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Pain is a common reason for an ED visit in children. Even children who do not initially present to the ED in pain often incur pain due to required medical procedures. There is ample evidence that children’s pain remains undertreated in the ED.1-3 Barriers to optimal pain management include failure to use clinical tools for pain assessment,4 poor documentation of pain,5,6 inadequate familiarity with pain management options, concerns regarding adverse effects, and perceived time constraints in a busy ED.

Children who receive appropriate pain relief in the ED have significant reductions in distress, improved rapport with the physician, improved intent to comply with discharge instructions,7 and higher levels of personal and caregiver satisfaction.8,9 Untreated pain in childhood leads to short- and long-term problems including anxiety, needle phobia,10 hyperesthesia,11 and fear of medical care as adults.12 Effective pain management is a cornerstone of high-quality care, supported by the World Health Organization, the American Academy of Pediatrics, and the Joint Commission on Accreditation of Healthcare Organizations.13

The experience of pain and distress in the ED is influenced by the patient (child age, prior experience with health providers, level of distress, developmental level); the illness (presenting complaint, pain severity, required procedures), and provider factors (skill level, ED resources). An appreciation of these elements should be the foundation for planning the approach to pain management. The key tools of analgesia, anxiolysis, and procedural sedation overlap and influence one another. Effective pain management begins at the initial triage assessment and continues with comprehensive discharge instructions (Figure 115-1).

FIGURE 115-1.

The continuum of pediatric pain assessment and treatment in the ED.

This chapter includes best evidence for the assessment of pain in children; physical, psychological, and pharmacologic strategies to manage both pain and distress; and methods for overcoming barriers to providing timely and effective analgesia.


The first step in the treatment of pain and distress in children is to quantify the severity of symptoms. The level of pain or distress may be obvious, as with a fracture, or less straightforward, as with abdominal pain or headache. Specific pain scales have been developed for children at different developmental stages and ages (Table 115-1). Physiologic parameters, such as heart rate, oxygen saturation, and blood pressure, in isolation are inadequate to accurately assessing a child’s degree of pain and should not be used as the sole measures of pain intensity.14

TABLE 115-1Assessment of Pain by Age: Currently Recommended Pain Scales

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