Fact Sheet: Procedural Pain in Children and Adolescents

Procedural pain refers to the pain that children experience during medical procedures. Biological (e.g., pain receptor density), psychosocial (e.g., anxiety, parent behaviors) and procedural (e.g., invasiveness of procedure, environmental setting) factors have been implicated in children’s experience of procedural pain.

Prevalence and Course

Hospitalized children undergo numerous painful medical procedures. Recent research found that 78 percent of hospitalized children had at least one painful procedure in the last 24 hours. Healthy children (including newborns) also experience numerous painful procedures as part of routine medical care. Medical procedures that can result in procedural pain include immunizations, blood draws, circumcision and many others. To date, the majority of research and clinical practice guidelines have focused on needle-related pain. Immunizations are the most common source of procedural pain in children and occur throughout childhood.

Health and Psychosocial Consequences

Beyond immediate negative consequences such as increased distress and longer procedures, inadequate management of children’s procedural pain has been linked to long-term negative physical and psychological consequences (e.g., sensitization to future pain). Children’s memories of painful medical procedures have been shown to influence pain and distress during future procedures, which may persist into adulthood through fear and avoidance of medical care. 

Evidence-based Assessment

Pain is a personal, subjective experience, thus, self-report is considered an integral part of pain assessment for children 3 years and older. The Faces Pain Scale-Revised is recommended for measuring acute procedural pain in children between the ages of 4 and 12 years, and the Visual Analogue Scale is additionally recommended for children and adolescents age 8 years and older. Parent and health professional proxy report and observational scales are also often used, particularly when cognitive impairment or sedation limit child self-report.

Culture, Diversity, Demographic and Developmental Factors

Numerous demographic factors are related to children’s procedural pain responses. Younger children display more distress in response to procedural pain, and report greater pain intensity than older children. Developmental factors (e.g., cognitive development) are important in children’s ability to understand, report, and cope with procedural pain. Research on interethnic differences in children’s procedural pain is limited, but suggests that differences between individuals are greater than differences between ethnic groups.

Evidence-based Interventions

Breathing exercises, child or nurse directed age-appropriate distraction strategies, hypnosis, and combined cognitive-behavioral interventions are efficacious for reducing pain and distress during needle-related procedures. Caregivers should avoid reassuring (“You’re okay”) or apologizing to children during procedures, as these strategies are ineffective and may actually exacerbate child distress. In addition to behavioral interventions, pharmacological (e.g., topical local anesthetic creams) and physical strategies (e.g., injecting the least painful vaccine first in the case of multiple immunizations) are important complements for acute procedural pain.

References

Stevens, B.J., Abbott, L.K., Yamada, J., Harrison, D., Stinson, J., Taddio, A., et al. (2011). Epidemiology and management of painful procedures in hospitalized children across Canada. Canadian Medical Association Journal, 183(7), E403-E410.

Stinson, J. N., Kavanagh, T., Yamada, J., Gill, N., & Stevens, B. (2006). 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, 125, 143-157.

Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., et al. (2010). Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. Canadian Medical Association Journal, 182(18), E843-E855.

Uman, L.S., Chambers, C.T., McGrath, P.J., & Kisely, S. (2008). A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: An abbreviated Cochrane Review. Journal of Pediatric Psychology, 33, 842-854.

von Baeyer, C.L., & Spagrud, L.J. (2007). Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain, 127, 140-150.