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Children of all ages feel pain; even neonates perceive pain.1 Visits to the ED and previous experiences with health care providers provoke anxiety in children and their caregivers. Anxiety may be more troubling than pain itself. Anxiety is also “contagious” within the family group. Parental anxiety in turn potentiates that of the child and can lead to a cycle of escalation.

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This chapter discusses pharmacologic and nonpharmacologic measures to minimize pain and anxiety experienced by children in the ED.

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The developmental stages of childhood affect the approach to the pediatric patient (see Chapter e109.1, Assessment of the Child in the Emergency Department: A Practical Application of Normal Child Development). Developmentally appropriate techniques are used to minimize the negative experiences of patients of different ages.

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Newborn and Infant (Ages 0 to 9 Months)

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The neonate and infant have unique developmental attributes relevant to pain and anxiety (Table 39-1). These attributes mean that the infant can often be examined independent of his or her parents, and that one brief painful experience (e.g., injection of local anesthetic) will not affect the infant’s response to the next procedure (e.g., suturing).

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Table 39-1 Developmental Attributes of the Neonate and Infant  
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Toddler (Ages 10 to 36 Months)

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The ED experience of the toddler is largely shaped by the normal developmental phenomenon that characterizes this age group: “stranger anxiety.” Separation, or even the perceived possibility of separation from a caregiver, can cause great distress. This distress, coupled with a lack of temporal abstraction in this age group, makes for a challenging scenario. So, parental presence and even participation in the preparation for painful procedures is important. Children in this age group should nearly always be examined, at least initially, in their parents’ laps or arms. Parents may also lie in the stretcher with the patient to provide comfort. Toddlers are also beginning to develop a sense of independence and to make choices, but logical thought and reason are not part of the toddler repertoire. The health care team should involve the toddler in decision making, but within the parameters of the patient’s cognitive abilities: if a shot is necessary, for instance, it is appropriate to provide a choice between the arm or the leg, but asking “is it OK if we give you a shot?” will never be successful.

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School-Aged Patients (Ages 4 to 10 Years)

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School-aged children have begun to individuate from parents, so ...

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