Wilcox , C. ( 2010 ). Gastrointestinal consequences of infection with human immunodefi cien cy virus . In M. Feldman , L. S. Friedman , and L. J. Brandt , (eds) Sleisenger and Fordtra n \200\231s gastrointestinal and liver disease , pp. 523 \200\223536. Philadelphia, PA : S aunders . Ravilly , S. , Robinson , W. , Suresh , S. , Wohl , M. E. , and Berde , C. B. ( 1996 ). Chronic pain in cystic fi brosis . Pediatrics , 98 , 741 \200\223747. Yaster , M. and Schechter , N. ( 1996 ). Pain and human immunodefi ciency virus infection in children . Pediatrics , 98 , 455 \200\223456. Riquelme , I. , Cifre , I. , and Montoya , P. ( 2011 ). Age-related changes of pain experie nce in cerebral palsy and healthy individuals . Pain Med , 12 , 535 \200\223545. Yogev , R. C. , and Chadwick , E. G. ( 2011 ). Acquired immunodefi ciency syndrome . In R. M. Kleigman , B. F. Stanton , N. F. Schor , J. W. St. Geme , and R. E. Behrman (eds) Nelson textbook of pediatrics , 1157 \200\2231176. Philadelphia, PA : Saunders . Robinson , W. M. , Ravilly , S. , Berde , C. B. , and Wohl , M. E. ( 1997 ). End-of-life care in cystic fi brosis . Pediatrics , 100 , 205 \200\223209. CHAPTER 33 Common pain problems in the outpatient setting F. Ralph Berberich and Neil L. Sc hechter Summary Th is chapter will review key concepts pertaining to pediatric pain relief in offi ce settings. Included are general principles important to achieve pain reduction, pain attr ibuted to normative develop- mental processes such as teething, colic, and \200\230growing pains \200\231, pain from infections such as otitis media and pharyngitis, and pain from m inor procedures. Th ere is enormous individual variability in response to a painful stimulus Pain is a compl ex multifactorial phenomenon with enormous variation from person to person. Th ere is no pr edictable level of pain response for a given nociceptive stimulus. Th e pain experience for any child is a composite of various factors including temperament, age, previous experienc e, parental response, social modeling, genetic predisposi- tions, and psychological state ( Blount et al., 2008 ; McMurtry et al., 2010; Schechter et al., 2007 , 2010). A clinician wh o knows the child and family well can anticipate how the child might respond based on uniqu e attributes of the child and his or her previous response to pain- ful procedures. Clinici ans also can benefi t from the parent \200\231s in-depth knowledge of the child. Awareness of prior reactions, temperamental characteristics, and family dynamics may suggest non-phar macologi- cal strategies and stave off more aggressive interventions. Introduction Unfortunately, many advances in pediatric pain management have not been applie d to the pediatric offi ce (Berberich and Schechter, 2012 ). For example, despite their exp onential increase in number, immunizations are oft en still administered in a manner simila r to the way they were 40 years ago, continuing to contribute to a rate of needle phobia of 10% or more. Furthermore, little research has been done on relieving the pain of otitis or pharyngitis, common problems which are a signifi cant source of discomfort. Th e reasons f or this are mani- fold but certainly due at least in part to the less dramatic and oft en e phemeral nature of pain in the offi ce. Th ere exists additional concern that systematicall y addressing these issues might reduce offi ce pro- ductivity and effi ciency. Despite thes e barriers, addressing pain may prevent some of its short- and long-term consequences. Addi tionally, attention to pain is likely to enhance the relationship between the phy- sician a nd the child and his or her family (Schechter et al., 2007 ). Explanation and guidance regarding pain may help reduce it Anticipatory guidance has become a cornerstone of pediatric practice. Although children display signifi cant individual dif f er- ences, they develop, in general, predictable sequences that allow us to anticipate wh at their challenges will be. Routinely incorporating information about pain into well child visits may allow children and families to prepare for, and appropriately cope with, the pa in- ful experiences that arise during childhood. Th is includes identi- fying helpful indiv idualized strategies as well as recognizing when analgesics may be of value, and how best t o use them. Two of the constructs are discussed in the following two sections. General principles Th e offi ce based clinician, who typically has a long-term relationship with the child and family, and is well versed in child development, is in position to inco rporate the principles of pain reduction into the practice setting. By doing so, he or she can lower the cumulative impact and memory of repeated \200\230minor \200\231 painful insu lts (Von Baeyer et al., 2004 ). He or she can perhaps prevent the development of nee- dle p hobia, teach parents to provide comfort for their children, and reduce the anticipatory fea r and anxiety that oft en surrounds visits to a health care professional (Schechter et al., 2010 ). Development of a pediatric offi ce that routinely employs the following principles will improve the quality of life not only for the child and his or her family but also for the pediatric offi ce staff (Schechter et al., 2010 ). Anticipate and/or prevent pain whenever possible Th e importance of anticipating pain and t he prompt use of pain reduction strategies should be emphasized at the outset of the phy- s ician \200\223patient relationship. Pain may be more easily controlled if it can be prevent ed or addressed early on. Clinicians should give information about medication dosing and sa fe intervals between doses. Parents should understand that pain medication can be given pro actively in anticipation of pain aft er injury or during illness or before procedures such as venepuncture. When a medication is appropriate for either pain or fever, parents should be instructed not to omit that medication \200\230because there is no fever \200\231. CHAPTER 33 common pain problems in the outpatient setting 329 Promote self-mastery in the child Teaching children techniques that can allow them to contr ol their pain decreases the helplessness that they may feel when confronted with a painful situation. Th e clinician periodically can support and reinforce the importance of particip atory distraction and encour- age parents to identify the most appropriate and eff ective c oping measures for their child. Th ey best know their child \200\231s temperament, and the strategies that have been eff ective previously. Measures such as singing a song together, reading a story, watching a video, are ways to reduce the \200\230bother \200\231 and trau ma of a painful or fright- ening event. Th ese techniques, as well as others incorporated i nto an immunization sequence, can diminish the pain response and its associated anxiety (Be rberich and Landman, 2009 ). Many of these techniques could be practiced at home to enhance their mastery. As the child grows, the clinician can remind parents to bring along stuff e d animals, books, or smartphones and to help engage in self- calming non-procedural talk an d activities. Parents should learn that it helps to look forward to something pleasurable, i.e. \200\230When we \200\231ve fi nished here, then we can \200\231 child through painful procedures in the offi ce. When medically safe, upright comfort posit ioning, oft en on a parent \200\231s lap, is the best choice for the examination or any pro cedure that could be seen as inva- sive (Lacey et al., 2008 ; Schechter et al., 2007 ; Spar ks et al., 2007 ). If restraint on an exam table is required, positioning a parent near the child \200\231s head and seeking cooperative possibilities reduces anxiety. Analgesics in the outpatient setting Th e judicious use of pharmacological agents remains a mainstay of successful pain treatment. Acetaminophen (paracetamol, APAP) and non-steroidal anti-infl ammatory drugs (NSAIDs), typically ibuprofen, constitute the primary fi rst line agents. Th ey are con- sidered to be equally safe although ibuprofen may be a bit more eff ective (Pierce and Voss, 2010 ). Until there is suffi cient evidence to support one agent over another, a step wise approach, similar to the World Health Organization pain ladder, s eems reasonable when pain persists despite a properly administered single agent. Th is enta ils adding one agent to the other at safe dose intervals (Wright and Liebelt, 2007 ). While there seems to be no antipyretic advantage to an \200\230alternating \200\231 3 h acetami nophen/ibuprofen sched- ule other than its perceived simplicity (Wright and Liebelt, 2007 ) , analgesia may be enhanced by utilizing both in combination (Ong et al., 2010 ). To avoid confusion, written administration plans are advisable (Wright and Liebelt, 2007 ). Physicia ns need to prepare parents so that they completely understand how to use these medi- cation s and neither overdose nor underdose. Handouts or offi ce web sites for parents are oft en helpful. Attention to the language and demeanor of the clinician and the parent is critical Language and demeanor have a critical role in shaping the child \200\231s experience of, and respon se to, painful situations. Children readily read verbal and non-verbal signals, such as fac ial expressions, tone, pitch of voice, whether a sentence rises or falls, and the degree of confi dence and security displayed by a parent (Blount et al., 2008 ). If the content of w hat is said is at odds with the non-verbal message, the child may be confused and suff er u ncertainty and paradoxical anxiety. Parental demeanor projecting excessive worry and a sens e of catastrophe oft en will cause exaggerated responses in children (Vervoort et al., 2011 a , 2011b ). Parental modeling can contribute to the development of fear and enduring phobi as (de Roznay et al., 2006 ). Th erefore, parents should be advised to be cognizant of thei r own attitudes towards pain and how any negative prejudice or anxi- ety might be transmitt ed to their child. Th e clinician may face situations in which pain is not treated adequately with acetaminoph en or NSAIDs. Oxycodone and hydrocodone deliver predictable and potent levels of analgesia and are available in liquid preparations. Despite the lack of clinical trials and potential concerns about opioid abuse, fear of untoward out- comes, and lack of published guidelines , pediatricians and family physicians should be prepared to consider these opioids when fac ed with moderate to severe pain. Tramadol (Ultram \204 ) is an atypical opioid that has b een used safely and eff ectively in children at an oral dose of 1 to 2 mg/kg every 6 h. Th ose who treat children should not prescribe codeine-containing medications because of its i nef- fectiveness in many children and toxicity in some. Inert codeine is metabolized to its active metabolite, morphine at a 10:1 ratio in \200\230normal \200\231 metabolizers. Howe ver, there are clinically signifi cant, even fairly large, numbers in whom the CYP2D6 enzym e responsible for that metabolism is genetically altered. In many individuals, up to 30% of the general population, this enzyme variant of CYP2D6 results in poor metabolism, which tr anslates to ineff ectiveness. In others, especially those of North African descent, ultrara pid con- version to morphine may result in toxic levels and a risk of mor- tality (Kelly et al., 2012 ). All opioids tend to produce constipation and this side eff ect is best antici pated with consideration of stool soft ening and laxative agents. Pruritis, hallucinations and dreams, and somnolence should be encountered relatively less frequently in outpatients receiving appropriate doses and short courses. Words uttered in the doctor \200\231s offi ce have greater than expected impact (Berberich, 2007 ). Parents and clinicians should be aware that children might take to heart what may seem like relatively \200\230innocent \200\231 analogies such as \200\230like a bee sting \200\231 (Berberich and Schechter, 2011) or statements that confl ict with what the child is thinking, such as \200\230It \200\231s OK \200\231 or \200\230Don \200\231t worry \200 \231. It is far better to instruct parents, pointing out the nuances of language as well as the possible contradiction between intent and eff ect when speaking to children. In partic ular, a frightened child may hear as a threat what is actu- ally intended only as a light-h earted parental tease, so the clinician should respond appropriately to comments of this ki nd. Curiously, there is evidence indicating that excessive reassurance is not always reassu ring and over-empathizing may actually increase anxiety and discomfort rather than diminish ing them (Schechter et al., 2010 ). Parents have a critical role to play in pain reduction Parents should be encouraged to be a ctive, supporting participants in every medical encounter and be informed how they can be m ost helpful. We have learned that parents, when properly informed and respected, can play a n essential role in the reduction of the pain problems. Parents can help us identify the ty pe and timing of preparation that seems most eff ective. Th ey can practice now- familiar d istraction techniques at home and use these to coach the Table 33.1 lists step-up groupings of common pain medica- tions applicable to the pediatric offi ce setting. Th ese will have a variety of trade names and formulations. Opioids are r egulated in most countries and may require special prescription forms. One must be especial ly cautious when prescribing combination opioid medications that may include other analgesi cs, decongestants, or SECTION 4 pain in specific populations and diseases 330 Table 33.1 Pediatric oral pain medications (formulations may vary) Drug Dose (mg/kg) Interval (h) Suspensions (mg/ml) Tabs (mg) APAP 15 4 \200\2236 160/1 160/5 160, 325, 500 Ibuprofen 10 6 \200\2238 100/5 200, 400 600 Tramadol 1 \200\2232 4 \200\2236 N/A (US) 50, 100 \200\223300 Hydrocodone 0.1 \200\2230.2 4 \200\2236 2.5/5 2.5, 5, 10 Hydromorphone 0.05 4 \200\2236 5/5 5 Oxycodone 0.1 4 \200\2236 1/1 5 antitussives. For example, Lortab elixir contains hydrocodone 2.5 mg per 5ml, but also h as APAP 167 mg, requiring dose adjustment of any concurrent APAP for pain or fever. It also contains 7% alco- hol. In addition, any condition that aff ects drug metabolism or con- cu rrent medication such as diphenhydramine, atropine, or some psychotropic drugs may compound or mask common side eff ects such as somnolence, nausea, and pruritis. Systemic oral analgesics are recommended fi rst. Most commonly, these are acetaminophen, ib uprofen, or combinations of both, as previously described. It may take up to an hour for ac etaminophen and ibuprofen to become noticeably eff ective. In the case of AOM without perfo ration, local analgesic therapy may bridge this gap and allow for rapid comfort. In the US, Auralgan (antipyrine, benzocaine, and glycerin) is popular for this purpose, although d efi nitive benefi t remains to be established. A double blind, rand- omized, placebo-contro lled pediatric study using topical aqueous 2% lignocaine showed a 50% reduction in pain sco res from baseline at 10 and 30 min (Bolt et al., 2008 ) but the validity of the study has b een challenged (Bharti and Bharti, 2008 ). In a non-controlled multicentre observational st udy of a little over 400 children, most of whom had AOM, another comparable analgesic, proc aine with phenazone yielded physician rated effi cacy of \200\230good \200\231 or \200 \230very good \200\231 in more than 95% (Adam et al., 2009 ). However, an earlier Cochrane review found insuffi cient evidence to support the eff ectiveness of either topical analges ia or naturopathic herbal eardrops (Foxlee et al., 2006 ). Clinicians confronted with intra ctable otalgia should be prepared to utilize opioids, as they are likely to be eff ective. It is important to alert families to formulation variance, idiosyn- cratic dropper markings , expiration dates, the importance of closing childproof containers, and proper disposal of unused opioid medi- cation. Parents should be encouraged to consider pain apart from its c ause and an independent symptom that calls for independent attention. It is still the case that parents sometimes withhold pain medication for fear that important symptoms may be mas ked and the validity of the physical examination compromised (Bromberg and Goldman, 2007 ). It may be appropriate to introduce general guidelines for analgesic medications early, per haps coinciding with immunizations at 2 months of age. Periodic reinforcement can be provid ed at intervals during well child visits. Pain associated with speci \201 c conditions In the following section, specifi c pain prob lems will be reviewed. Th ese include pain arising from the evaluation and treatment of spe cifi c disease states, pain that stems from normative processes, and pain from commonly per formed procedures. Needle proce- dures are discussed elsewhere in this text (Taddio, Chapte r 19 ). In AOE, it seems clear that antibiotic ear drops with or without hydrocortisone plus suspen sion of water exposure leads to the most rapid resolution of pain as well as the infection (Roland et al., 2008 ). A variety of warm oils and hot compress applications may provide tr ansient symptomatic relief, but have not been tested rigorously. Otalgia is a common occurrence and parents should be edu- cated about pain treatment in adv ance of the fi rst ear infection. In a report describing an education program at the 15-mon th well- child examination, to which was added a proactive prescription for antipyrine-benz ocaine otic drops (Auralgan ), the study group experienced reductions of 80% emergency r oom, 40% urgent care, and 28% primary care visits for otalgia (McWilliams et al., 2008 ). Pain stemming from speci \201 c disease processes Otitis and otalgia Acute otitis media (A OM) is the most common cause of childhood physician visits in the US, generating 16 million outpatient encounters and 13 to 15 million prescriptions per year, as well as signifi cant fi nan- cial costs (Woodwell and Cherry, 2004 ). Additionally, about 2.4 mil- lion US heal thcare visits occur for the treatment of acute otitis externa (AOE) (Centers for Disease Co ntrol and Prevention (CDC) 2011a). Acute pharyngitis In a sample of 160 families that included approximately 240 chil- dren, 4 1% experienced at least one episode of acute sore throat in a 16-month prospective study pe riod (Danchin et al., 2007 ). Bacterial infection, notably by group A Streptococcus account s for roughly 20% to 35% of pharyngeal infections (Shaikh, et al., 2010). While the literat ure is replete with articles about group A strep- tococcal disease, evidence-based pain man agement protocols are lacking. Th is persists despite the observation that antibiotics do l it- tle to ablate pharyngeal pain. Common to both entities is otalgia, which is oft en quite intense (Narcy et al., 2006 ). Th e structures of the external canal, middle ear, and tympanic membrane contain a wealth of nociceptive innerva- tion responsive to infl ammation and pus under pressure (Zempsky and S chechter, 2000 ). Antibiotics do not have a rapid or profound eff ect on the resolution of pain (Spiro et al., 2008 ). While contro- versy continues to surround recommendations for t he institution and choice of antibiotics, the treatment of otalgia remains a press- ing con cern, especially for parents confronted with crying children and sleepless nights. Pain control here as with many other conditions begins with the administration of oral anal gesics, specifi cally acetaminophen and ibuprofen. Medication may be harder to give because of pain CHAPTER 33 common pain problems in the outpatient setting 331 Pain associated with normal growth and development Certain events are so oft en encountered during the course of normal growth and development that it is hard to consider them abnorm al. However frequency does not dismiss the signifi cance and validity of the pain experienc ed. Few interventions have been identifi ed as effi cacious for these problems and reassuri ng parents of their benign nature and supporting them through them these episodes is perhap s the most valuable contribution that the clini- cian can make. and dysphagia, or from illness-associated vomiting. When either is prominent, rectal acetam inophen may be the better choice. Although most pharyngeal pain resolves by 48 h, prescribi ng around-the-clock analgesic increases that resolution from 55% to more than 70% (Bertin e t al., 1991 ). Tramadol or opioid-ibuprofen/ acetaminophen combinations may be indicated to relieve refrac- tory pain and maintain hydration. Th e treatment of mononucleosis-associated exudative tonsillitis may require maximum analge sia eff orts. Once a presumptive diag- nosis is established, a short course of steroids may provide relatively rapid relief. Steroids have been found eff ective for other forms of se vere pharyngitis as well (Korb et al., 2010 ). In two randomized clinical trials in which p ediatric patients received dexamethasone, 0.3 mg/kg to 15 mg maximum (Roy et al., 2004 ), o r 0.6 mg/kg sin- gle dose to 10 mg maximum (Olympia et al., 2005 ), versus placebo, sore th roat resolved earlier and faster, whether or not patients tested positive for group A Strep tococcus or mononucleosis. Colic Colic was defi ned almost half a century ago by the rule of 3s, coined by Wessel as e xcessive crying and fussing for more than 3 h per day, more than 3 days a week, for more th an 3 weeks \200\231 dura- tion. Colic is one of childhood \200\231s most disconcerting, yet physi- ologically benign, conditions, occurring in up to 20% of infants (Shergill-Bonner, 2010 ). Th ere are those who maintain that colic is not painful, but rather a state of pain -unrelated excessive cry- ing without identifi ed cause (Lucassen and Assenfelft , 2001). D espite its unknown etiology, there seems to be agreement that abdominal distress is associa ted with amplifying aerophagia and distension. No medication resolves colic and there also is no other proven standard therapy (Hall et al., 2011 ). Herb teas and similar preparation s such as fennel-containing gripe water are oft en suggested, but none have been studied sy stematically. Other approaches such as formula alterations, probiotics, acu- puncture, chir opractic manipulations, and massage have been advocated by some (Arikan et al., 2008 ), but remain unsupported by evidence. Lozenges and cough drops designed to soothe throats are not advised for children under the age of 4 years or for others in whom there is an aspiration risk. A transient benefi t for older children may be presumed to represent benign intervention, but no studies actually ex ist to demonstrate pain relief or signifi cant soothing. A randomized clinical trial in adu lts undertaken in the UK showed about 2 h relief from amylmetacresol/2,4 dichlorobenzoyl al cohol lozenges (McNally et al., 2010 .) Some practitioners or parents may favor herbal prep arations or a variety of home remedies, but their safety and effi cacy likewise still need to be tested. Gingivostomatitis In children, stomatitis, faucal ulcers and gum swelling, are com- monly a ssociated with primary herpes simplex or herpangina due to Coxsackie infections. A majority of children will have had pri- mary herpes simplex or another form of viral pharyngitis by age 5 years. Pain and reluctance to eat and drink are the primary symp- toms of concern, a s the illnesses themselves typically run a benign course. Measures undertaken by clinicians currently seek to mini- mize parental distress, maintain bonding, and off er reassurance as to the absence of long-term consequences (Keefe et al., 2006 ). Dietary alterations only help if there is an identifi ed intolerance. (Shergill-Bon ner, 2010 ). Interruption of breastfeeding or multiple formula changes may be undesirable c onsequences of well-inten- tioned interventions. Given the frustration of parents, a variet y of unproven interventions such as gentle rocking while pacing, long rides in the car, swa ddling and \200\230shushing \200\231 (Karp, 2007 ), competing noise such as that generated by a vacuum cleaner, and parental ear plugs, all continue to be suggested. Analgesic medications, acetaminophen and ibuprofen, may be prescribed around the clock and timed to reach peak eff ect at mealtimes. If dehydration or inadequate oral intake result, opioid combinations or intravenous rehydration may be necessary. Acidic foods such as citru s or vinegar may cause pain. Milk-based shakes or their equivalent may be preferred to soli d food. Depending on the location of lesions, drinking through a large straw may be accepte d. Teething A variety of behaviors, such as irritability, intermittent crying, and increased c hewing may indicate teething during the fi rst 6 months of life (Feldens et al., 2010 ), al though the caveat is that these may also be part of normal development. Much is falsely bla med on tooth eruption, especially by parents surrounded by teething lore (Owais et al., 201 0 ). Prospective cohort studies have revealed only weak association with previously reporte d symptoms, and no asso- ciation with severe illness (Ramos-Jorge et al., 2011 ). Local pai n and low-grade fever may be attributed to teething legitimately only by a process of elimi nation. Acyclovir may shorten the duration and thus indirectly aff ect pain (Faden, 2006 ). A numbe r of topical medications can be pre- scribed, most of them derived from experience with che motherapy and radiation-induced stomatitis. Th e rationale behind these agents is to coat e xposed ulcers. Th us either diphenhydramine-bismuth subsalicylate (Kaopectate ), or diph enhydramine-aluminum/mag- nesium hydroxide is oft en used on an anecdotal basis. Th ere are no published prospective trials comparing the treatment options. Viscous xylocaine 2% is attractive for its numbing properties but carries a theoretical ris k for aspiration and the possibility of a child biting his own buccal mucosa. Th ere have b een documented toxici- ties, some fatal, due to overdose or swallowing rather than \200 \230swish and spit \200\231 (Curtis et al., 2009 ). Application of the lidocaine directly t o the lesions may be safer, but saliva is likely to carry at least some throughout the orop harynx and therefore entail the same risks. Oral ibuprofen and acetaminophen have long been used to treat teething pain, especially whe n it interferes with sleep. Opioids are not recommended because there is no evidence for ef fi cacy in the setting of a relatively mild, yet protracted condition. Parents may be cauti oned that a baby who immediately soothes when picked up may not be suff ering from teething pain. Th ere is no evidence that topical and homeopathic preparations, ice pack massages, or SECTION 4 pain in specific populations and diseases 332 frozen foods applied locally provide eff ective relief. However, fro- zen solid, non-phthal ate containing teething rings, hard apples, frozen bagels, are popular. Agents containing l idocaine, benzo- caine or comparable anesthetics can be toxic, rarely associated with metha emoglobinaemia, even occasionally lethal (Curtis et al., 2009 ). Some teething gels have be en associated with salicylate tox- icity (Williams et al., 2011 ). Although widely availabl e, there is no evidence to support herbal and other over-the-counter teething remedies. Gomco, Plastibell, or Mogen. Local anesthesia infi ltration con- sisted of dorsal penile ne rve block (DPNB), ring block, or topical anesthesia. DPNB is carried out in a fairly standa rdized manner with 1% lidocaine without adrenaline 0.2 to 0.5 ml delivered at the 10:00 and 02:00 position subcutaneously at the base of the penis penetrating Buck \200\231s fascia ( Kirya and Werthman, 1978). A circum- ferential ring block is performed with the same lidoca ine injected mid-shaft or behind the corona. Choice of clamp may refl ect operator training, degree of comfort, or perceived risk of per forming the procedure as much as evidence- based data. In combination with DPNB, the Mogen clamp entails less pain and a shorter procedure time than the Gomco clamp (Kurtis et al., 1 999 ). Growing pains Th e term describes a poorly understood syndrome of recurring bilateral lower limb discomfort, typically occurring at night in active children during the pre-pubertal g rowth years. Th e inci- dence is estimated at 10% to 20% between the ages of 3 to 12 years, with a peak occurrence between ages 4 to 8 years (Goodyear-Smith and Arroll, 2006 ). Th e pain may be suffi cient to awaken the child. Characteristically, there are no physical fi n dings and no other limbs or muscle groups are involved. Children are asymptomatic during th e day. Th e diagnosis is made by exclusion; yet the recur- ring nature of symptoms without anatomic explanation may arouse anxiety on the part of parents and this in turn my intensif y symp- tom reports. A recent literature search disclosed the absence of evidence to endors e any particular form of therapy (Evans, 2008 ). Systemic oral analgesics such as ibuprofen or acetaminophen may be administered in conjunction with local measures such as mas- sage, stretching, and warmth. Th e latter may be accomplished with heavy-duty cotton, wool, or p olyester socks that extend over the calf. To enhance warmth, these can be preheated in the dryer. Microwaved heat packs may be useful, but need to be assessed for hot spots before be ing applied. Taddio has summarized the substantial data confi rming the eff ectiveness and safety of DPN B (Taddio, 2001 ) versus placebo or no treatment. A 1997 randomized clinical trial compared pain using a ring block, DPNB, and topical lidocaine-prilocaine cream. Th e study showed a n advantage for ring block in that it alone was eff ective for the foreskin separation and incision phases of circum- cision ( Lander et al., 1997 ). What topical analgesia gains by being simple to use, eff ective, and portable, it loses as it provides relatively poor analgesia during the brief probe lysis of glans adhesions. Th e duration of the pre- procedure application of topical anesthetics infl uences the clinical outcome. Taddio has cited a range of 45 to 90 min as well as a dos- age range of 0.5 to 5 g (Taddio, 2001 ). However, the depth of anaes- thetic eff ect relates to the duration of a pplication and is greater with longer wait times of up to 120 min in at least one adult stu dy (Wahlgren and Quiding, 2000 ). Th ere does exist the theoretical potential for methaemog lobinaemia related to prilocaine, however the clinically signifi cant risk has been estimat ed to be 0% (Taddio, 2001 ). Liposomal lidocaine cream (LMX-4) also has been shown to be sa fe and eff ective, comparable to lidocaine-prilocaine cream in a randomized trial (Lehr et al., 2005 ). Pain associated with common procedures Circumcision Surgical removal of the penile foreskin is probably the most com- mon, and controversial perinatal procedure in pediatrics. In the US, roughly half or 1.2 million male newborns are circumcised each year. For about one-fi ft h of the world \200\231s population, circumci- sion is a religious expectation. Th ere i s recent data suggesting cir- cumcision may contribute to a reduction in the incidence of H IV/ sexually transmitted infections (Bailey et al., 2007 ) and this may in turn signal an i ncrease in its acceptance (CDC, 2011b). Medical, ethical, and legal pros and cons aside, th e issue of pain management persists, whether circumcision is carried out in the offi ce, ho spital, or elsewhere. A Cochrane Review evaluated 35 trials involving 1997 newborn males to generate best evidenc e conclusions regarding effi cacy of pain interventions (Brady-Fryer et al., 2004 ). Th e m eta-analysis indicated that DPNB and lidocaine-prilocaine cream both reduce circumcision pa in when compared to placebo and that DPNB is relatively more eff ective than lidocaine-pril ocaine cream applied for 60 to 90 min. However, strict comparability of studies was rare as the choice of clamp utilized and length of wait time varied. Additional measures to lessen discomfort include non-nutritive sucking, sucrose, and having the baby securely and properly held by a person as opposed to a plastic molded restraint ( Stang et al., 1997 ; Taddio, 2001 ). Acetaminophen may be eff ective postopera- tively, but has little eff ect before the procedure (Taddio, 2001 ). Recently, the American Academy of Pediatrics issued a policy statement, which reaffi rms th e appropriateness and specifi cs of proper analgesia (American Academy of Pediatrics, 2012) . Th e American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists, Canadian Pediatric Society, British Medical Association, and the British Ass ociation of Pediatric Urologists have issued comparably supportive policy statements. Witho ut analgesia, circumcision causes physiological signs of marked distress, such as elevated heart rate, blood pressure, and plasma cortisol, increased crying, and augmented reactions to painful stimuli in infancy (Taddio et al., 1997 ). Cerumen impaction Excessive earwax may impede the accurate diagnosis of middle ear disease. Its mechanical removal can cause pain, trauma, and bleeding. A 2004 literature review and meta-analysis of adult and pediatric studies showed a 40% clearance rate when water or oil- based otic cerumenolytic agents were instilled for several days. A 2009 Cochrane review in dicated that while otic wax removal drops were more eff ective than water, none stood out a s being superior to any other (Burton and Doree, 2009 ). In order to avoid being confronted with an acute need to remove cerumen, a cli- nician can begin dealing with it whenever it is noted. Instilling Taddio summarized the infl uence of circumcision technique and topical and local anesthetic s on the attenuation of this dis- tress. Circumcisions were performed with one of three cla mps, the CHAPTER 33 common pain problems in the outpatient setting 333 Tick removal Some children may be disturbed by the sensation of skin tenting during removal by traction. Others may seek rapid removal know- ing an insect has attached and burrowed i nto their skin. A 4 to 10 sec spray of vapocoolant (PainEase ) may relieve pain and prov ide kinaesthetic distraction as well. Ocular foreign body and corneal abrasion Proxymetacai ne anesthetic drops can facilitate examination and provide a more accurate diagnosis of for eign body (Sklar et al., 1989 ). A temporary burning sensation may still be experienced. An esthetic drops are instilled only for diagnosis, and not for treat- ment, because of toxici ty and sensitization risks. Patching the eye oft en stops the pain. Subungual hematoma Subu ngual hematomas cause pain secondary to pressure, which can be relieved by creating a hole in the aff ected nail. Th is may provoke anxiety, but should not be painful when accomplish ed by means of a hand-held single-use cautery (Bovie ). Th e cautery tip is gently appli ed to the nail over the hematoma in short bursts, following the manufacturer \200\231s safe ty directions, until suffi cient penetration allows the underlying blood to extrude. A trep hining drill or rotating nee- dle can accomplish drainage as well, but some pressure is req uired and this itself causes pain and potential anxiety, while other asso- ciations such as drill with needle may arouse fear or panic. Children should be told in advance and shown t hat the nail feels no pain. over-the-counter cerumenolytics several times a week during sleep may prove useful, as long as there is no otorrhoea. Faced with blocked ear canals in the offi ce, irrigation with sa line, plain water or a 50:50 hydrogen peroxide/water mixture has been found to be eff ectiv e; however, electric irrigators produce noise that may frighten some children and the sensa tion of water fl ooding the external canal may prove unpleasant for others. Preceding irrig a- tion with a 10 min instillation of liquid ducosate sodium (Colace ) may aid cerumenol ysis, but this method has not been studied sys- tematically. Published guidelines do not in dicate a preference or endorse one removal method over another (Hand and Harvey, 2004 ; Rol and et al., 2008 ). Th ere is no demonstrable effi cacy to support a variety of folk remedi es such as the instillation of oils and garlic. Others, such as candling are ineff ective a nd can cause injury (Zackaria and Aymat, 2009 ). Urinary catheterization Despite its imperfections sterile catheterization remains the gold standard to diagnose urinary tract infection (UTI; Wingerter and Bachur, 2011 ). Suprapubic aspiration is associated with pain and a tendency towards more procedure failures than uri nary catheteri- zation (El-Naggar et al., 2010 ). In a randomized controlled trial, the adm inistration of oral sucrose reduced pain scores and showed a relatively more rapid return t o baseline in infants less than 30 days of age (Rogers et al., 2006 ). However, this benefi cial eff ect was not apparent beyond the fi rst month of life. In addition to catheterization for UTI diagnosis, this procedure is an integral part of the voiding cystourethrogram (VCUG). New guidelines could reduce the necessity for VCUGs (Schr oeder et al., 2011 ), but not entirely eliminate them. Topical 2% lidocaine gel instillatio n may reduce catheterization pain (Vaughan et al., 2005 ), although the evidence is mixed i n clinical trials. Even though VCUGs are not conducted in the pediatric offi ce, the clinic ian may become involved by preferentially referring patients to institutions that attend to the associated discomfort. A 2005 randomized study reported eff ectiveness of hypnotic rel axation in children who had a prior VCUG and were more than 4 years of age (Butler et al, 2 005 ). Successful sedation with 70% nitrous oxide (Zier et al., 2007 ), intra- nasal fentan yl (Chung et al., 2010 ), and midazolam (Herd, 2008 ) has been reported, although others qu estion whether it is benefi cial for the properly prepared child (Sandy et al, 2011). Th e decision might best be individualized by the physician who actually knows the patient. For some, off ering preparation, procedural narration and distraction (Salmon et al., 2006 ), o ft en the province of child life specialists, may be an appropriate stand alone or suppleme ntal choice. Th e \200\230pain-sensitive \200\231 o \203 ce By systematically incorporating the previo usly described principles and strategies into practice, the burden of pain in the pediatric offi ce can be reduced signifi cantly. Additionally, attention to the offi ce environment, physician and staff participation and a general declared emphasis on pain reduction can ma ke a diff erence. O \203 ce environment It is stands to reason that the best pediatric off i ce milieu is one that is cheerful and non-threatening, or better yet, calming, both in it s physical surroundings and in the demeanor of its personnel. Most practitioners assume tha t age appropriate toys, books, and media that utilize innate curiosity can do much to put c hildren at ease. Given the relationship between anxiety and pain perception, envi- ronmenta l props and offi ce fl ow policies that generate a mood of calm could be expected to have a n impact on that anxiety, for better or for worse. Yet there is no data establishing precis e formulas for how those are to be constituted.