubMed
      1. Pershad J,
      2. Wan J,
      3. Anghelescu DL
      . Comparison of propofol with pentobarbital/midazolam/fentanyl sedation for magnetic resonance imaging of the brain in children. Pediatrics. 2007;120(3). Available at: www.pediatrics.org/cgi/content/full/120/3/e629pmid:17698968
      OpenUrlAbstract/FREE Full Text
      1. Rothermel LK
      . Newer pharmacologic agents for procedural sedation of children in the emergency department-etomidate and propofol. Curr Opin Pediatr. 2003;15(2):200–203pmid:12640279
      OpenUrlCrossRefPubMed
      1. Havel CJ Jr,
      2. Strait RT,
      3. Hennes H
      . A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department. Acad Emerg Med. 1999;6(10):989–997pmid:10530656
      OpenUrlCrossRefPubMed
      1. Andolfatto G,
      2. Willman E
      . A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults. Acad Emerg Med. 2011;18(3):237–245pmid:21401785
      OpenUrlCrossRefPubMed
    136. ↵
      Mallory MD, Baxter AL, Yanosky DJ, Cravero JP. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011;57(5):462.e1–468.e1
      1. Green SM,
      2. Andolfatto G,
      3. Krauss B
      . Ketofol for procedural sedation? Pro and con. Ann Emerg Med. 2011;57(5):444–448pmid:21237532
      OpenUrlCrossRefPubMed
      1. da Silva PS,
      2. de Aguiar VE,
      3. Waisberg DR,
      4. Passos RM,
      5. Park MV
      . Use of ketofol for procedural sedation and analgesia in children with hematological diseases. Pediatr Int. 2011;53(1):62–67pmid:20626642
      OpenUrlCrossRefPubMed
    137. ↵
      1. Nejati A,
      2. Moharari RS,
      3. Ashraf H,
      4. Labaf A,
      5. Golshani K
      . Ketamine/propofol versus midazolam/fentanyl for procedural sedation and analgesia in the emergency department: a randomized, prospective, double-blind trial. Acad Emerg Med. 2011;18(8):800–806pmid:21843215
      OpenUrlCrossRefPubMed
    138. ↵
      1. Litman RS,
      2. Berkowitz RJ,
      3. Ward DS
      . Levels of consciousness and ventilatory parameters in young children during sedation with oral midazolam and nitrous oxide. Arch Pediatr Adolesc Med. 1996;150(7):671–675pmid:8673188
      OpenUrlCrossRefPubMed
    139. ↵
      1. Cravero JP,
      2. Beach ML,
      3. Blike GT,
      4. Gallagher SM,
      5. Hertzog JH,
      6. Pediatric Sedation Research Consortium
      . The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108(3):795–804pmid:19224786
      OpenUrlCrossRefPubMed
    140. ↵
      1. Cravero JP
      . Risk and safety of pediatric sedation/anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol. 2009;22(4):509–513pmid:19512915
      OpenUrlCrossRefPubMed
    141. ↵
      1. Champagne T,
      2. Stromberg N
      . Sensory approaches in inpatient psychiatric settings: innovative alternatives to seclusion & restraint. J Psychosoc Nurs Ment Health Serv. 2004;42(9):34–44pmid:15493494
      OpenUrlPubMed
      1. Cooley WC,
      2. McAllister JW
      . Building medical homes: improvement strategies in primary care for children with special health care needs. Pediatrics. 2004;113(5 suppl):1499–1506pmid:15121918
      OpenUrlAbstract/FREE Full Text
    142. ↵
      1. Raphael JL,
      2. Zhang Y,
      3. Liu H,
      4. Tapia CD,
      5. Giardino AP
      . Association of medical home care and disparities in emergency care utilization among children with special health care needs. Acad Pediatr. 2009;9(4):242–248pmid:19608125
      OpenUrlCrossRefPubMed
    143. ↵
      1. Biersdorff KK
      . Incidence of significantly altered pain experience among individuals with developmental disabilities. Am J Ment Retard. 1994;98(5):619–631pmid:8192908
      OpenUrlPubMed
    144. ↵
      1. Oberlander T
      . Pain assessment and management in infants and young children with developmental disabilities. Infants Young Child. 2001;14(2):33–47
      OpenUrlCrossRef
    145. ↵
      1. Oberlander TF,
      2. O’Donnell ME
      . Beliefs about pain among professionals working with children with significant neurologic impairment. Dev Med Child Neurol. 2001;43(2):138–140pmid:11221906
      OpenUrlCrossRefPubMed
    146. ↵
      1. Schneider F,
      2. Habel U,
      3. Holthusen H,
      4. et al
      . Subjective ratings of pain correlate with subcortical-limbic blood flow: an fMRI study. Neuropsychobiology. 2001;43(3):175–185pmid:11287797
      OpenUrlCrossRefPubMed
    147. ↵
      1. Breau LM,
      2. Burkitt C
      . Assessing pain in children with intellectual disabilities. Pain Res Manag. 2009;14(2):116–120pmid:19532853
      OpenUrlPubMed
      1. Lotan M,
      2. Ljunggren EA,
      3. Johnsen TB,
      4. Defrin 2R,
      5. Pick CG,
      6. Strand LI
      . A modified version of the non-communicating children pain checklist-revised, adapted to adults with intellectual and developmental disabilities: sensitivity to pain and internal consistency. J Pain. 2009;10(4):398–407pmid:19201658
      OpenUrlCrossRefPubMed
    148. ↵
      1. Malviya S,
      2. Voepel-Lewis T,
      3. Burke C,
      4. Merkel S,
      5. Tait AR
      . The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006;16(3):258–265pmid:16490089
      OpenUrlCrossRefPubMed
    149. ↵
      1. Solodiuk JC,
      2. Scott-Sutherland J,
      3. Meyers M,
      4. et al
      . Validation of the Individualized Numeric Rating Scale (INRS): a pain assessment tool for nonverbal children with intellectual disability. Pain. 2010;150(2):231–236pmid:20363075
      OpenUrlCrossRefPubMed
    150. ↵
      1. Green SM
      . Propofol in emergency medicine: further evidence of safety. Emerg Med Australas. 2007;19(5):389–393pmid:17919210
      OpenUrlCrossRefPubMed
    151. ↵
      Miner JR, Burton JH. Clinical practice advisory: emergency department procedural sedation with propofol. Ann Emerg Med. 2007;50(2):182–187, 187.e1
    152. ↵
      1. Couloures KG,
      2. Beach M,
      3. Cravero JP,
      4. Monroe KK,
      5. Hertzog JH
      . Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics. 2011;127(5). Available at: www.pediatrics.org/cgi/content/full/127/5/e1154pmid:21518718
      OpenUrlAbstract/FREE Full Text
    153. ↵
      1. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists
      . Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004–1017pmid:11964611
      OpenUrlCrossRefPubMed
    154. ↵
      1. Coté CJ,
      2. Notterman DA,
      3. Karl HW,
      4. Weinberg JA,
      5. McCloskey C
      . Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;105(4 pt 1):805–814pmid:10742324
      OpenUrlAbstract/FREE Full Text
    155. ↵
      1. Krauss B,
      2. Hess DR
      . Capnography for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007;50(2):172–181pmid:17222941
      OpenUrlCrossRefPubMed
    156. ↵
      1. Anderson JL,
      2. Junkins E,
      3. Pribble C,
      4. Guenther E
      . Capnography and depth of sedation during propofol sedation in children. Ann Emerg Med. 2007;49(1):9–13pmid:17141136
      OpenUrlCrossRefPubMed
    157. ↵
      1. Coté CJ,
      2. Wilson S,
      3. American Academy of Pediatrics,
      4. American Academy of Pediatric Dentistry,
      5. Work Group on Sedation
      . Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587–2602pmid:17142550
      OpenUrlAbstract/FREE Full Text
    158. Mace SE, Brown LA, Francis L, et al. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008;51(4):378–399, 399.e1–399.e57
      1. Green SM,
      2. Krauss B
      . Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med. 2004;44(5):460–471pmid:15520705
      OpenUrlPubMed
      1. Cravero JP,
      2. Blike GT,
      3. Beach M,
      4. et al.,
      5. Pediatric Sedation Research Consortium
      . Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118(3):1087–1096pmid:16951002
      OpenUrlAbstract/FREE Full Text
      1. Krauss B,
      2. Green SM
      . Procedural sedation and analgesia in children. Lancet. 2006;367(9512):766–780pmid:16517277
      OpenUrlCrossRefPubMed
      1. Krauss B
      . Managing acute pain and anxiety in children undergoing procedures in the emergency department. Emerg Med (Fremantle). 2001;13(3):293–304pmid:11554860
      OpenUrlPubMed
      1. Kennedy RM,
      2. Luhmann JD
      . The “ouchless emergency department”. Getting closer: advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am. 1999;46(6):1215–1247, vii–viiipmid:10629683
      OpenUrlCrossRefPubMed
      1. Jagoda AS,
      2. Campbell M,
      3. Karas JS,
      4. et al.,
      5. American College of Emergency Physicians
      . Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 1998;31(5):663–677pmid:9581157
      OpenUrlCrossRefPubMed
    159. ↵
      1. Hoffman GM,
      2. Nowakowski R,
      3. Troshynski TJ,
      4. Berens RJ,
      5. Weisman SJ
      . Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics. 2002;109(2):236–243pmid:11826201
      OpenUrlAbstract/FREE Full Text
    160. ↵
      1. McDevit D,
      2. Perry H,
      3. Tucker J,
      4. Zempsky W
      . Sedation in the pediatric emergency department: a survey of emergency department directors’ adherence to sedation guidelines [abstract 106]. Ann Emerg Med. 2000;36(suppl):S28
      OpenUrlCrossRef
    161. ↵
      1. Roback M,
      2. Wathen J,
      3. Bajaj L
      . Effect of NPO time on adverse events in pediatric procedural sedation and analgesia [abstract 620]. Pediatr Res. 2003;53:109A
      OpenUrl
      1. Phrampus E,
      2. Pitetti R,
      3. Singh S
      . Duration of fasting and occurrence of adverse events during procedural sedation in a pediatric emergency department [abstract 612]. Pediatr Res. 2003;53:109A
      OpenUrl
    162. ↵
      1. Agrawal D,
      2. Manzi SF,
      3. Gupta R,
      4. Krauss B
      . Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 2003;42(5):636–646pmid:14581915
      OpenUrlCrossRefPubMed
      1. Peña BMG,
      2. Krauss B
      . Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 1999;34(4 pt 1):483–491pmid:10499949
      OpenUrlCrossRefPubMed
      1. Green SM,
      2. Kuppermann N,
      3. Rothrock SG,
      4. Hummel CB,
      5. Ho M
      . Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med. 2000;35(1):35–42pmid:10613938
      OpenUrlCrossRefPubMed
      1. Green SM,
      2. Krauss B
      . Pulmonary aspiration risk during emergency department procedural sedation—an examination of the role of fasting and sedation depth. Acad Emerg Med. 2002;9(1):35–42pmid:11772667
      OpenUrlCrossRefPubMed
    163. ↵
      1. American Society of Anesthesiologists Committee
      . Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495–511pmid:21307770
      OpenUrlCrossRefPubMed
    164. ↵
      1. Green SM,
      2. Roback MG,
      3. Miner JR,
      4. Burton JH,
      5. Krauss B
      . Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007;49(4):454–461pmid:17083995
      OpenUrlCrossRefPubMed
    165. ↵
      1. Malviya S,
      2. Voepel-Lewis T,
      3. Ludomirsky A,
      4. Marshall J,
      5. Tait AR
      . Can we improve the assessment of discharge readiness? A comparative study of observational and objective measures of depth of sedation in children. Anesthesiology. 2004;100(2):218–224pmid:14739792
      OpenUrlCrossRefPubMed
    166. ↵
      1. Miaskowski C
      . Monitoring and improving pain management practices. A quality improvement approach. Crit Care Nurs Clin North Am. 2001;13(2):311–317pmid:11866411
      OpenUrlPubMed
      1. Gordon DB,
      2. Pellino TA,
      3. Miaskowski C,
      4. et al
      . A 10-year review of quality improvement monitoring in pain management: recommendations for standardized outcome measures. Pain Manag Nurs. 2002;3(4):116–130pmid:12454804
      OpenUrlCrossRefPubMed
    167. ↵
      1. American Pain Society Quality of Care Committee
      . Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874–1880pmid:7500539
      OpenUrlCrossRefPubMed
    168. ↵
      1. Krauss B,
      2. Green SM
      . Training and credentialing in procedural sedation and analgesia in children: lessons from the United States model. Paediatr Anaesth. 2008;18(1):30–35pmid:18095963
      OpenUrlPubMed
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    Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems
    Joel A. Fein, William T. Zempsky, Joseph P. Cravero, THE COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE AND SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE
    Pediatrics Nov 2012, 130 (5) e1391-e1405; DOI: 10.1542/peds.2012-2536

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    Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems
    Joel A. Fein, William T. Zempsky, Joseph P. Cravero, THE COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE AND SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE
    Pediatrics Nov 2012, 130 (5) e1391-e1405; DOI: 10.1542/peds.2012-2536
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