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Sedation wi th nitrous oxide compared with no sedation during catheterization for urologic imaging in c hildren . Pediatr Radiol , 37 (7), 679 \200\223684. Wansink , B. , Shimizu , M. , and Camps , G. ( 2012 ). What would batman eat?: priming chil dren to make healthier fast food choices . Pediatr Obes , 7 (2), 121 \200\223123. Zempsky , W. T. , and Schechter , N. L. ( 2000 ). Offi ce-based pain management . Williams , G. D. , Kirk , E. P. , Wilson , C. J. , Meadows , C. A. , and Chan , B. S. ( 201 1 ). Salicylate intoxication from teething gel in infancy . Med J Aust , 194 (3), 146 \200 \223148. Pediatr Clin North Am , 47 (3), 601 \200\223615. Zempsky , W. T. , and Schechetr , N. L. ( 2003 ). What \200\231s new in the management of pain in children . Pediatr Rev , 24 (10), 337 \200\223348 Supplementary online materials Figure 33.1 O \203 ce poster. CHAPTER 34 E \200 ective management of children \200\231s pain and anxiety in the emergenc y department Robert M. (Bo) Kennedy Summary Eff ective management of children \200\231s pain and anxiety during emer- gency dep artment (ED) visits facilitates medically necessary care and procedures and increases patie nt, family, and health care provider satisfaction. Th is chapter will review evidence-based techniques for achieving this goal. A signifi cant focus is upon non- pharmacological stra tegies to relieve children \200\231s anxiety because high levels of anxiety exacerbate sens itivity to pain and disrupt coping mechanisms of the child and parent. In addition, advance s in techniques for pain relief for specifi c procedures will be detailed. Aspects of proce dural sedation and analgesia that are especially pertinent to the ED will also be reviewed along with two recom- mended regimens for moderate and deep sedation. a calm, playful style can signifi cantly reduce both the child \200\231s and parent \200 \231s apprehension. Redirecting the child \200\231s attention away from his pain and impend ing medical care can signifi cantly reduce dis- tress. Family members can aid in these dist raction strategies but may need specifi c guidance (Bauchner et al., 1994 ; see Cohen et al ., Chapter 53, this volume) Most children desire to have their parent present during medi- cal care, even when they kno w their parent cannot reduce their pain (Ross and Ross, 1984 ). In addition, most parents w ish to be with their child in these situations because they believe they can help reduce th eir child \200\231s distress and be helpful to the health care providers (Bauchner et al., 1989 ). Allowing young children to assume \200\230positions of comfort \200\231 when feasi ble, e.g. suggesting the child lay in his parent \200\231s lap during suturing or sitting c hest-to- chest with the parent giving a gentle but controlling hug during a venous catheter insertion reduces distress in young children and their parents, when local anesthesia is a lso used (Sparks et al., 2007 ). Introduction Pain due to injury or illness and fear of painful medical procedures are commo n experiences for most children seeking care in the ED (Drendel et al., 2006 ; Zempsky et a l., 2004a ). Although the truly \200\230Ouchless ED \200\231 (Kennedy and Luhmann, 1999 ) is more a philosophi- cal concept than a concrete goal, there are many strategies to reduce pain and distress in this setting. Poorly managed pain is distress- ful for children, thei r parents, and health care providers and may produce physiological and psychological reacti ons that have acute and long-term consequences in children of all ages (Pate, 1996 ; Taddio et al., 1997 ; von Baeyer et al., 2004 ; Weisman et al., 1998 ). Inadequate pain control i s also a signifi cant cause of dissatisfac- tion with emergency care (R. W. Smith et al., 2 007 ). Finally, eff ec- tive management of children \200\231s pain and anxiety facilitates accurate physical exam assessments, performance of necessary medical pro- cedures, and comp liance with recommendations. Analgesics in the ED Painful conditions are usually identifi ed when the child is initially triaged upon presentation to the ED. Interventions can be initiated at this time for many patients, including for anticipated painful medical interventions. Placement of topical loc al anesthetics which require 30 to 60 min absorption time to be eff ective also can improve effi ciency of care. Examples include instillation of lidocaine-epine- phrine (adrenaline) -tetracaine (LET) gel into lacerations (Priestley et al., 2003 ) or application of anesthet ic skin creams on a child who is likely to require venous cannulation. When a fracture is s us- pected, splinting the injury and administering oral oxycodone at triage prior to sendin g the child for radiographs safely reduces the child \200\231s pain, including during manip ulation of the injured extrem- ity for the radiographs (Charney et al., 2008 ). Rapid initi ation of pain relief for other painful conditions such as burns or sickle-cell vaso-occlusi ve episodes can also be achieved with administration of oxycodone at triage. Standing order s for nurse initiation of these strategies greatly facilitates this practice. A child \200\231s perception of pain is signifi cantly aff ected by his emo- tional state, temperament, prior painful experiences, and coping skills, as well as by parent and health care provider interactions (Khan and Weisman, 2007 ). Anxiety, exacerbated by the unknown a nd frightening ED environment, oft en interferes with a child \200\231s and his parent \200 \231s coping mechanisms. Approaching the child with CHAPTER 34 effective management of children \200\231s pain 339 Acetaminophen (paracetamol) and ibuprofen are frequently used oral analgesic medications fo r mild to moderate pain, whereas ketorolac and opioids are commonly administered intravenou sly (IV) for more severe pain. Because some people poorly metabo- lize codeine to its activ e form and others experience increased adverse eff ects from relatively small doses when th ey ultra-rapidly metabolize the drug, codeine is considered an unreliable analgesic agent ( Gasche et al., 2004 ; Williams et al., 2002 ). Oxycodone is an eff ective and safe oral ana lgesic for signifi cant pain (Charney et al., 2008 ). 1989 ) and behavioral interventions are used (see also Zempsky, Chapter 47, this volume). Gels containing 4% lidocaine, 0.1% epinephrine (adrenaline), and 0.5% tetracaine (LET), whe n instilled for at least 30 min into an open wound, are suffi ciently absorbed to provide l ocal anaes- thesia (Eidelman et al., 2011 ; G. A. Smith et al., 1997 ). Th ese gels provide complete anesthesia for 70% to 90% of facial and scalp lac- erations and about half of ext remity lacerations (Singer and Stark, 2001 ; G. A. Smith et al., 1997 ). Th us, supplementa l injected anaes- thetic is oft en necessary. Application of gel formulations directly into the wound is more eff ective than placement of gauze soaked with anesthetic solution atop, perhaps due to improved contact of the anesthetics with the wound (Resch et al., 1998 ). B ecause topical anesthetics can cause toxicity due to rapid absorption when applied on mucos al membranes and large abrasions, only small amounts should be applied on these wounds, e.g . use a cotton swab to apply a drop of LET into a lip laceration (Bonadio, 1996 ). Applicat ion of LET to fi ngers for 45 min is eff ective and safe (White et al., 2004 ). Acetaminophen (paracetamol) is administered at 10 to 15 mg/kg/ dose orally every 4 to 6 h, not to exceed fi ve doses in 24 h; maxi- mum daily dose: 4000 mg/day. Ibuprofen is administered orally 75 mg/kg/day not to exceed 3750 mg/day. Administration wit h food or milk decreases gastroin- testinal upset. Ibuprofen 10 mg/kg provided similar redu ction in fracture-related pain as oxycodone 0.1 mg/kg (Koller et al., 2007 ) or acetaminoph en with codeine (Friday et al., 2009 ) and better than acetaminophen or codeine alone (Clar k et al., 2007 ). Ketorolac is usually administered IV for moderate to severely painful conditions such as mi graine headache (Brousseau et al., 2004 ). For children aged 2 to 16 years and those older than 16 years who weigh less than 50 kg, the recommended dose is 0.5 mg/kg as a single dose ; maximum dose: 15 mg. For children older than 16 years and greater than 50 kg, the recomme nded dose is 30 mg. Numerous studies confi rm local anesthetics signifi cantly reduce the pain of needle punctu re during IV catheter insertion, blood sampling, and intramuscular vaccine injections (Sche chter et al., 2007 ; Zempsky, 2008 ). Topical anesthetic creams containing lido- caine-pril ocaine (EMLA ), tetracaine (amethocaine; Ametop ), or liposomized lidocaine (L.M.X. 4 ) reduce venepuncture pain but require 30 to 90 min for penetration (Eidelman et al., 2 005 ). A topical patch uses warming to hasten onset of topical anesthesia (Synera ; Seth na et al., 2005 ). Th ese anesthetics may be applied in triage when it is clear the child w ill need venepuncture or IV insertion. Morphine (0.05 \200\2230.1 mg/kg IV) is the mainstay for potent analge- sia in the pediatri c ED. It reliably provides sustained relief for most painful conditions. However, other med ications may have advan- tages in specifi c conditions. Fentanyl (1 \200\2232 mcg/kg IV), unlike morphine, does not cause clini- cally signifi cant histamine release and thus is preferred in patients who have increased potential for hypot ension, e.g. trauma or sepsis. Its rapid onset facilitates titration to eff ective analgesi a. Intranasal (IN) administration of fentanyl (1.5 \200\2232 mcg/kg) has been shown to prov ide similar analgesia as intravenously administered morphine for fracture-related pain (Bor land et al., 2007 ). It can also be used to augment sedation for painful procedures, e.g. w ith nitrous oxide (N 2 O) for abscess incision and drainage or fracture reduction (Seith et al., 2012 ). IN administration is facilitated by devices that create a fi ne mist to incre ase broad distribution of the drug onto nasal mucosa (Wolfe, 2007 ). Buff ering lidocaine, lidocaine with adrenaline, or bupivacaine to a neutral pH signifi can tly reduces the pain of infi ltration without impacting eff ectiveness (Christoph et al., 1 988 ; McKay et al., 1987 ). Adding 1 ml of sodium bicarbonate (8.4%) per 10 ml of anestheti c brings the pH of the solution to 7.2 to 7.4. Because buff ered lido- caine begins to degr ade aft er 2 to 4 weeks, it must be mixed locally or purchased from specialty pharmaceutica l companies. To assure eff ective local anesthesia in lacerations, consider injecting buff - ered lidocaine through the wound aft er 30 to 45 min of application of LET (see Box 34.1 ). Buff ered lidocaine can be injected through a 30-gauge needle with minimal pain and achi eves immediate deep local anesthesia for IV catheter insertion (Klein et al., 1995 ; Luhman n et al., 2004 ; McNaughton et al., 2009 ). Because of the rapid onset and eff ectiveness o f anesthesia, lack of need for spe- cial equipment and low cost, this technique is used for more than 85% of IV insertions in children in the author \200\231s ED (unpublished data). Of note, use of local anesthetics has been found by some to improve success rate on the fi rst attempt (74% with 4% lidocaine cream versus 55% for placebo; Taddio et al., 2005 ) and 84% with EMLA versus 65% with nothing (Baxter et al., 2005 ). Th e J-tip device can be u sed to drive lidocaine through intact skin without use of a needle (Jimenez et al., 2006 ). Oxycodone is an opioid analgesic medication that is readily absorbed by the oral route and is oft en administered for painful conditions when no IV access is established, e.g. at tri age for pos- sible fractures or burns (Charney et al., 2008 ). It can also be used to augme nt sedation for painful procedures without vascular access, e.g. with N 2 O. For out-of- ho spital analgesia 0.05 \200\2230.15 mg/kg is recommended. For ED analgesia, 0.2 mg/kg admini stered at triage to children with painful injuries caused tiredness but not seda- tion or c linically apparent changes in ventilation or oxygenation (Charney et al., 2008 ). For proce dural analgesia, 0.2 mg/kg may be administered along with N 2 O for minor fracture reductio n, burn debridement, or abscess drainage. Pain management for ED procedures Procedures commonly performed in the ED that are consider ed intensely painful by pediatric ED health care providers, with most painful fi rst, are s uprapubic aspiration, intramuscular injection, lumbar puncture, IV catheter insertion, uret hral catheterization, Local anesthesia Eff ective local anesthesia greatly reduces anxiety and the need for proce dural sedation, particularly when topical and nearly painless placement of anesthetics can be achieved (Pierluishi and Terndrup, SECTION 4 pain in specific populations and diseases 340 8 years of age, 65% were willing to stay an extra hour, 77% were willing to spend an extra $15, and 37% were willing to pay an extra $100 to ensure that the procedure was painless (W alsh and Bartfi eld, 2006 ). Box 34.1 Methods to minimize pain of local anesthesia (LA) injection 1. Distract patient. Health care providers fi nd performing venous access procedures in fearful and anxious chil dren to be stressful. Th e morale of nurses has been negatively impacted by perceptions tha t they cause sig- nifi cant procedural pain (Nagy, 1998 ). Nurses in our pediatric ED repor ted a signifi cant reduction in their distress associated with IV insertion aft er they beg an using comfort techniques and a protocol that empowered them to initiate use of local ane sthesia (Luhmann et al., 1999 ). 2. Use topical anesthetic gel prior to in \201 ltration of additional LA. 3. Warm LA to body temperature. 4. Buffer LA to neutral pH (add 1 ml of 8.4% sodium bicarbo- nate to 9 ml of anesthetic). 5. Use \201 ne needle (27 \200\22330 gauge). Even with complete anesthesia (see \200\230Local anesthetics \200\231), anxiety related to needle use causes distress in many kids, thus local anaes- thetic techniques are considera bly augmented by concurrent use of non-pharmacological techniques to reduce anxiety. In add ition to distraction simply allowing young children to sit upright on their parent \200\231 s lap during IV insertion, instead of being held supine on a stretcher, can signifi cantly lower distress, increase parent satisfac- tion, and does not alter the number of IV attempt s needed (Sparks et al., 2007 ). 6. Inject slowly. 7. Use smallest effective volume. 8. In \201 ltrate through wound, not skin. 9. Inject \200\230looser \200\231, deeper subdermal layer before \200\230tighter \200\231 dermal tissues. 10. Block individual nerves when possible. Adapted by permission from BMJ Publishing Group Limited. Emergency Medicine Journal , O. Qu aba et al., A users guide for reducing the pain of local anesthetic administration, Volume 22, Issue 3, pp. 188 \200\223189, Copyright 2005, http://emj.bmj.com/. Lacerations Children presenting to the ED for care of lacerations are typically frightened and anxious. Th ese moderately painful injuries cause concern in the patients and their par ents about additional pain during repair as well as cosmetic and functional outcomes. As pr e- viously discussed application of topical anesthetic gels and use oxycodone at the time o f triage immediately begins to address the child \200\231s pain and can improve effi ciency of care (Charney et al., 2008 ; Priestley et al., 2003 ). Use of injected anesthetics is d iscussed in the \200\230Analgesics in the ED \200\231 section. and nasogastric (NG) tube insertion (Babl et al., 2008a ). Eff ective pain management or al ternative procedures can be achieved for most of these procedures. Ceft riaxone can be reco nstituted with buff ered lidocaine to reduce injection pain when that antibiotic is adminis tered by the intramuscular route (Hayward et al., 1996 ). Strategies for the remaining proc edures are addressed in the fol- lowing sections. Many small lacerations may not need to be closed. In an intriguing study, patients (primari ly adults) with uncomplicated lacerations of the hand that would normally be sutured (full thickness, <2 cm, without tendon, joint, fracture, or nerve complications), were rand- omiz ed to either being sutured or conservative treatment (tap water irrigation, antibiotic oint ment, and gauze dressing for 1 \200\2232 days; Quinn et al., 2002 ). Both groups had simila r time to resumption of normal activities and cosmetic appearance with the conservative tre atment faster and less painful. In the author \200\231s ED most parents quickly accept the advantages of this \200\230common-sense \200\231 approach for minor hand/fi nger and foot/ toe lacerations when reminded of how they likely treated their own similar minor injuries. Although ini- tially worrisome in appearance, tongue lacerations very rarely need closure, including gaping lacerations extending to the tongue \200\231s edge (Patel, 2008 ). Venous access Venepuncture to obtain blood samples for medical tests or to insert indwellin g catheters is the most common painful proce- dure performed in the ED (see also Taddio, Ch apter 19; Zempsky, Chapter 47, this volume). Needle-sticks cause signifi cant pain, dis- tr ess, and negative memories for children of all ages (Humphrey et al., 1992 ). Among medical procedures during hospital encoun- ters, needle-sticks are a separate, critical, and distr essful event for most children (Fradet et al., 1990 ). Despite guidelines and increas- ing evidence highlighting the importance of pain associated with venous access procedures, mana gement of this pain is oft en inad- equate (Bhargava and Young, 2007 ; MacLean et al., 2007 ; Zempsky et al., 2004a ). Increasing evidence suggests infants experience needle-stick pain more intensely than older children (Anand and Scalzo, 2000 ; Kennedy et al., 2008 ). Furthermore, increased distress during needle- sticks, including in newborns and older infants (Peters et al., 2003 ; Tadd io et al., 2002 ), has been associated with negative memory and greater distress during fut ure procedures and avoidance of future medical care (Davey, 1989 ; Pate, 1996 ; von Baeyer et al., 2004 ). Surface skin adhesives (octyl- or butyl-cyanoacrylates) and adhesive-strips have been used for many years to close clean minor wounds in areas where there is little tension or motion (Farion et al., 2003 ; Zempsky et al., 2004b ). Cosmetic outcomes have been similar to clo sures with sutures and with reduced procedure pain and time. Careful approximation of irreg ular wound edges during gluing can be challenging in restless children, but a newly evaluat ed adhesive mesh used for initial approximation may make this easier and a stronger closure (Singer et al., 2011 ). Staples, while enabling rapid closure of wounds, require special t ools and a return visit to health care for removal, making this a less desirable technique than absorbable sutures, glue, or adhesive strips. Poorly managed venous access pain also impacts the child \200\231s family members. Increase s in heart rate, blood pressure, and anxiety have been measured in parents who observed the ir child receiving a venepuncture in the ED (R. W. Smith et al., 2007 ). In a prospective E D survey of parents of children younger than CHAPTER 34 effective management of children \200\231s pain 341 Use of absorbable sutures obviates the need for a second dis- tressful health care visit fo r suture removal. Suture materials that degrade signifi cantly by 3 to 10 days, e.g. 6 \200 \2230 fast-absorbing or plain gut or irradiated 5 \200\2230 polyglactin 910 (Vicryl Rapide \204 ), are used for facial laceration closure with similar cosmetic outcomes to closure with nylon (Al-Abdullah et al., 2007 ; Karounis et al., 2004 ; Luck et al., 2008 ). Slightl y longer lasting materials, e.g. 4 \200\2230 chromic gut or Vicryl Rapide \204 are used f or closure of trunk or extremity lac- erations. As an adjunct, the tissue adhesives may be used to cover, protect and reinforce fragile rapidly absorbed gut sutures, thus allowing ch ildren to shower. atraumatic (Baxter et al., 2006 ). Finally, a 2007 prospective evalu- ation of 1459 childre n, median age of 3 months, who were under- going LPs in a single ED, found that not using a local anesthetic was a signifi cant independent predictor of traumatic or unsuc- cessful L P on the fi rst attempt (35%; Nigrovic et al., 2007 ). Th ese studies suggest use of local anesthetics in infants reduces distress and struggling and increases the likelihood of a su ccessful atrau- matic LP. What is the most eff ective local anesthetic technique in older children also remains an op en question. No clinical trials of local anesthesia were found in non-infant children under going LP in the ED. Reduction of pain with EMLA prior to lumbar puncture has been found in children with cancer when the LP was success- ful on fi rst but not subsequent attempts (Holdsworth et al., 1997 ). Double-blinded randomized trials in older children undergoing L P in the ED are needed to evaluate the eff ectiveness of newer options such as buff ered li docaine, injection with 30-gauge needles, and liposomal lidocaine cream. Lumbar puncture Lumbar puncture (LP) is commonly performed in infants and tod- dlers withou t local anesthesia or other pain management, despite this being the standard in older child ren and adults. A 2004 survey found two-thirds of academic pediatric emergency physicians d o not routinely use local anesthesia for neonatal LPs (Baxter et al., 2004 ). In a 2007 sur vey of pediatric and emergency medicine resi- dents across Canada, pediatric residents repo rted performing LPs with no local anesthetic much more frequently than their emer- gency me dicine counterparts (Breakey et al., 2007 ). Slightly more encouraging, a 2011 prospective study found that local anesthetics were administered in 54% of infants less than 12 months of age and in 99% of toddlers 12 to 24 months of age undergoing LP for sus- pected meningit is in the ED or pediatric units at a university hos- pital (Gorchynski and McLaughlin, 2011 ). Emergency physicians exclusively used injected 1% lidocaine while pediatric physicians preferred a topical anesthetic. However, a 2011 survey of ED fac- ulty and pediatric emerge ncy medicine fellows at fi ve Midwestern US hospitals, with approximately half of responden ts trained in general emergency medicine, found that although 78% of the phy- sicians belie ved pain intervention is worthwhile for infant LPs, less than one-third regularly use pharm acological interventions to reduce LP pain in this age group (Hoyle et al., 2011 ). Many children benefi t from sedation during elective LP but children undergoing LP in the E D are oft en ill and may have compromised cardiopulmonary function, worsened by being held in a maximally fl exed position for the procedure, thus increasing the risk of adverse even ts associated with procedural sedation. For these patients, administration of an anxiolytic dose of midazolam or 50% N 2 O may improve patient tolerance of the procedure with minimal sedation and lessen the likelihood of respiratory depression. Th is strategy may also make children more amenable to distraction. Eff ective local anesthesia is cru- cial to this st rategy. Recommendations for ED patients undergoing LP are as follows: Infants : anesthetic cream (e.g. EMLA , LMX , Ametop ) fol- lowed by slow injectio n of buff ered lidocaine via 30-gauge needle, along with nutritive suckling (pacifi er, wit h sucrose for <6 weeks of age). Toddlers and older children : anxiolysis with midazolam (IV, PO, IN) along with topical ane sthetic cream (e.g. EMLA , LMX , Ametop ), distraction by Child Life Specialist or instructed fam- ily member or ED staff , slow injection of buff ered lidocaine via 30-gaug e needle. If N 2 O is available, may substitute or combine with midazolam, monitoring oxyge nation with pulse oximetry. If child is very distressed and has good cardiopulmonary functi on, may consider moderate or deep sedation. Th ere is a surprising lack of literature on the eff ectiveness of local anesthesia in redu cing the pain of LP in neonates (Madsen, 2009 ). In a randomized double-blind comparison of the topical anesthetic cream EMLA to placebo cream in newborns undergoing LP, all the n ewborns had evidence of pain (Pinheiro et al., 1993 ). However, compared with placebo, EMLA signifi cantly attenuated the pain response as shown by lower heart rates and behaviora l scores. Th is and other studies demonstrate that infants typically cry and struggle when simply positioned for a LP, whether or not topical or injected local anesthesia is used, an d that reduction in distress associated with use of a local anesthetic may be diffi cult to discern clinically (Porter et al., 1991 ). Administration of oral sucrose and use of non-n utritive sucking, in addition to local anesthetic, pro- vides additional reduction of distr ess. Urethral catheterization Urethral catheterization (UC) is considered by children and adults to be one of the most painful and distressing common procedures performed in the ED, with males reporting more pain than females (Babl et al., 2008a ; Kozer et al., 2006 ; Singer et al., 1998 ). Lubricating anesthetic gel is widely recommended in adults to reduce the pain caused by the friction and pressure from the catheter \200\231s pas- sage through the uret hra into the bladder, but this adjunct is rarely used in pediatric ED patients, perhaps due to time constraints and because of only moderate reduction of distress (MacLean et al., 20 07 ; Vaughan et al., 2005 ). Common rationales for not using injected lidocaine in infants include that its use makes th e infant suff er \200\230two sticks instead of one \200\231 and that the injected lidocain e makes the LP more dif- fi cult by obscuring landmarks. However, a 1993 study of neonates undergoing LP found that while the infants struggled when infi l- trated with lidocaine, th ose who received lidocaine struggled sig- nifi cantly less during the spinal needle inserti on (Pinheiro et al., 1993 ). Consistent with these fi ndings, a 2006 prospective obser- vat ional study of infants in a university ED found LPs performed with local anesthetic were tw ice as likely to be successful and UC has been found in infants to cause less pain and be more likely successful in obtaining urine for analysis and culture, com- pared to suprapubic aspiration, without increased adve rse events (Pollack et al., 1994 ; Tobiansky and Evans, 1998 ). In a study of SECTION 4 pain in specific populations and diseases 342 febrile full-term infants, less than 2 months of age, suprapubic aspi- ration through skin anesthetized by EMLA was also found to be more painful than UC using a 5-French feeding tube lubricated with sterile 2% lidocaine gel (Kozer et al., 2006 ). In contrast to the studies in adults, Babl and colleagues, in a well-designed comparison of nebulized 2% lidocaine at 4 mg/kg to saline placebo in children between 1 to 5 years of ag e in the ED, found distress scores were very high in both groups during NG tube insertion a nd terminated the study early (Babl et al., 2009 ). No child demonstrated any evidence of l idocaine toxicity but, of note, the trachea was inadvertently intubated in one child in eac h group, emphasizing the need for confi rmation of gastric placement by pH, radiograph, or other means (Kuo et al., 2010 ). Further investiga- tions in children are needed to determi ne how best to reduce the pain of NG tube insertion. Perhaps as important, clinicians may r econsider whether NG tube insertion can be avoided (Witting, 2007 ). In older infants and toddlers, behavioral pain scores were high and did not diff er during UC in children less than 2 years of age when 1 to 2 ml of either non-anesthetic or 2% lidoc aine gel was applied topically to the genital mucosa for 2 to 3 min before cath- eterizatio n and the remainder of the gel used as lubricant on the catheter (Vaughan et al., 2005 ). H owever, others found reduced distress when 2% lidocaine gel was applied topically for 2 min then instilled into the urethra for 2 more minutes when compared to non-anesthetic gel in febrile 2- to 24-month-old ED patients (Mularoni et al., 2009 ). When considering the available evidence, it is recommended cli- nicians administer intranas al 2% lidocaine at 4 mg/kg (0.2 ml/kg of 2%) as a gel or atomized spray to children at leas t 5 min prior to NG tube insertion. Oxymetazoline or phenylephrine nasal sprays may be co-a dministered to shrink the nasal mucosa and reduce epistaxis. Most children will show signs of distress during the administration of the lidocaine and NG tube insertion but it is like ly a signifi cant portion of the pain of the procedure will have been abated. Blunting of p rotective airway refl exes may occur with these techniques. In children between 4 and 11 years of age, use of 2% lidocaine gel was associated with sign ifi cantly less pain and distress during UC for cystograms compared to non-anesthetic gel w hen the lidocaine gel was applied with suffi cient time to provide anesthesia (Gerard et al ., 2003 ). A cotton ball soaked with either lidocaine or placebo lubricant was placed on th e urethral meatus and held in place for 1 to 2 min. Th en, dependent upon the size of the c hild, 0.5 to 2.0 ml lubricant or lidocaine gel was instilled into the urethra. Th e instill - lation was repeated twice more, with 2 min intervals between each instillation. A child l ife specialist provided distraction and sup- port during the procedure and rated the child \200\231s distress. Th e group receiving 2% lidocaine gel had signifi cantly lower self-rep ort pain and observed distress. Abdominal pain Abdominal pain is a common nonspecifi c complaint in children seeking medica l evaluation in the ED (Reynolds and Jaff e, 1992 ; Scholer et al., 1996 ). Acute cramping abdominal pain from self- limited minor illnesses such as gastroenteritis or viral infectio ns is not eff ectively reduced by analgesic medications and may be pro- longed by opioids t hat exacerbate intestinal ileus. Many systemic ill- nesses may cause abdominal pain, includ ing diabetic ketoacidosis, haemolytic uremic syndrome, Henoch \200\223Sch nlein purpura, hepati- tis, and myocarditis, the diagnosis of which are usually made with a careful histo ry and physical exam, and, occasionally, specifi c ancil- lary tests. Some causes of abdomi nal pain may require antibiotic treatment including lower lobe pneumonias, urinary tract in fec- tions, streptococcal pharyngitis, and pelvic infl ammatory disease. It is also importa nt to evaluate for conditions that may require urgent surgical intervention such as trauma, volvulus, intussusception, ovarian torsion, incarcerated hernia, or appendicitis. For many of these conditions, administration of an analgesic medication aft er a diagnosis or furth er evaluation or therapeutic intervention is begun will provide some patient relief without obscuring the diagnosis or increasing management errors (Ranji et al., 2006 ). Th e best s tudied example is when the diagnosis of appendicitis is being considered, administration of morphine or buccal oxycodone has been found not to interfere with clinical diagnosis while reducing pain preop- eratively and facilitates diagnostic techniques such as abdominal ult rasound (Sharwood and Babl, 2009 ). However, this practice is frequently underutilized (Gol dman et al., 2006 ; Kim et al., 2003 ). Because signifi cant pain and distress occurs with UC despite use of anesthetic gel, altern ative adjuncts have been investigated. Oral sucrose solution (24%) administered 2 min prior to UC reduced pain scores and crying in infants less than but not older than 30 days of ag e (Rogers et al., 2006 ). Midazolam 0.6 mg/kg orally induced complete amnesia for UC in 60% and partial amnesia in 31% of very anxious children (mean age 4.4 years; Elder and Longene cker, 1995 ) and intranasal midazolam 0.2 mg/kg signifi cantly reduced distress in children median age 2 to 3 years (Stokland, 2003 ). Intranasal fentanyl, 2 mcg/kg, of note, did not reduce UC pain in children 4 to 8 years of age (Chung et al., 2010 ). Most successfully, N 2 O 50% to 70% has been found to reduce distress behavior and need for restraint in childr en during UC compared to non-sedated controls or to those receiving oral midazolam (Keidan et al., 2005 ; Zier, 2007 ). Nasogastric intubation Although emergency physicians and nurses acknowledge the marked disc omfort, NG tube insertion is typically performed with- out any form of pain relief other th an a lubricant in children (Juhl et al., 2005 ; Stock et al., 2008 ). Studies in adults des igned to fi nd an eff ective local anesthetic technique for NG tube insertion have pri- mar ily focused upon use of 2% to 10% lidocaine as a gel, nasal spray, or nebulized mist (Galla gher, 2004 ; Kuo et al., 2010 ). Cetacaine and cocaine have also been investigated but are not recommended due to associated toxicities (US Food and Drug Administration, 2011). A sys tematic review of fi ve randomized controlled trials in adults concluded that administratio n of nebulized or atomized lidocaine before NG tube insertion can decrease pain by 60% (Kuo et al., 2010 ). Two more recent randomized controlled trials in adults like- wise found be nefi t from lidocaine spray (Chan and Lau, 2010 ) and gel (Uri et al., 2011 ). Headache Headache is a common chief complaint in children presenting to the ED (Burton et a l., 1997 ; Kan et al., 2000 ; Lewis and Qureshi, 2000 ). Th e majority of these children ar e diagnosed with viral ill- nesses or migraine headaches. Aft er viral infections, rebound headaches from chronic daily use of ibuprofen or acetaminophen (Vasconcellos et al., 1998 ) , and rare but life-threatening causes of headache, including meningitis, encephalitis, int racranial abscess CHAPTER 34 effective management of children \200\231s pain 343 or hemorrhage, hydrocephalus, hypertension, or brain tumor are excluded by a careful histor y, neurological exam, and, if necessary, intracranial imaging (Kan et al., 2000 ; King, 201 2 ), the diagnosis of migraine headache should be considered (Lewis, 2009 ). Migraine heada ches in children are defi ned as recurrent headaches with pain- free intervals and at least three of the following six symptoms: (1) an aura; (2) unilateral location; (3) throbbing o r pulsatile pain; (4) nausea, vomiting, or abdominal pain; (5) relief aft er sleep; and (6) a family history of migraines (Lewis, 2009 ; Prensky and Sommer, 1979 ).