Author: Dr Veena Anand, MD Paediatrics, M Phil clinical epidemiology, GFPM. Associate professor, Paediatrics, SAT, Govt. Medical college Thiruvananthapuram, Kerala, India
Procedural pain in children remains one of the most difficult aspects of care for both kids and parents (1). I have seen how repeated painful procedure, even though medically necessary, can lead to lasting imprints of fear and suffering. I have come to understand the importance of both pharmacological and non-pharmacological strategies to lessen procedural pain for children and the need of holistic, family centred and team approach to ensure comfort for every child.
Introduction
In my early years of career as a paediatrician, I felt proud when I could do procedures with technical precision, inserting lines, catheters performing lumbar punctures, and performing procedures like bone marrow aspirations, fluid tapping, biopsies etc. But later when I came to palliative care, I realised that the procedure was not the only story. The kid’s anticipatory fear, the parent’s helpless gaze and shadow of previous painful procedures often defined the experience more than the needle itself.
Now as a paediatrician focused on paediatric palliative care, I see procedural pain management not just as a clinical task but as a responsibility. Every intervention we have to focus to maintain compassion, trust and dignity.
Understanding procedural pain
Procedural pain is mostly predictable, time bound but aggravated by anxiety. A child who remembers a painful iv cannulation in the past may resist even before the alcohol swab touches their skin or even entering the place where it was given previously. Parents also anxiously recall these moments, often asking, “Can it be done more gently this time?”
Pain in this context also is multidimensional having physical, psychological, and social dimensions (1). Ignoring this increases the child and parent’s distress.
Pharmacological approaches
Paediatricians are rightly cautious with drugs, but caution must not become the reason for undertreatment. Practical measures include (1,2)
Topical anaesthetics (lidocaine prilocaine cream) for venous access.
Short acting opioids or benzodiazepines titrated for invasive procedures.
Proportional sedation, maintaining interaction and comfort, and not simply suppressing distress.
Protocols matter. Clear, anticipatory planning reduces distress, and it assures that comfort is not an afterthought.
Nonpharmacological measures
One of my most practical lessons from palliative care is that children often respond as much to their environment as to medication.
Distraction– blowing bubbles, music or tablets can shift attention
Comfort positioning– allowing parent to hold the child transforms restraint into reassurance.
Preparation-explaining the procedure in age-appropriate language, often with play therapy, reduces anticipatory fear.
These interventions do not replace analgesia, but they complement and dignify it.
Team dynamics and family involvement
No single professional can own this process. Nurses anticipate distress and suggest timing; psychologists and play therapists empower children; doctors balance necessity with gentleness. Families are not passive bystanders—they are active partners.
One mother told me, “It wasn’t the injection that mattered—it was that my kid felt respected and safe.”
This sentence remains etched in my clinical practice philosophy.
Common hurdles and overcoming them
Despite availability of procedural pain management protocols and growing awareness, several hurdles persist. Limited time in busy settings often leads to shortcuts, where analgesia or preparation is sacrificed for lack of time/staff shortage. Also, resource constraints such as unavailability of topical anesthetics or trained team can further limit options. Some professionals, under the pressure of workload, may underestimate or ignore the psychological dimensions of pain, focusing only on technical completion. Many a times, parents too aggravate stress by transmitting their own anxiety to the child. Overcoming these barriers requires proper planning: integrating pain management as a non-negotiable part of the procedure, ensuring that even small measures like comfort positioning or distraction are meticulously applied, and advocating for institutional policy in essential supplies and training. Building a culture where every team member feels responsible for the child’s comfort transforms pain management from an optional add on into a mandatory standard of care.
Reflections and Conclusion
My journey from paediatrics to palliative care has taught me that procedural pain management is less about avoiding pain sensation and more about cultivating an environment where the child feels safe, supported and respected.
As palliative care physicians, our goal is not only to relieve pain but also to preserve dignity in all the encounter; whether inserting a cannula or changing a dressing. Each procedure, when done with compassion and coordinated teamwork, becomes an act of care that extends beyond medicine to the very heart of human connection.
References: –
- https://childkindinternational.org/childrens-pain-matters/last accesed on 03.10.2025
- Olsen K, Weinberg E. Pain-Less Practice: Techniques to Reduce Procedural Pain and Anxiety in Pediatric Acute Care. Clin Pediatr Emerg Med. 2017.
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