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. As most children oft en wait in examination rooms aft er leaving the waiting area, the same kind of props should be available in that location. Th ere is no direct evidence favoring one color scheme or set of books and magazines over another, and this would be hard to come by as cultural, age, and individual preferences all vary widely, and gender also infl uenc es choices. It nevertheless remains a worthy goal to seek the means to divert the child \200\231s attention from preoccupation with the pending examination, immunizations, and oth er disquieting procedures or treatment (Berberich and Landman 2009 ; Du et al., 2008 ; Sche chter et al., 2007 ). Cauterization and foreign body removal Intranasal silver nitrate cauterization for epistaxi s can cause dis- comfort. Th is and nasal swabbing are both swift , but the stinging and sn eezing can be quite unpleasant. Clinicians oft en are faced with having to retrieve a pea o r bead from a nostril. Similarly, obtaining a nasopharyngeal sample by means of a swab may be considered invasive. Where indicated in a fearful child, topi- cal 4% lidocaine delivere d by means of a reusable bottle metered dose atomizer with a disposable applicator (MADomiz er \204 ) may be acceptable prior to instrumentation. Alternatively, anesthetic solutions can be compounded 50:50 with a nasal decongestant con- taining oxymetazoline. An environment rich in distracting materials may be helpful in shift ing focus, especially as it allows, even encourages, parents to engage in non-procedural talk (Schechter et al., 2007 ). Although supporting data are lacking, the choice of wall color, posters and SECTION 4 pain in specific populations and diseases 334 images likely can do much to support a sense of comfort and famili- arity and engage the ch ild. When choosing the elements that will characterize the offi ce and examination rooms, t he suggestibility of children should be kept in mind although the evidence for positive eff ect is mixed (Berberich and Landman, 2009 ; Kohen and Olness, 2011 ). By posting photograp hs of patients and families, children can recognize themselves, perhaps their friends, and be given an anxiety-tempering message of normalcy and familiarity. Similarly, posters of an imals or amusing cartoons provide suggestions of lev- ity and arouse interest. aff ecting the degree of negative conditioning that result from it (Harrington et al., 2012 ). Th e development and dissemination of evidence-based, online, video, and written materi al instructing parents how to approach medical offi ce visits and uncomfortable procedures would be most welcome. Attention to comfort In the pain-sensitive offi ce, comfort measures such as nursing, non- nutritive sucking, and sucrose administration are supported ( Pillai Riddell, et al., 2011 ). Easy access to oral 24% sucrose (Sweetease \204 ) or topical anesthetics will promote their use. Respect for a child \200\231s autonomy tempers fear as does parental proximity. Until it becomes a yes or no option for a curious child, the examination table is best avoi ded unless absolutely necessary. Being supine with a physician hovering over you can be int imidating. Th e timesaving importance of allowing children to adopt positions of security h as been iden- tifi ed in the context of IV placement (Sparks et al., 2007 ). Most pediatric ians become quite adept at demonstrating instruments and creating games as part of the phys ical examination. Th ey will already have learned to save the most invasive parts of the ex am for last. Th e active participation of the child is one of the best routes to cooperatio n. Areas of pain are best approached gradually and with careful attention to facial express ion and body language. Posting signs and web site information indicating that the offi ce i s commit- ted to addressing pain emphasizes commitment. Children \200\231s affi nity for animals, how they uniquely relate to them, and their assig nment of animals to characters and \200\230personality \200\231 traits are themselves subj ects of study (Melson, 2005 ). Some may be associated with bravery (lions, tigers), others with nurturing (birds in a nest, mother bears and cubs), and yet others with cozi- ness (pu ppies, kittens). Children readily absorb the messages that such stories and images provide. Further, they may use associations and implications to change behaviors (Wansink et al., 2 012 ). Since so many children gravitate towards inanimate representations of animals to pro vide emotional support and security (Triebenbacher, 1998 ), having a stuff ed, easy-to-wipe -down, offi ce \200\230mascot \200\231 to cud- dle may provide yet another useful prop. O \203 ce Pain \200\230Champion \200\231 Even if an offi ce has committed itself to being \200\230pain sensitive \200\231, it is helpful to identify a pain champion who can recrui t the ongoing participation of colleagues and staff , remain current by reviewing pediatric pain literature, and set the tone for staff commitment to foster comfort (Kuttner, 2010 ; Schechter, 2008 ). Th at dedicated cli- nician can generate appropriate literature for pare nts and educate the offi ce staff in order to maintain a pain minimizing focus. For patient s with chronic pain conditions, pertinent books and web site links can be made available. I n complex situations, the offi ce pain champion can become an in offi ce consultant and gui de appropri- ate referral to a pediatric pain specialist (Berberich and Schechter, 2012 ). Communication about pain Th ere is no uniform agreement as to what constitutes authentic- i ty and honesty when kids ask about procedures that may cause discomfort. Deceit and tricker y permanently destroy trust. Yet \200\230informing \200\231 can be phrased as a negative o r positive suggestion, even taking into account the unpredictable individuality of each chi ld. Th erapeutic language is that which is craft ed to elicit positive coping responses. Th at skill is taught, among others, by experts in the fi eld of pediatric hypnosis, which, t ogether with biofeedback, can be useful for procedures (Butler et al., 2005 ) and for acute and chronic pain (Kohen and Olness, 2011 ). In the United States, the National Pediatric H ypnosis Institute and the American Society for Clinical Hypnosis currently provide training workshops. Th e Milton Erickson Society of Germany is also active in promoting pediatric h ypnosis instruction. Proactive pain management Because of the negative conditioning eff ect of pain, and simply because it causes distress, its infl iction should be avoided wher- ever possible, especial ly in very young children (Schechter, 2008 ; Zempsky and Schechter, 2003 ). A proactive app roach might be termed anticipatory anticipation ! A prime example would be to pre- scribe 2 .5% lidocaine-prilocaine cream or 4% Lidocaine (LMX-4 ) cream together with instructions for a 90 \200\223120 min covered applica- tion before elective blood draws such as lead le vel determinations. Parents can apply these agents at home, eliminating the need for offi c e application and the wait time, and thus reducing barriers to their use. Similarly, parent s of infants can be reminded before the 2-, 4-, and 6-month visits about acetaminophen or i buprofen administration aft er immunizations, as well as how to apply local measures such a s cool compresses. At the 12-month visit, when toddlers begin to walk and stumble and injur e themselves, the clinician can remind parents to use local measures and medicate early for \200\230minor \200\231 pain. Because the crying associated with pain is so unnerving, rep etition serves to embed the parents \200\231 responses in a way that these become more auto matic and prompt. Teaching appropriate consolation could shorten the distress associated wi th injections, inducing more rapid resolution of pain and possibly Conclusion In this chapter, we have sought to coalesce some of the limited avail- able info rmation on pain treatment in pediatric outpatient facili- ties. While recognizing the need for additional research, uniform application of what we already know will go a long way tow ard reducing the burden of outpatient pain. Despite perceived obstacles and past patterns o f indiff erence, pain in pediatric offi ces can and should receive the attention it deserve s. What is required is a long view, one that acknowledges the signifi cance of the \200 \230little \200\231 insults that can be avoided with a bit of eff ort and the expenditure o f a small amount of time. Attention to pain can improve the doctor/ patient/family relation ship by rendering a child more cooperative and less frightened. Th at leads to an adult who feels more com- fortable within the medical system rather than fearful and avoid- ing of i t. Every clinic setting deserves a pain \200\230champion \200\231 to prod all those delive ring the health care at that facility to be mindful of, and proactive in, dealing with pain . CHAPTER 33 common pain problems in the outpatient setting 335 trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children . J Pediatr , 119 (5), 811 \200\223814. Case examples, with and without a pain-sensitive approach A 2-year-old girl presents crying with an earache and a tempera- ture of 39 C having sle pt poorly and received a single dose of acetaminophen during the previous night. Th e docto r examines the patient and fi nds the ear canal occluded by cerumen. He takes a plastic cur ette and places it in the external canal to remove ear- wax. Th e child jerks her head and cries out in pain. Th e child appears upset and her mother asks, \200\230Did that hurt her ? \200\231. He tries again and notices that there is some bleeding in the external canal. S till unable to see, he orders an ear wash. Th e child cries throughout. When the doctor ret urns, he is still unable to visu- alize the tympanic membrane, and the child writhes and cr ies loudly each time he approaches to insert the otoscope. He pre- scribes a course of amox icillin, telling the parent that the child likely has an ear infection. Bharti , B. and Bharti , S. ( 2008 ). Is topical lignocaine for pain relief in acute otitis media really eff ective ? Arch Dis Child , 93 (8), 714 . Bolt , P. , Barnett , P. , Babl F. E. , and Sharwood L. N. ( 2008 ). Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo- controlled randomize d trial . Arch Dis Child , 93 , 40 \200\22344. Blount , R. L. , Devine , K. A. , Cheng , P. S. , Simons , L. E. , and Hayutin , L. ( 2008 ). Th e impact of adult behaviors on infant distress during immunizations . J Pediatr Psych ol , 33 (10), 1163 \200\2231174 Brady-Fryer , B. , Wiebe , N. , and Lander , J. A. ( 2004 ). Pain relief for neonatal circumcision . Cochrane Database Syst Rev , 4 , CD004217 . Bromberg , R. and Goldman , R. D. ( 2007 ). Does analgesia mask diagnosis of appendicitis among children? Can Fam Physician , 53 , 39 \200\22341. Burton , M. J. , and Doree , C. ( 2009 ). Ear drops for the removal of ear wax . Cochrane Database Syst Rev , 1 , CD004326 . Butler , L. D. , Symons B. K. , Henderson , S. L. , Shortliff e , L. D. , and Spiegel , D. ( 2005 ). Hypnosis reduces distress and duration of an invasive medical procedure for child ren . Pediatrics , 115 (1), e77 \200\22385. A 2-year-old girl presents crying with an earache, having slept poorly and received a singl e dose of acetaminophen during the previous night. While waiting for the doctor, she is giv en a dose of acetaminophen at the pediatrician \200\231s request. Th e tympanic membrane ca nnot be visualized due to impacted cerumen. Th e pediatrician instills \200\230magic \200 \231 docusate drops and places a cotton wick \200\230furry ball \200\231 in the external c anal. As his patient lies in her mother \200\231s lap, she reads some stories and plays a s martphone game with her daughter while he attends to another patient. Aft er 10 min, the me dical assistant comes in, explains to the child that her ear is going to have a little bath so the doctor can see bet- ter and she gently irrigates the ear. Th e doctor returns, than ks the child for helping him by being brave and wicks the canal dry revealing an infl amed and retracted, but non-bulging tympanic membrane. He chooses to treat with analgesics alone , explaining around the clock administration of ibuprofen to the parent and presenting her with a written step-up plan based on the addi- tion of acetaminophen. He also prescribes Au ralgan drops in the event pain returns before the next dose of analgesia is due. Th e pa rent is given a dose sheet upon which the per-weight ibuprofen and acetaminophen doses appr opriate for the child are indicated and circled. A follow-up parental phone report is arran ged. Centers for Disease Control and Prevention (CDC). ( 2011 a). Estimated burden of acute otit is externa \200\224United States, 2003 \200\2232007 . MMWR Morb Mortal Wkly Rep , 60 (19), 605 \200\223609. Centers for Disease Control and Prevention (CDC). ( 2011 b). 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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 ).