Procedural Pain

Evidence repositories are collections of best available resources and evidence (clinical guidelines, peer reviewed literature, systematic reviews, etc.), collated by our knowledge synthesis team and content advisors. This evidence repository is not intended to be an exhaustive list of resources for a topic, but rather a curated list of current, evidence-based resources, based on expert consensus of relevance and usability for a general emergency department setting. We search databases (Cochrane Library, PubMed, TRIP Database) and web search engines (Google, Google Scholar) to locate evidence. Additionally, hospital websites are browsed for guidance documents, such as clinical practice guidelines (CPG) for healthcare professionals.

Every effort is made to identify resources that are open access (i.e. publicly available, free of charge, not requiring a subscription).

More information about the creation of our evidence repositories can be found at https://pubmed.ncbi.nlm.nih.gov/28537762/

Thank you to the following content experts and Knowledge Synthesis team who led the development of this evidence repository.

Samina Ali, Mdcm, Frcp (PEM) Professor, Departments of Pediatrics & Emergency Medicine, University of Alberta, and Adjunct Professor of Emergency Medicine

Amy Drendel, DO, MS Pediatric Emergency Medicine Physician; Associate Professor, Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin

Corrie Chumpitazi, MD, MS Associate Professor of Pediatrics Baylor College of Medicine, Division of Emergency Medicine, Texas Children’s Hospital

Naveen Poonai, MSc, MD, FRCPC Associate Professor, Pediatrics, Internal Medicine, Epidemiology & Biostaistics, Schulich School of Medicine & Dentistry Scientist Child Health Research Institute Research Director, Division of Pediatric Emergency Medicine

Marc Vazquez, MHA/MBA, PMP EIIC Knowledge Broker Baylor College of Medicine

TREKK developed resources for healthcare providers and parents & families can be found here.

1. Chumpitazi CE, Chang C, Atanelov Z, et al. Managing acute pain in children presenting to the emergency department without opioids. J Am Coll Emerg Physicians Open. 2022;3(2):e12664.
2. Alberta Health Services. Application of topical local anesthetic for potentially painful skin-breaking procedures. 2020.
3. Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, et al. Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures. Paediatr Child Health. 2019;24(8):509-35.
4. ENA Clinical Practice Guideline Committee. Clinical practice guideline: Needle-related or minor procedural pain in pediatric patients. J Emerg Nurs. 2019;45(4):437.e1-.e32.
5. McPherson C. Premedication for endotracheal intubation in the neonate. Neonatal Netw. 2018;37(4):238-47.
6. Olsen K, Weinberg E. Pain-less practice: Techniques to reduce procedural pain and anxiety in pediatric acute care. Clinical Pediatric Emergency Medicine. 2017;18(1):32-41.
7. Ali S, McGrath T, Drendel AL. An evidence-based approach to minimizing acute procedural pain in the emergency department and beyond. Pediatr Emerg Care. 2016;32(1):36-42; quiz 3-4.
8. Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: An update. Pediatrics. 2016;137(2):e20154271.
9. Association of Paediatric Anaesthetists of Great Britain and Ireland. Good practice in postoperative and procedural pain management, 2nd edition. Paediatr Anaesth. 2012;22 Suppl 1:1-79.
10. Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: An evidence-based clinical practice guideline. Cmaj. 2010;182(18):E843-55.
11. Spence K, Henderson-Smart D, New K, et al. Evidenced-based clinical practice guideline for management of newborn pain. J Paediatr Child Health. 2010;46(4):184-92.
12. Royal College of Nursing. The recognition and assessment of acute pain in children. 2009.

1. Children’s Healthcare Canada. Procedural pain management in children & youth: A toolkit for health professionals. 2023.
2. Curtis S, Wingert A, Ali S. The Cochrane library and procedural pain in children: An overview of reviews. Evidence- Based Child Health: A Cochrane Review Journal. 2012;7(5):1363-99.

1. Pansini V, Curatola A, Gatto A, et al. Intranasal drugs for analgesia and sedation in children admitted to pediatric emergency department: A narrative review. Ann Transl Med. 2021;9(2):189.
2. Mace SE, Whiteman P, Avarello JT, et al. Local and topical anesthetics for pediatric patients in the emergency department. Pediatr Emerg Care. 2020;36(12):593-601.
3. Gates M, Hartling L, Shulhan-Kilroy J, et al. Digital technology distraction for acute pain in children: A meta- analysis. Pediatrics. 2020;145(2).
4. Ballard A, Khadra C, Adler S, et al. Efficacy of the buzzy device for pain management during needle-related procedures: A systematic review and meta-analysis. Clin J Pain. 2019;35(6):532-43.
5. Zhu Y, Peng X, Wang S, et al. Vapocoolant spray versus placebo spray/no treatment for reducing pain from intravenous cannulation: A meta-analysis of randomized controlled trials. Am J Emerg Med. 2018;36(11):2085-92.
6. Porter KM, Dayan AD, Dickerson S, et al. The role of inhaled methoxyflurane in acute pain management. Open Access Emerg Med. 2018;10:149-64.
7. Chan E, Foster S, Sambell R, et al. Clinical efficacy of virtual reality for acute procedural pain management: A systematic review and meta-analysis. PLoS One. 2018;13(7):e0200987.
8. Birnie KA, Noel M, Chambers CT, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;10(10):Cd005179.
9. Tayeb BO, Eidelman A, Eidelman CL, et al. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database Syst Rev. 2017;2(2):Cd005364.
10. Johnston C, Campbell‐Yeo M, Disher T, et al. Skin‐to‐skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews. 2017(2).
11. Harrison D, Larocque C, Bueno M, et al. Sweet solutions to reduce procedural pain in neonates: A meta-analysis. Pediatrics. 2017;139(1).
12. Chua ME, Firaza PNB, Ming JM, et al. Lidocaine gel for urethral catheterization in children: A meta-analysis. J Pediatr. 2017;190:207-14.e1.
13. Chen S, Zhang Q, Xie RH, et al. What is the best pain management during gastric tube insertion for infants aged 0- 12months: A systematic review. J Pediatr Nurs. 2017;34:78-83.
14. Stevens B, Yamada J, Ohlsson A, et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2016;7(7):Cd001069.
15. Harrison D, Reszel J, Bueno M, et al. Breastfeeding for procedural pain in infants beyond the neonatal period. Cochrane Database Syst Rev. 2016;10(10):Cd011248.
16. Pillai Riddell RR, Racine NM, Gennis HG, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2015;2015(12):Cd006275.
17. Lee GY, Yamada J, Kyololo O, et al. Pediatric clinical practice guidelines for acute procedural pain: A systematic review. Pediatrics. 2014;133(3):500-15.
18. Hogan ME, Smart S, Shah V, et al. A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults. J Emerg Med. 2014;47(6):736-49.
19. Shah PS, Herbozo C, Aliwalas LL, et al. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev. 2012;12(12):Cd004950.
20. Kassab M, Foster JP, Foureur M, et al. Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age. Cochrane Database Syst Rev. 2012;12(12):Cd008411.
21. Fein JA, Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):e1391-405.
22. Pillai Riddell RR, Racine NM, Turcotte K, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2011(10):Cd006275.
23. Harrison D, Yamada J, Adams-Webber T, et al. Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Cochrane Database Syst Rev. 2011(10):Cd008408.
24. Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clin Psychol Rev. 2010;30(8):1011-8.
25. Zempsky WT. Pharmacologic approaches for reducing venous access pain in children. Pediatrics. 2008;122 Suppl 3:S140-53.
26. Walco GA. Needle pain in children: Contextual factors. Pediatrics. 2008;122 Suppl 3:S125-9.
27. Klassen JA, Liang Y, Tjosvold L, et al. Music for pain and anxiety in children undergoing medical procedures: A systematic review of randomized controlled trials. Ambul Pediatr. 2008;8(2):117-28.
28. Kennedy RM, Luhmann J, Zempsky WT. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008;122 Suppl 3:S130-3.
29. Shah V, Ohlsson A. Venepuncture versus heel lance for blood sampling in term neonates. Cochrane Database Syst Rev. 2007(4):Cd001452.
30. Piira T, Sugiura T, Champion GD, et al. The role of parental presence in the context of children’s medical procedures: A systematic review. Child Care Health Dev. 2005;31(2):233-43.
31. Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002;2002(3):Cd003326.

1. Chang CD, Saidinejad M, Atanelov Z, et al. Emergency department strategies to combat the opioid crisis in children and adolescents. J Am Coll Emerg Physicians Open. 2021;2(4):e12512.
2. Caltagirone R, Raghavan VR, Adelgais K, et al. A randomized double blind trial of needle-free injected lidocaine versus topical anesthesia for infant lumbar puncture. Acad Emerg Med. 2018;25(3):310-6.
3. Stoltz P, Manworren RCB. Comparison of children’s venipuncture fear and pain: Randomized controlled trial of EMLA® and J-Tip needleless injection system®. J Pediatr Nurs. 2017;37:91-6.
4. Lunoe MM, Drendel AL, Levas MN, et al. A randomized clinical trial of jet-injected lidocaine to reduce venipuncture pain for young children. Ann Emerg Med. 2015;66(5):466-74.
5. Herreros ML, Tagarro A, García-Pose A, et al. Accuracy of a new clean-catch technique for diagnosis of urinary tract infection in infants younger than 90 days of age. Paediatr Child Health. 2015;20(6):e30-2.
6. Hartling L, Newton AS, Liang Y, et al. Music to reduce pain and distress in the pediatric emergency department: A randomized clinical trial. JAMA Pediatr. 2013;167(9):826-35.

1. Krauss BS, Krauss BA, Green SM. Videos in clinical medicine. Managing procedural anxiety in children. N Engl J Med. 2016;374(16):e19.
2. Drendel A, Helman A. Emergency medicine cases podcast: Pediatric procedural sedation. Emergency Medicine Cases. 2016.
3. Sucrose as a procedural analgesic for infants up to 12 months of age. BC Children’s Hospital. 2011.
4. Psychological interventions. BC Children’s Hospital. 2011.
5. Pain Ease®: Topical anesthetic skin refrigerant. BC Children’s Hospital. 2011.