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  • Untreated pain in children causes short- and long-term consequences.

  • Buffering intradermal lidocaine with 1:9 concentration of sodium bicarbonate will reduce pain from chemical irritation.

  • Oral sucrose on a pacifier can provide pain relief for small infants during painful procedures.

  • In children, the most painful part of fracture management is obtaining radiographs. Reduce this pain with early pain management and splinting of the fracture site.

  • Intranasal medications are an effective and needle-free way to administer potent analgesics.

  • Behavioral techniques for management of pain include distraction, relaxation exercises, deep breathing, and imagery.

Pain is the most common reason a patient presents for health care. It is often undertreated for children in ED settings despite recognition of its importance.1


Untreated pain in children causes short- and long-term consequences. For example, pain in infants can have lasting negative effects on neuronal development, pain threshold and sensitivity, coping strategies, emotionality, and pain perceptions.2 Children receive less pain medication than adults for the same emergent complaints. The reasons for this “oligoanalgesia” include persistence of myths that children do not experience or remember pain, fear of using opioids in young patients, and difficulty assessing pediatric pain.3 The effects of untreated pain impact medical outcomes and are remembered even by preverbal children.2 These effects may amplify with age: adolescents may avoid medical treatment, adults may refuse to donate blood, and geriatric patients may refuse flu shots because of the fear of needle pain. Children with a history of negative medical experiences show higher levels of anxiety prior to a venipuncture procedure and are less cooperative during the procedure. Further, high pain during medical visits predicts missed future medical appointments and poor health care follow-up.4 Older children also suffer sequela: untreated pain from lumbar puncture (LP) increases pain response with subsequent procedures.5 Immediate and long-term patient health are affected by inappropriate analgesia.


In the ED, the periodic evaluation of pain using self-reported pain scales has become routine for both staff and patients. The Wong-Baker Faces Pain Scale is widely used in the United States, but suffers from two methodological flaws: the smiling anchor to the left is rarely appropriate for anyone in the ED, and cultural and concrete thinking biases may limit endorsement of the tearful face (Fig. 14-1).6 The Faces Pain Scale – Revised is used more widely throughout the world, especially in the empirical literature (Fig. 14-2).7,8 Other validated options include a vertical, graduated, and colored analog scale to assess pain.9 This upside-down triangle has the topmost part wide and red, representing the worst pain and the bottom part narrow and white, representing no pain. The scale has been found to be easier to administer than a standard visual analogue scale (VAS) and avoids the most common ...

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