Note: This guideline is currently under review. 

Introduction 

Aim

Definition of Terms

Assessment and Measurement

Special Considerations

Companion Documents

Links

References

Evidence Table

Introduction

Children receiving health care are exposed to multiple and ongoing invasive medical procedures as part of their treatment [1]. The pain associated with these medical procedures is reported as the most significant and distressing cause of pain for hospitalised children [2]. The cumulative effects of these painful experiences can result in adverse psychological outcomes for the child and their family, including fear and the rapid development of conditioned anxiety response to medical procedures [3]. The negative experiences associated with medical procedures can have a lifelong impact [3]. Due to this, it is imperative that any exposure to a painful experience be the best experience possible for the child. Every child has a right to be kept from harm and it is the responsibility of health care professionals that ensure that every step is taken to protect children from unnecessary pain [4].
The goal of procedural pain management at RCH is to minimise pain, distress and anxiety associated with medical procedures for children. Managing procedural pain is best done with a multimodal approach that combines pharmacological and non-pharmacological interventions[4]. There are many simple and evidenced based interventions that have been demonstrated to reduce the pain and distress associated with medical procedures  for children [3]. 

Aim 

To aim of this guideline is to provide guidance to clinical staff regarding effective interventions to support the management of procedural pain and pain-related distress for children and young people receiving health care. 

Definition of terms

• Procedural pain: Short-lived acute pain associated with medical investigations and treatments conducted for the purpose of health care.
• Pain related distress: The use of the term pain is often used in conjunction with distress to describe pain related fear, anxiety, depression and agitated behaviour that is often noticeable when children are undergoing a medical procedure [5]. In children, because it is often difficult to distinguish between pain, fear and anxiety, the combination is often referred to globally as pain related distress [6].
• Procedural support: Procedural support is a process of preparing children and their families for medical procedures and coaching children to utilise coping skills to reduce the perception of procedural pain
• Procedural support team: A multidisciplinary health professional team working in conjunction with the child’s caregivers form the basis of a procedural support team. The aim of the procedural support team is to promote coping and mastery of medical procedures for the child receiving healthcare. The multidisciplinary team may be comprised of medical, nursing, allied health and administration health professionals.
• Procedural sedation: Procedural sedation is the technique of administering a sedative or dissociative agent +/- analgesia to induce a state of consciousness that allows patients to tolerate/cope with unpleasant procedures whilst preserving cardiorespiratory function.

Procedural pain assessment and management

Introduction to the key principles of procedural pain management

There are 6 essential elements of procedural pain management that have been demonstrated to reduce pain and distress associated with medical procedures: 
1. Planning
2. Preparation 
3. Pharmacological
4. Physical
5. Psychological
6. Promoting recovery and resilience 

Optimal procedural pain management maintains the comfort of the child during the 3 distinct phases of a medical procedure: (1) before, (2) during and (3) after the medical procedure. The essential elements can be applied to the continuum of the medical procedure with each stage requiring differing priorities to ensure the ongoing comfort of the child. Adherence to these key principles at each stage of the medical procedure will enhance the success of a procedural pain management plan.

For more information on each phase of procedural pain management, please click the hyperlinks. 

Before the medical procedure

Planning for medical procedures
Step 1:  Find out the child’s likes and dislikes
Step 2: Assess previous procedural experiences
Step 3:  Establish a procedural support plan
Step 4: Communicate the procedural support plan
Step 5: Refer children at high risk for procedural pain and distress
Step 6: Consult with the appropriate procedural support team

Preparing for medical procedures
Step 1: Prepare the child
Step 2: Prepare the family
Step 3: Prepare the environment
Step 4: Prepare the procedural support team

Multimodal management of procedural pain

It is recommended that a multimodal approach to pain management be provided to children receiving medical procedures.
A multimodal approach to procedural pain management combines both pharmacological and non-pharmacological interventions with the purpose of targeting different areas involved in pain processing [26]. 

Principles of pharmacological pain management

Topical anaesthesia

• When to use topical anaesthesia
• Uses for topical anaesthetics
• Choosing a topical anaesthetics
• Recommendations for the dosage of topical anaesthesia
• Application of topical anaesthetics
• Blood sampling or vascular access
• Alternatives to topical anaesthetic agents

Promote comfort of the child
Assessment of procedural pain

During the medical procedure

Principles of non-pharmacological pain management

Non-pharmacological methods of managing procedural pain are interventions that target the contextual, physical, behavioral and psychological factors related to procedural pain or pain-related distress [19]. 
This Clinical Practice Guideline provides recommendations for the non-pharmacological management of procedural pain with:

Physical interventions

• Positioning for comfort
• Procedural strategies for intramuscular injections

Psychological interventions

• Attention
• Breathing
• Break down the steps
• Give control wherever possible
• Procedural coaching
• Coping and distress promoting behavior
• Empower parents
• Distraction
• Distraction equipment
• Using technology for distraction with children

After the medical procedure

Promote resilience and recovery

• When medical procedures do not go as planned

Special considerations

• Infants
• Adolescents
• Medically unwell children

Companion documents

Procedural Sedation for Ward and Ambulatory Areas procedure (RCH access only)

Links

References

1. Stevens, B.J., et al., Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ: Canadian Medical Association Journal, 2011. 183(7): p. E403-10 1p.
2. Birnie, K.A., et al., Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag, 2014. 19(4): p. 198-204.
3. Taddio, A., et al., Reducing pain during vaccine injections: clinical practice guideline. Canadian Medical Association Journal, 2015.
4. Twycross, A., S. Dowden, and E. Bruce, Managing pain in children: a clinical guide. 2009, Wiley-Blackwell: United Kingdom.
5. Franck, L.S., C.S. Greenberg, and B. Stevens, Pain assessment in infants and children. Pediatr Clin North Am, 2000. 47(3): p. 487-512.
6. Berde, C. and J. Wolfe, Pain, anxiety, distress, and suffering: interrelated, but not interchangeable. Journal of Pediatrics, 2003. 142(4): p. 361-3.
7. Flowers, S.R. and K.A. Birnie, Procedural Preparation and Support as a Standard of Care in Pediatric Oncology. Pediatric Blood & Cancer, 2015(S5): p. 668.
8. Srouji, R., S. Ratnapalan, and S. Schneeweiss, Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics, 2010. 2010: p. 11.
9. Schechter, N.L., et al., Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics, 2007. 119(5): p. e1184-98.
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16. Paediatric Integrated Cancer Service. Procedural Pain Management.  [cited 2016 28th of February].
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18. Young, K.D., Pediatric procedural pain. Ann Emerg Med, 2005. 45(2): p. 160-71.
19. Pillai Riddell, R.R., et al., Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev, 2011(10): p. CD006275.
20. The Royal Australasian College of Physicians, Guideline Statement: Management of Procedure-related Pain in Children and Adolescents, P.C.H. Division, Editor. 2005, The Royal Australasian College of Physicians Sydney.
21. Jaaniste, T., B. Hayes, and C.L. Von Baeyer, Providing Children With Information About Forthcoming Medical Procedures: A Review and Synthesis. Clinical Psychology: Science and Practice, 2007(2): p. 124.
22. Czarnecki, M.L., et al., Barriers to Pediatric Pain Management: A Nursing Perspective. Pain Management Nursing, 2011. 12(3): p. 154-162.
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34. Chambers, C.T., et al., Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther, 2009. 31 Suppl 2: p. S77-S103.
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38. McMurtry, C.M., et al., When “don’t worry” communicates fear: Children’s perceptions of parental reassurance and distraction during a painful medical procedure. Pain (03043959), 2010. 150(1): p. 52-58.
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44. Shah, P.S., et al., Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev, 2012. 12: p. CD004950.
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Evidence Table

The evidence table for this guideline can be viewed here. 

Please remember to read the disclaimer. 

The development of this nursing guideline was coordinated by Karin Plummer, Clinical Nurse Consultant, Anaesthesia and Pain Management, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2016.