Most children who come into the Emergency Department present with pain or experience pain during their ED stay.1,2,3 Pain and distress during a procedure can leave a lasting impact on a child and contribute to mistrust of the medical system and compliance with future procedures.1 ,4,5 Children who use active forms of coping report less pain and distress during a procedure.3 To help with coping, when feasible, involve parents or family, nursing and a child life specialist. If the parents are willing, try to get them involved in all parts of the medical procedure.2,3 This includes positioning the patient with a parent in a secure parental-hugging hold or maintaining close physical contact throughout the procedure.6 This can easily replace immobilization of a child or the use of restraints which can cause increased fear and escalate the degree of anxiety in a child.2


Distraction can also be used by providers or parents and is effective in helping a child cope with pain, fear or distress.1,3,7 Since children under 7 years often cannot understand verbal reasoning or reassurance, distraction techniques during a painful procedure can be even more valuable.2 Distractors that have proven to be effective include:3

  • Blowing bubbles
  • Cartoons
  • Books
  • Movies
  • Imagery
  • Music
  • Toys
  • Counting
  • Video games
  • Hypnosis

These techniques reduce stress not only in the child but also the parents and family of the patient.8,9 When deciding on a distractor, try to involve the child and give choices when feasible.

Local anesthesia

With laceration repair, topical anesthetic reduces pain associated with needle procedures. 2,9 Additionally, the use of buffered lidocaine (mixing 1% lidocaine and 8.4% sodium bicarbonate in 9:1 ratio) and warming the medication to room temperature can reduce the burning pain associated with lidocaine infiltration.9

Scalp laceration trick

When faced with a scalp laceration on a child with hair length of at least 1 cm, consider the hair apposition technique (HAT). HAT is associated with a higher rate of patient satisfaction compared to suture or staple repair, equal healing rates and fewer complications reported compared to suturing.10

Tetanus prophylaxis

For tetanus prophylaxis management, it is important to know specific vaccination status—not just if they are up to date. Depending on the age, it’s possible to be up to date and still need a tetanus vaccine following a wound. Therefore, ask when he or she received the last tetanus vaccination. CDC guidelines suggest giving a tetanus booster to a child with a large or dirty wound who has not had a tetanus booster in the past 5 years. Finally, children under 7 years old should receive a DTaP instead of TdaP.

Cavender K, Goff M, Hollon E, Guzzetta C. Parents’ positioning and distracting children during venipuncture. Effects on children’s pain, fear, and distress. J Holist Nurs. 2004;22(1):32-56. [PubMed]
Ruest S, Anderson A. Management of acute pediatric pain in the emergency department. Curr Opin Pediatr. 2016;28(3):298-304. [PubMed]
Krauss B, Calligaris L, Green S, Barbi E. Current concepts in management of pain in children in the emergency department. Lancet. 2016;387(10013):83-92. [PubMed]
Young K. Pediatric procedural pain. Ann Emerg Med. 2005;45(2):160-171. [PubMed]
Birnie K, Noel M, Parker J, et al. Systematic review and meta-analysis of distraction and hypnosis for needle-related pain and distress in children and adolescents. J Pediatr Psychol. 2014;39(8):783-808. [PubMed]
Stephens B, Barkey M, Hall H. Techniques to comfort children during stressful procedures. Adv Mind Body Med. 1999;15(1):49-60. [PubMed]
Uman L, Birnie K, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013;(10):CD005179. [PubMed]
Wente S. Nonpharmacologic pediatric pain management in emergency departments: a systematic review of the literature. J Emerg Nurs. 2013;39(2):140-150. [PubMed]
Ali S, McGrath T, Drendel A. An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond. Pediatr Emerg Care. 2016;32(1):36-42; quiz 43-4. [PubMed]
Ozturk D, Sonmez B, Altinbilek E, Kavalci C, Arslan E, Akay S. A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations. World J Emerg Surg. 2013;8:27. [PubMed]
Ashley Foster, MD

Ashley Foster, MD

PEM Fellow
Boston Children's Hospital
Delphine Huang, MD

Delphine Huang, MD

Resident Department of Emegency Medicine (EM) UCSF-San Francisco General Hospital EM Residency Program
Sonny Tat, MD MPH

Sonny Tat, MD MPH

Assistant Professor
Pediatric Emergency Medicine
University of California, San Francisco