Th e temperature of the injectate may also aff ect pain. Lidocaine solutions that are warme d to body temperature, for example, cause less pain during infi ltration, even if the lidoc aine is buff ered (Hogan et al., 2011b). No benefi t has been observed for warmed vaccines, and thus, is not recommended for vaccinations (Taddio et al., 2009a). Pharmacological interventions A variety of pharmacological interventions are available for reduc- ing pain from needle procedures. Th e most common are local anesthetics and sweet so lutions. Evidence-based interventions for pain management Th ere are numerous eff ective, safe, and feasible interventions for managing pain from needle procedures. Th ese interventions Local anesthetics Local anesthetics are the most studied class of pharmacological intervent ions for reducing pain from needle procedures in children. SECTION 4 pain in specific populations and diseases 186 >1 hour to 1 hour 1 to 2 minutes Strategies at time of needle procedure Less painful procedure \200 Less painful injectate \200 For vaccine injections: Rapid I M injection without aspiration, most painful last Procedural Strategies Positioning upright/holding \200 Tactile stimulation near site Physical Strategies Distraction \200 Deep breathing Psychological Strategies Breastfeeding \200 Sugar water \200 Non-nutritive sucking \200 Facilitated tucking/sw addling Infant Strategies EMLA (lidocaine-prilocaine 5%) \200 AMETOP (tetracaine 4%) \200 MAXILENE (liposom al lidocaine 4%) Pharmacological Strategies Education \200 Preparation Family & Child Figure 19.1 Timeline for pain relieving strategies prior to and during needle procedures: p rocedural, physical, psychological, and pharmacological strategies (plus infant and family/ child). IM = intramuscular. Local anesthetics provide analgesia by blocking nociceptive trans- mission in nerve cells. Th ey are administered to the site of the nee- dle procedure using non-invasive (i.e. topic al) and invasive (i.e. needle) methods. Table 19.1 Commercially available topical anesthetics Topical anesthetic Availability Recommended application duration in minutes Table 19.1 summarizes currently marketed products that are applied topically on intact skin and rely on passive diff usion to achieve dermal anesthesia. Depending on the product, cli nically reliable local anesthesia is achieved aft er a contact time of 20 to 60 min. Commer cial preparations available in a disc/patch formula- tion have the local anesthetic embedde d within the delivery sys- tem and are adhered to the skin. Other preparations require that the appropriate dosage (usually about 1 g) be applied to the skin in a mound, and then cov ered with an occlusive dressing. Occlusion facilitates absorption of the anesthetic and pre vents accidental removal and/or ingestion. It may be necessary to apply topical anesthetics to more than one body region (or site) to account for multiple procedures. Care must be ta ken, however, to ensure that maximum recommended dosages are not exceeded in order to pre- vent systemic toxicity. Lidocaine 2.5% \200\224 prilocaine 2.5% Cream, patch 60 Lidocaine 7% \200\224 tetracaine 7% Heat delivery patch 20 Liposomal lidocaine 4% Cream 30 Tetracaine 4% Gel 40 Multiple systematic reviews and meta-analyzes have concluded that local anesthetics are eff ective and safe for reducing pain from common needle procedures (Fetzer, 2002; Lander et a l., 2006; Shah et al., 2009) (see also Zemspky, Chapter 47, this volume). Th ere is evidenc e that they may improve procedure success rate (e.g. insertion of indwelling cannula or pro curement of blood sample is achieved on the fi rst attempt) and reduce total procedure dura - tion time as well, presumably due to reduced pain and movement during procedures (Taddio et al., 2005b). One meta-analysis found tetracaine to be superior to lidocaine-prilocaine f or reducing pain from venepuncture (Lander et al., 2006), suggesting that not all preparati ons are equianalgesic. No diff erences, however, have been observed in procedural success r ate among various preparations (Arendts et al., 2008). Needle procedures are usually undertaken right aft er the required contact time has been me t and both the dressing and anesthetic have been removed. If a procedure is not undertaken immediately, a non-toxic marker can be used to mark the site where the anaes- thetic was ap plied \200\224 this prevents subsequent needle puncture in an unanaesthetized area. Attent ion should be given to the elapsed time following removal, as the anesthetic eff ect will b egin to fade thereaft er. Elapsed times of more than 1 h are not generally recom- mended in order to minimize the risk of analgesic failure. CHAPTER 19 needle procedures 187 Despite their demonstrated eff ectiveness, topical anesthetics are under-utilized for needl e procedures. Th is is due, at least in part, to perceptions about their eff ectiveness and feasibility. Th ere is an expectation that topical anesthetics will lead to painless needl e procedures. However, this is not usually the case. Pain perception is complex, and a resu lt of multiple interacting factors including anxi- ety and fear, which topical anesthetics may not eliminate. In addi- tion, anesthetics do not block all sensation \200\224 sensatio ns of pressure are still present, which may be interpreted by children and/or adults as pai n. Th e depth of penetration is several millimeters, resulting in partial blockade of nocic eptive input for most procedures. Finally, the presence of genetic polymorphisms may predis pose some chil- dren to analgesic failure (Kleiber et al., 2007). accompanied by strategies to reduce injection pain, including: buff - ering lidocaine with sodium bicarbonate (Cepeda et al., 2010) and warming the solution to body temperature (Hoga n et al., 2011b). More recently, novel technologies have been developed that allow for rapid administration o f local anesthetics without the need for needle puncture (Zempsky, 2008). For the most part , there is very limited experience with these technologies and they are not readily availab le in most clinical settings. Th ese technologies off er alter- native methods of administe ring local anesthetics and may come to have an important role in the management of cutaneou s pain in children in the future. Th ey are discussed in further detail by Zempsky (Chapter 47, this volume). With so many options available, the choice of which local anesthetic administration method to use depends primarily on: urgency of procedure, procedure site, child factors, availabil ity of equipment, and availability of experienced staff . If procedures are required urgent ly, only techniques with a short onset of action are suitable. For topical preparations, di sc/patch dosage modalities may be more convenient to use provided that the contact surface area and geography of body region allow them to be suitably applied. Th e presence of speci fi c child factors, such as age, distress levels, allergies, or child preferences lend them selves to the selection of certain preparations over others. Finally, the presence of requi site equipment and trained staff are needed to administer them. Another barrier to the use of topical anesthetics relates to per- ceptions of feasibility. Th e requisite waiting time makes it impos- sible to use topical anesthetics for emergency procedures. Most needle procedures, however, are not required on an urgent basis. Studies p erformed in a wide variety of clinical settings demonstrate that topical anesthetics can be incorporated within usual waiting times for most needle procedures (Fein, 1999; MacLean et al., 2007; Robieux et al., 1990; Taddio et al., 2012a). Th e person applying the preparati on must also know where to apply the topical anesthetic. Concerns that parents are unable t o apply topical anesthetics to the appropriate site(s) are unsupported by primary research (Koh et al., 1999; Taddio et al., 1994). Sweet solutions Sweet solutions have analgesic eff ects in infants up to 12 months of age ( Gaspardo et al., 2005; Harrison et al., 2010; Shah et al., 2009; Stevens et al., 2010). Th eir mechanism of action is unknown; however, it has been speculated to involve taste-induce d release of endogenous opioids, calming through non-nutritive sucking, and/ or distraction . Th ere are a plethora of studies showing reduced pain behaviors in infants given sweet so lutions while undergoing nee- dle procedures (reviewed in detail by Harrison et al., Chapte r 49, this volume). Of note, a recent study failed to demonstrate an eff ect on pain-specif i c brain activity (Slater et al., 2010), questioning whether sweet solutions are \200\230 true analgesics \200\231. However, at present, the clinical signifi cance of that study is not known. Topical anesthetics are well tolerated and considered safe in most children. When used for immunization, they do not appear to interfere with antibody response (Shah et al., 2009). S ystemic toxicities have been reported rarely and have included seizures, dysrhythmias, and methaemoglobinaemia. Methaemoglobinaemia is a toxicity of lidocaine-prilocaine, owing to th e oxidizing eff ects of metabolites of prilocaine. Neonates and young infants are more susc eptible because of immature enzyme activity. For the most part systemic toxicities have onl y occurred aft er either excessive doses or durations of application were used. Careful att ention to dose and duration of application are required to minimize signifi cant absorp- ti on and systemic eff ects (Shachor-Meyouhas et al., 2008). Transient local side eff ects are relatively common \200\224 they occur in one-fourth to o ne-half of individuals, and include transient skin color changes (erythema, blanching), oed ema, and itching. Allergic contact dermatitis is uncommon or rare, and may be more likely w ith ester-based topical anesthetics (tetracaine; Shah et al., 2009). To reduce the onset of action of topical anesthetics and increase the depth of penetration of the active agent, a lternative methods of administration have been used. Of these, injection of local anaes- th etics is the oldest and most common method currently in use. Typically, small volumes (0.1 \200\2230.3 ml) of lidocaine 1% solution are injected intradermally or subcutaneously using a narrow-gauge (27 or 30) needle (Klein et al., 1995; Luhmann et al., 2004; Soliman et al. , 1988). Th e onset of anesthesia is approximately 1 to 3 min. A variety of natural and artifi cial sweet compounds have been evaluated; the most widely u sed is sucrose (Taddio et al., 2009b). Sucrose solutions are administered on the infant \200\231s tongue with a pacifi er, syringe, or cup. Administration with a pacifi er stimula tes non-nutritive sucking and may improve eff ectiveness (Buscemi et al., 2008; Stevens et al., 2010). Th e onset of action is fast (within 10 sec), with a peak eff ect at 2 min, and duration of action of up to 10 min (Buscemi et al., 2008). Th e usual single dose is 0.5 t o 2 ml of 12% to 24% strength (weight/volume; Stevens et al., 2010). Multiple-dose regimens utilize lower single doses, particularly in preterm infants (Stevens et al., 2010) owing t o concerns about potential adverse eff ects. It is not clear whether there is a dose \200 \223re- sponse eff ect (Harrison et al., 2010; Stevens et al., 1997). Th ere is reluctance about using lidocaine injection in some clinical settings. Th is is no t surprising, given its administration is associated with an additional needle puncture, an d pain from the needle puncture and the lidocaine itself (which causes a burning/ stinging sensation). It should be noted however, that the pain from lidocaine injection is less than that from the needle procedure for which it is being utilized; hence, there is an overall net benefi t of less pain when lidocaine injection is used for needle procedures. Neverthel ess, when lidocaine injection is utilized, it should be Sucrose is well tolerated \200\224 adverse eff ects are rare and transient, including chok ing and oxygen desaturation (Stevens et al., 2010, Taddio et al., 2008). One multiple dose study in preterm infants, however, suggested worse neurobehavioural development and severit y of illness scores at selected follow-up testing ages with increasing sucrose exposure (Jo hnston et al., 2002) \200\224 the signifi - cance of this fi nding is unknown (see Harriso n et al., Chapter 49, this volume, for a more detailed review). SECTION 4 pain in specific populations and diseases 188 Psychological interventions Psychological interventions include cognitive and behavioral te chniques aimed at reducing child anxiety and pain. Th e proposed mechanism of action is hyp othesized to involve the \200\230gate con- trol theory \200\231 of pain, whereby descendin g nerve signals involving thoughts, beliefs, emotion, and attention modulate ascending pain signals (Cohen 2008; Schechter et al., 2007). Distraction Distraction involves any technique that removes a child \200\231s attention fro m the needle procedure to something more pleasant. It is viewed as a key non-pharmacologica l intervention for essentially all ages of children. Multiple reviews and meta-analyzes dem onstrate the eff ectiveness of distraction for reducing pain during needle proce- dures (Ch ambers et al., 2009; DeMore and Cohen, 2005; Kleiber and Harper, 1999; Richardson et al., 2 006; Uman et al., 2006) (see also Cohen et al., Chapter 53, this volume). Distraction is us ually commenced before the procedure begins, and is continued during and aft erwards \200 \224 this helps reduce anticipatory anxiety and pain, and enhances recovery (Cohen, 2008). For the most part, psychological interventions do not require specialized equipment, and ar e devoid of toxicity. However, their eff ectiveness oft en hedges on the competence of indi viduals deliv- ering them. Parents and clinicians may not be adequately trained, resulting in limited success. Distraction interventions typically use a combination of cog- nitive and behavioral approac hes. Th ey can consist of relatively simple, cost-neutral or low-cost techniques, such as n on-proce- dural talk, breathing exercises, bubble blowing, playing with toys/ games, and wa tching movies. Alternatively, they can involve more complex and cognitively-based intervent ions such as hypnosis (Buscemi et al., 2008). Th e time required to teach an individual to use simple distractions is short (up to 15 min), making it feasible for most clinical setti ngs (DeMore and Cohen, 2005). Cognitively- based interventions, however, usually require fa cilitation by a trained individual such as a child life specialist, hence, are not eas- ily implemented. In addition, cognitive interventions can realisti- cally only be used in chil dren aged 3 years and older (Richardson et al., 2006). Preparation of parents and children Having parents present during needle procedures underta ken in children is consistent with parent and child preferences and hence, supports family- centered care (Gonzalez et al., 1989; Piira et al., 2005; Pruitt et al., 2008; Ross and Ros s 1984; Stephens et al., 1999). Parental presence has the added benefi t of promoting respe ct for the child \200\231s emotional welfare. Two separate studies correlated parental pres ence with enhanced use of pain strategies in hospi- talized infants (Carbajal et al., 2008; Johnston et al., 2011), either because parents request pain-relieving interventions or the ir pres- ence prompts clinicians to administer them (Carbajal et al., 2008; Johnston et al. , 2011). Parent behavior signifi cantly infl uences child distress and pain during needle procedures , both positively and negatively (Blount et al., 2001; Cohen et al., 2002; Frank et al., 19 95; Gonzalez et al., 1993; Liossi et al., 2007; Rocha et al., 2003; Sweet and McGrath, 1998 ). Parents should therefore be targeted for education about strategies that reduce a child \200\231s distress and pain (Cohen, 2008). In general, children \200\231s distress response s are reduced when adults are calm and use coping-promoting strategies such as coaching chi l- dren to cope and distracting children (diverting children \200\231s atten- tion away fro m the procedure). Conversely, responses are increased when adults are anxious and use distr ess-promoting strategies such as apologizing, criticizing, reassuring, or empathizing. Th e latter may focus children \200\231s attention on the procedure by their nature and the man ner in which they are communicated. Th e most eff ective distractors stimulate multiple sensory modali- ties (e.g. vision, hear ing, touch), elicit positive aff ective states (e.g. laughing), or require overt behavioral responses (Cohen, 2008; DeMore and Cohen, 2005). Th e critical aspect for any distractor, however, is that a child is actively engaged in it \200\224 otherwise, it will be ineff ec tive. To this end, it is important to select age-appropri- ate and engaging distractions (S chechter et al., 2007). Facilitation, either from a health provider or parent is also impor tant, in order to ensure the child \200\231s attention is maintained on the distraction (Co hen, 2008; DeMore and Cohen, 2005). For infants, the proposed primary methods of distraction include parental use of coping-pro moting behaviors and physical inter- ventions (Schechter, 2006) rather than the use of exte rnal items (e.g. toys, books). A recent systematic review and meta-analysis found insuffi c ient evidence to recommend toy-mediated distrac- tion in infants and young children (up to 3 years; Pillai Riddell et al., 2011). Th e same review, however, found suffi cient evidenc e of eff ectiveness for video-mediated distraction in the same popula- tion (Pillai Riddell et al., 2011). Some of the observed inconsisten- cies in the overall eff ectiveness of dis traction may be explained by who delivers the distraction (clinicians versus parents; Chamb ers et al., 2009). Parents may be less eff ective than clinicians because they are: (1) ins uffi ciently trained or experienced to administer dis- traction, (2) unable to undertake ot her soothing behaviors while performing distraction, or (3) anxious and transmit their anxi ety to children. Children should be prepared for needle procedures ahead of time as prior preparation helps to reduce an individual \200\231s anxiety and pain perception (Jaaniste et al., 2007; Suls and Wan 1989). Preparation includes developmentally-appropriate explanations of procedural and sensory information, including: what will happen, how it will feel, what will be done t o prevent discomfort, and what children can do to help (Schechter et al., 2007). It may als o involve demonstrations and/or practice opportunities. Children should not be told \200 \230it won \200\231t hurt \200\231 \200\224 this is an ineff ective strategy and promotes distrust (Taddio et al., 2010a). In general, preparation should not be performed too far in advance \200\224 this may cause children to become fi xated on the event and become more anxious, or to forget procedure d etails (Cohen 2008). Children should have enough time to process the informa- tion and plan how they will cope. Th e information can be pre- sented the day prior to or on the day of the procedure depending on the individual child (Cohen, 2008). Preparation may be suitable commencing at age greater than 2 years (Schechter et al., 2007); however, it may have great er benefi t in children 7 years and older (Cohen, 2008). Physical interventions Physical interventions target body position and physical activity. T h ey are generally cost-neutral. Numerous physical interventions have been shown to reduce pain responses in infants and children undergoing needle procedures. CHAPTER 19 needle procedures 189 Breastfeeding for infants Breastfeeding reduces pain responses in infants up to 1 year of a ge (Shah et al., 2007, 2009). Although categorized as a physical pain- relieving interventi on, the analgesic eff ects of breast milk are hypoth- esized to be mediated by multiple mec hanisms, including touch/ maternal presence (skin-to-skin contact), non-nutritive sucking, sweet-taste and other potentially analgesic substances, and smell. Compared to other pain-r elieving strategies such as sweet-tasting substances and local anesthetics, breastfeeding o ff ers a natural, cost-neutral, and convenient option. Breastfeeding is commenced before th e needle puncture and continued throughout the procedure and aft erward. Th us, an adequate latch must be established prior to the procedure commencing \200\224 this may take a few minutes. Upright positioning and holding Upright position and parent holding are regarded as optimal ways to position children during needle procedures (Sparks et al., 2007; Taddio et al., 20 09a). It is hypothesized that individuals feel less fear when positioned upright than when positioned supine (Lacey et al., 2008) and that parental holding adds support and comfort ( Stephens et al., 1999). Th ere are limited data, however, in young infants and one systemat ic review found confl icting evidence for a benefi t of holding (and/or rocking; Pillai Rid dell et al., 2011). Despite this result, upright positioning has been recommended beginning as soon as infants can hold themselves up (3 \200\2235 months; Stephens et al., 1999). Several variations in positioning and holding have been sug- gested: the most popular invol ves seating children on a parent \200\231s lap, with the child facing the parent. Alternati vely, children can sit on the examination table, with the parent holding the child around t he trunk. Care must be taken to avoid restraining chil- dren as this can increase movement and distress (Stephens et al., 1999). Concerns have been raised about the potential for breastfeeding analgesia to cause infants to choke. To date, this adverse eff ect has not been documented. Another concern is that in fants might learn to associate breastfeeding with pain, which will negatively impact on fut ure breastfeeding. Th is adverse eff ect is also unlikely as needle procedures are sporadic ; hence, breastfeeding would not be a reli- able cue for an impending painful procedure (Sh ah et al., 2009). Upright positioning and parent holding is a simple, cost-free pain relieving intervention t hat can be employed in any clinical setting, provided that clinicians are comfortable with it. Some clinicians may be hesitant about this technique (Lacey et al., 2008; Sparks et al. , 2007), due to perceptions that it is unsafe (i.e. children \200\231s extremi- ties are in suffi ciently immobilized) and that it increases workload (i.e. requiring additional time o r personnel). In addition, clinicians may have to modify their procedure technique to accom modate the child \200\231s position \200\224 this may cause some to feel insecure in their abil- ity to carry out needle procedures successfully (Sparks et al., 2007). Methods to im prove clinician experience and acceptability of this intervention are needed. Other physical interventions for infants and young children A variety of physical intervent ions have been evaluated for their eff ectiveness in infants and young children undergoing painful medical procedures, including skin-to-skin contact (also called kangaroo care/kanga roo-mother care), non-nutritive sucking, rocking, and swaddling (Pillai Riddell et al., 201 1; Taddio et al., 2009a; van Sleuwen et al., 2007). Skin-to-skin contact involves holding infants clad only in a nappy against the bare skin of a parent. In a recent systematic review, there was suffi cient evidence to support skin-to -skin contact as a pain relieving intervention in preterm infants but not full-term neonate s (Pillai Riddell et al., 2011). At present, the optimal exposure time for skin-to-skin con tact prior to needle procedures is unknown and an insuffi cient exposure time in full-term neonates may explain the inconsistent fi ndings. Skin-to-skin contact is described further by Johnston and Campbell-Yeo (Chapter 58, this volume). Tactile stimulation Tactile stimulation is a physical intervention that involves touching t he skin near the procedure site. It may be delivered using a vari- ety of techniques includ ing rhythmic rubbing, manual pressure, pressure devices (e.g. ShotBlocker \204 ), and vib ration devices (e.g. Buzzy \204 ). Most of the studies evaluating this intervention have uti- lized either rubbing or manual pressure delivered by the operator performing the proce dure \200\224 both techniques are ideally suited for use in any clinically setting as they do not require any equipment, advanced preparation, or additional cost (Taddio et al., 200 9a). Th e proposed mechanism of action is hypothesized to involve the \200\230gate control theory \200\231 of pain, whereby nociceptive signal transmission to the brain is reduced b y simultanous competitive transmission of touch sensation. Th e end result is a lower pain signal reaching the brain. Non-nutritive sucking involves the placement of a pacifi er in an infant \200\231s mouth to stimulate sucking. Sucking is postulated to release neurotransmitters that modify pain per ception (Buscemi et al., 2008). Non-nutritive sucking has been shown to reduce pain respons es in preterm infants, full-term neonates, and older infants (Pillai Riddell et al., 2011). Adults may be required to keep pacifi - ers in place. Th e combination of sweet solutions and non-nutritive sucking may improve the eff ectiveness of non-nutritive sucking (Buscemi et al., 2008; Stevens et al., 2010). Tactile stimulation is currently not recommended for use in chil- dren less than 4 years of age due to lack of data supporting its eff ec- tiveness. Limited research in the infant po pulation (Beaver, 1987; Hogan et al., 2013; Jain et al., 2006) does not demonstrate a clear benefi t. One possible explanation for the negative result observed in one trial (Hogan et al., 2013) is that tactile stimulation was delivered by a parent instead of the health car e provider. It is pos- sible that the intervention was not delivered appropriately or that it interfered with the parent \200\231s ability to soothe infants. Additional investigation of the eff ectiveness of clinician-led tactile stimulation is recommended in this populati on. Facilitated tucking or swaddling involves containing the infant \200\231s limbs close to th e infant \200\231s trunk in a fl exed position. Th is physical intervention has been shown to reduce pain in preterm infants and neonates (Pillai Riddell et al., 2011). Care must be taken to avoid over-bundling which contributes to elevated body temperature (van Sleuwen et al., 2007). Some aforementioned physical interventions require the pres- ence of a parent. Involving pa rents supports their preferences to be included in their infant \200\231s care and promotes parent \200\223infant bonding (Franck et al., 2005; Gale et al., 2004), however, this may not always be possible. SECTION 4 pain in specific populations and diseases 190 Cold Skin refrigerants/vapocoolants A variety of volatile chemicals are associated with an evaporation- induced cooling sensation aft er application to the skin. Based on the hypothe sis that cooling reduces pain sensation in cutaneous sensory neurons, these agents have bee n investigated as potential analge- sics for needle procedures (Zempsky, 2008). At present, there are two marketed preparations: Ethyl Chloride and Pain Ease . Th ey are sprayed o n the site continuously until blanching of the skin is observed (and for up to 10 sec). Th e cooling eff ect is short-lived, necessitating needle insertion within 1 min, or re-applic ation. Some individuals experience discomfort with application of these cold solutions; oth erwise side eff ects are limited with appropriate use. interventions are available, however, at present, they are under- utilized. Knowledge trans lation initiatives that target the family, health providers, and institutions are recommend ed to improve current practices (Zhu et al, 2012; Chan et al, 2013; Schechter et al, 2010) (described in detail by Yamada and Hutchinson, Chapter 61, this volume). References Ammentorp, J., Mainz, J., and Sabroe, S. (2005 ). Parents \200\231 priorities an d satisfaction with acute pediatric care. Arch Pediatr Adolesc Med , 159 , 127 \200\223131 . Arendts, G., Stevens, M., and Fry, M. (2008 ). Topical anesthesia and intravenous cannulati on success in pediatric patients: a randomized double-blind trial. Br J Anaesth , 100 , 521 \200\223524 . Numerous studies conducted over the past two decades have not demonstrated a consistent ana lgesic eff ect of vapocoolants, irrespec- tive of age of the individual (child or adult) or procedure (venous access or injection) (Hogan et al., 2011a). Possible reasons for incon- sistent results include: increased or reduced pain perception arising from the cooling sens ation, varied administration methods, or mild (equivocal) eff ects (Shah et al., 2009; Zemp sky, 2008). Vapocoolant sprays are therefore not recommended for widespread use. Beaver, P. K. (1987 ). Premature infants \200\231 response to touch and pain: can nurses make a diff erence? Neonatal Netw , 6 , 13 \200\22317 . Bijttebier, P. and Vertommen, H. (1998 ). Th e impact of previous experience on children \200\231s reactions to venepunctures. J Health Psychol , 3 , 39 \200\22346 . Blount, R. L., Bunke, V., Cohen, L. L., and Forbes, C. J. (2001 ). Th e Child- Adult Medical Procedure In teraction Scale-Short Form (CAMPIS-SF): validation of a rating scale for children \200\231s and adults \200\231 behaviors during painful medical procedures. J Pain Symptom Manage , 2 2 , 591 \200\223599 . Buscemi, N., Vandermeer, B., and Curtis, S. (2008 ). Th e Cochrane Li brary and procedural pain in children: an overview of reviews. Evid Based Child Health , 3 , 260 \200\223279 . Ice Based on the same mechanism of action as vapocoolant sprays, local cooling of the skin can be achieved via application of ice. Similar to studies of vapocoolant sprays, studies w ith ice do not demonstrate a consistent pattern of eff ectiveness (Movahedi et al., 2006; T addio et al., 2009a). Hence, ice cannot be recommended as an analgesic for needle procedure s. Carbajal, R., Rousset, A., Danan, C., Coquery, S., Nolent, P., Ducrocq, S., et al . (2008 ) . Epidemiology and treatment of painful procedures in neonates in intensive care units. JAM A , 300 , 60 \200\22370 . Cepeda, M. S., Tzortzopoulou, A., Th ackrey, M., Hudcova, J., Arora Gandhi, P. and Schumann , R. (2010 ). Adjusting the pH of lidocaine for reducing pain on injection. Cochrane Databa se Syst Rev , 8 , CD006581 . Chan, S., Pielak, K., McIntyre, C., Deeter, B., and Taddio, A. (2013). Implementation of a new clinical practice guideline regarding pain management during childhood vaccine injectio ns. Paediatr Child Health , 18: in press. Combining the 4 Ps of pain management for needle pain Needle pain is an iatrogenic harm; he nce, the goal of pain manage- ment is to prevent it (Chorney et al., 2010). No single pain- relieving intervention reliably achieves analgesia, thus interventions should be combined t o improve eff ectiveness. Pain treatments that are con- sistently applied for all needle pr ocedures experienced commenc- ing from birth ensure the greatest likelihood that procedures are minimally painful, if not pain-free, and that the negative sequelae of unmitigated pai n are averted. When children are suffi ciently mature and/or have developed coping strategi es and preferences, pain management can be tailored to their preferences (Cheng et al., 200 3; Kortesluoma et al., 2008). Chambers, C., Taddio, A., Uman, L.S., McMurtry, M., and HELPinKIDS. (2009 ). Psychological interventions for reducing pain and distress during routine childhood immunizations: a syst ematic review. Clin Th er , 31 , S77 \200\223S103 . Chen, E., Zeltzer, L. K., Craske, M. G., and Katz, E. R. (2000 ). Children \200\231s memori es for painful cancer treatment procedures: implications for distress. Child Dev , 71 , 933 \200\223947 . Cheng, S. F., Foster, R. L., and Hester, N. O. (2003 ). A review of factors predicting chil dren \200\231s pain experiences. Issues Compr Pediatr Nurs , 26 , 203 \200\223216 . Cohen, L. L. (2008 ). Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics , 122 , S134 \200\223S139 . Pain and anxiety might not be completely eliminated by use of pain-relieving interventions. Children may still be anxious because of negative previous experiences, unfamiliar individ uals and/or set- tings, or other reasons. Th ese circumstances in no way negate the use of pain-relieving interventions; instead, they call for additional interventions. Cohen, L. L., Bernard, R. S., Greco, L. A., and McClellan, C. B. (2002 ). A child-focused i ntervention for coping with procedural pain: are parent and nurse coaches necessary? J Pedi atr Psychol , 27 , 749 \200\223757 . Cummings, E. A., Reid, G. J., Finley, G. A., McGrath, P. J., and Ritchie, J.A. (1996 ). Pre valence and source of pain in pediatric inpatients. Pain , 68 , 25 \200\22331 . DeMore, M. and Cohen, L. L. (2005 ). Distraction for pediatric immunization Conclusion Attending to pain from needle procedures undertaken in chil- dren supports child ren \200\231s health because it: (1) reduces acute suff ering, which improves the experienc e of children undergo- ing needle procedures, their caregivers, and operators, and (2) redu ces long-term harms, including non-compliance with future health care interventions as a re sult of minimizing the develop- ment of needle fears. Numerous evidence-based and feasible pain: a critical review. J Clin Psychol Med Sett , 12 , 281 \200\223291 . Diekema, D. S. (2012 ). Improving childhood vaccination rates. 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