Procedural Anxiety and Fear

Anxiety and fears about medical procedures are common in children/youth: two-thirds report needle fear and 10% report needle phobia.¹ Addressing this anxiety/fear is critical, as up to half of children seen in the Emergency Department undergo painful procedures (e.g., IVs, blood tests, catheterizations, wound repair). Procedural pain is complex, involving both physical pain and anxiety/fear.² Inadequate management of either increases future anxiety and can lead to healthcare avoidance that persists into adulthood. Managing both improves procedural success and optimizes future care.³

This document complements TREKK’s Caring for Patients with Anxiety Bottom Line Recommendations, with a focus on medical procedures.

• Ask ALL children/youth and caregivers about past procedure experiences before the procedure to identify anxiety/fear and discuss both pain and anxiolysis management options.
• Observe verbal and nonverbal behaviours and reactions. Procedural anxiety/fear can present as externalizing (e.g., crying, screaming, acting out) or internalizing (e.g., stoicism, withdrawal) behaviours.
• Recognize that caregivers may also have procedural anxiety/fear. Despite this, caregivers can be a great source of support to their child and should be involved as much as they and the child wish.
• Apply principles of trauma-informed care (e.g., safety, trust, transparency, collaboration, empowerment and choice). Poorly managed procedures are potentially traumatic.
• Delay non-urgent procedures until supports are in place (e.g., transfer to Pediatric Referral Centre or involvement of a Child Life Specialist, if available).
• Consider other factors that may be influencing the child’s anxiety and/or distress (e.g., hunger, time of day).
• Prevent and treat pain with pharmacologic, physical, and psychosocial interventions. Pain and fear/distress are closely related, and treating one often makes the other better. Refer to TREKK’s Procedural Pain Bottom Line Recommendations.
• Complete a pre-procedure assessment if pharmacologic anxiolysis (i.e., “light sedation”) is being considered. Refer to TREKK’s Procedural Sedation Bottom Line Recommendations.

AVOID

• Minimizing, dismissing, and/or criticizing a child’s behaviour.
• Assuming or holding biases about whether a child will experience procedural anxiety or how they may express it (e.g., based on age, past medical experiences, sex or gender, culture, ethnicity, verbal or cognitive ability, medical condition).

1. Use supports when available (e.g., Child Life Specialist).
2. Prepare and partner. Develop a coping plan with children and caregivers. Ensure they all have a supportive and active role in implementing coping strategies (e.g., comfort positioning, distraction).
3. Never physically restrain the child. If the child cannot remain still or safe, pause and refocus on coping strategies. Use of restraint can contribute to a traumatic event in the moment and avoidance of future medical care. Use comfort holds instead (e.g., sitting on caregiver’s lap in a big hug).
4. Try digital (e.g., mobile phone, tablet, show) or non-digital (e.g., i-spy books, bubbles, music, conversation) distraction to draw a child’s attention away from the procedure.
5. Encourage in-the-moment coping (e.g., deep breaths, positive coping statements like “I can do this”).
6. Ask about culturally relevant strategies/practices (e.g., Indigenous traditions, prayers).
7. Offer a calming environment (e.g., low lighting, reduced noise, fewer people, privacy, one person speaking to child at a time).
8. Use clear, honest, and supportive language before, during, and after the procedure. Describe what they will see, smell, feel, or hear. Offer encouraging statements about coping and what went well.
9. Offer appropriate and realistic choices. Ensure consent/assent. Assent can be obtained even when a child is highly anxious. When able, modify procedures to reduce distress (e.g., IV location choice).
10. Use applied muscle tension for children with fainting: tense arms/legs/trunk 10-15 seconds until they feel a warm sensation in the head, then relax 20-30 seconds. Repeat 5 times.

• A single dose of a single agent above is considered minimal sedation; monitor for adverse events (e.g., nausea, vomiting, dizziness, bradycardia, hypotension, rash) as per institution-specific guidelines if available.
• If institution-specific guidelines not available, monitoring should include continuous O₂ saturation monitoring; additional monitoring could also include heart rate, respiratory rate, end-tidal CO₂, and blood pressure. A full set of vital signs should be completed prior to the procedure, at least once within 30 minutes of medication administration, and before discharge.
• Observe the child/youth until able to perform their baseline activities as appropriate for time of day.

• If distress persists despite strategies, procedural sedation with batching of procedures will be required. Refer to TREKK’s Procedural Sedation Bottom Line Recommendations..
• For future support, refer to psychology, child life specialist, or similar professionals, if available, to develop coping plans and enable the family to access the quality care they need.

Thank you to the following content experts who led the development of the Procedural Anxiety and Fear Bottom Line Recommendations:

Erin Field
Parent Partner

Quinn Quatember
Youth Partner

Samina Ali, MD, FRCPC
Professor, Department of Pediatrics and Adjunct Professor, Department of Emergency Medicine, University of Alberta

Naveen Poonai, MSC, MD, FRCPC
Professor, Pediatrics, Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry Scientist, Child Health Research  Institute

Kathryn Birnie, PhD RPsych
Associate Professor, Cumming School of Medicine, Department of Anesthesiology, Perioperative and Pain Management, and  Department of Community Health Sciences, University of Calgary

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in  the development of this resource. Thank you as well to Megan Bale-Nick, TREKK Project Coordinator (University of Manitoba) who coordinated the development process.

To see our resource development process please visit our website here.

(as cited in the Procedural Anxiety and Fear Bottom Line Recommendations):

1. Solutions for Kids in Pain (SKIP) Procedural pain management in children and youth: A toolkit for health professionals.  (updated 2023)
2. Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S. Managing pain and distress in children undergoing brief  diagnostic and therapeutic procedures. Canadian Paediatric Society. (updated March 20, 2025)
3. Solutions for Kids in Pain (SKIP) and the Health Standards Organization. Pediatric Pain Management Standard (CAN/HSO 13200:2023):
4. Tsze DS, Woodward HA, McLaren SH, et al. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A  Randomized Clinical Trial. JAMA Pediatr. 2025;179(9):979–986.
5. Wang JY, Speechley K, Anderson KK, et al. Intranasal midazolam for procedural distress in children in the emergency  department: a systematic review and meta-analysis. CJEM. 2024;26(9):658-670.
6. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the  emergency department: a pilot study. Emerg Med Australas. 2013;25(2):161-167.
7. Poonai N, Spohn J, Vandermeer B, et al. Intranasal Dexmedetomidine for Procedural Distress in Children: A Systematic  Review. Pediatrics. 2020;145(1):e20191623.
8. Poonai N, Creene C, Dobrowlanski A, et al. Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis. CJEM. 2023;25(6):508-528.

For a complete list of the evidence that informed the creation of the Procedural Anxiety and Fear Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use