Increasing evidence has demonstrated that pain from venipuncture and intravenous cannulation is an important source of pediatric pain and has a lasting impact. Ascending sensory neural pain pathways are functioning in preterm and term infants, yet descending inhibitory pathways seem to mature postnatally. Consequently, infants may experience pain from the same stimulus more intensely than older children. In addition, painful perinatal procedures such as heel lancing or circumcision have been found to correlate with stronger negative responses to venipuncture and intramuscular vaccinations weeks to months later. Similarly, older children have reported greater pain during follow-up cancer-related procedures if the pain of the initial procedure was poorly controlled, despite improved analgesia during the subsequent procedures. Fortunately, both pharmacologic and nonpharmacologic techniques have been found to reduce children's acute pain and distress and subsequent negative behaviors during venipuncture and intravenous catheter insertion. This review summarizes the evidence for the importance of managing pediatric procedural pain and methods for reducing venous access pain. Pediatrics 2008;122:S130-S133 E LIMINATION OR RELIEF of pain and suffering, whenever possible, is an important responsibility of physicians caring for children, 1 because unmanaged pain can result in a variety of negative long-term consequences. 2 This general precept encompasses the management of pain associated with venipuncture and intravenous (IV) cannulation, routine procedures that may be viewed by many health care professionals, erroneously, as having little significance and impact. Increasing evidence has demonstrated that venous access procedures are an important source of pediatric pain that should be managed proactively. The purpose of this review is to briefly summarize the data demonstrating the importance of managing pediatric procedural pain in general, and venous access pain in particular. GENERAL CONSIDERATIONSUnderstanding of the ontogeny of the pediatric pain experience has increased significantly over the past 2 decades. Accumulating evidence has indicated that pain is perceived earlier in life than had been previously believed. By the middle of the third trimester of human gestation, ascending pain fibers fully connect to the primary somatosensory cortex of the brain. 3,4 Anand's landmark article 5 demonstrated that preterm infants given fentanyl in addition to nitrous oxide had significantly lower hormonal responses to surgery for ligation of the patent ductus arteriosus than did infants who did not receive fentanyl. Neonates who received high-dose sufentanil compared with halothanemorphine had improved survival rates after cardiac surgery, 6 whereas infants in the NICU have been shown to be able to distinguish real from sham heel sticks. 7 These results are consistent with the existence of functioning neural pathways for pain sensation at early times. Descending inhibitory pain pathways, on the other hand, seem to r...

With the exception of pain reported in the emergency department being higher for the splinted group, all other measures, including convenience, satisfaction, and preference, showed a clear trend favoring splints at almost every time period in the study. This study provides additional evidence that splinting is preferable to casting for the treatment of distal radial buckle fractures.

ABSTRACT. Background. Peripheral intravenous catheter (PIV) insertion is a common, painful experience for many children in the pediatric emergency department. Although local anesthetics such as injected buffered lidocaine have been shown to be effective at reducing pain and anxiety associated with PIV insertion, they are not routinely used. ELA-Max, a topical local anesthetic, has the advantage of needle-free administration but has not been compared with buffered lidocaine for PIV insertion.Objective. To compare the reduction of pain and anxiety during PIV insertion provided by subcutaneous buffered 1% lidocaine or topical ELA-Max in children.Methods. A randomized trial in children 4 to 17 years old undergoing PIV insertion with 22-gauge catheters was conducted. Children received either buffered lidocaine or ELA-Max. Buffered lidocaine was administered by using 30-gauge needles to inject 0.1 to 0.2 mL subcutaneously just before PIV insertion. ELA-Max was applied to the skin and occluded with Tegaderm 30 minutes before PIV insertion. Self-reported Visual Analog Scale (VAS) questionnaires (rating on a scale of 1-10; 1 ‫؍‬ no pain, anxiety) were completed by patients and their parents before PIV insertion to assess baseline perceptions about pain and anxiety associated with PIV insertion and immediately after PIV insertion to assess pain and anxiety associated with the experience. After PIV insertion, the nurse who inserted the PIV also completed a VAS questionnaire assessing technical difficulty and satisfaction with the local anesthesia. A blinded observer also completed a VAS questionnaire to assess pain and anxiety associated with the PIV insertion. Data were analyzed by using 2 and t tests.Results. Sixty-nine subjects were enrolled, and questionnaires were competed by all (mean age: 12.1 ؎ 4.5 years; 61% female). There were no differences for buffered lidocaine and ELA-Max groups in age, gender, race, prior IV experience, or baseline pain and anxiety. There were no significant differences between buffered lidocaine and ELA-Max in mean pain and anxiety after PIV insertion by patient, parent, and blinded observer ratings. Nurse ratings of technical difficulty, number of PIV-insertion attempts, and satisfaction with local anesthesia also were not significantly different for buffered lidocaine and ELA-Max groups.

Triage-administered O tended toward greater pain reduction compared with C in children with suspected forearm fractures. Although minor adverse effects occurred in both groups, itching occurred more in C. Identification of radiography as the most painful part of fracture evaluation underscores the need for early triage administration of analgesia for suspected fractures.

Fractures concerning for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse.