Pain and anxiety are very common experiences for patients of all ages in the ED, and both are frequently undertreated. This is particularly true for children. There are many reasons for this, including the idea that very young children do not experience true pain or will not remember, the perceived difficulty in measuring pain and anxiety in children, fear of masking the signs and symptoms of serious disease processes, concerns that addressing pain takes too much time or effort, and lack of familiarity and comfort with medication dosing in children. These concerns should not stand in the way of providing adequate analgesia, anxiolysis, and sedation for children, however, and addressing these concerns is the primary goal of this chapter.
Caring for children in the ED requires constant attention to pain and anxiety. Common situations include fractures, lacerations, abdominal pain, lumbar puncture, incision and drainage of abscesses, and IV placement. Full procedural sedation may be necessary for invasive procedures in children. This chapter discusses pain management goals (Table 113-1) and pharmacologic and nonpharmacologic measures to minimize pain and anxiety experienced by children in the ED, with an emphasis on both basic concepts and newer developments in this topic of daily relevance to ED care providers.
TABLE 113-1General Goals of Pediatric Analgesia, Anxiolysis, & Sedation |Favorite Table|Download (.pdf) TABLE 113-1 General Goals of Pediatric Analgesia, Anxiolysis, & Sedation
Minimize physical pain and discomfort
Minimize negative psychological responses to treatment
Control behavior/motion to expedite performance of procedures
Maintain safety and minimize risk to patient
ASSESSMENT OF PAIN AND ANXIETY BY AGE
The first step in the treatment of pain and anxiety in children is to quantify the severity of symptoms. The level of pain or distress may be obvious to the care provider, such as when a child has a visibly displaced fracture. Other scenarios are not as straightforward, however, such as the common complaint of abdominal pain. Preverbal and young children are especially challenging. As a result, specific pain scales have been developed for children at different developmental stages (Table 113-2). Familiarity with and application of these pain scales greatly reduces uncertainty in treating pain and anxiety in children of all ages. In addition, measuring and addressing pain is one of the Centers for Medicare & Medicaid Quality Measures.
TABLE 113-2Assessment of Pain by Age: Pain Scales |Favorite Table|Download (.pdf) TABLE 113-2 Assessment of Pain by Age: Pain Scales
Infants & toddlers
Young children (preschool)
Older children & adolescents
FLACC© (Face, Legs, Activity, Cry, Consolability) scale
Wong-Baker FACES© pain scale
Verbal Numeric Scale or Visual Analog Scale
Children with cognitive developmental delay may compound the challenges of assessing and treating pain and anxiety by combining the physical size and ...