Procedural Anxiety

Anxiety with procedures is common among pediatric patients and especially for children with special health care needs who have undergone multiple procedures. Procedural anxiety is usually due to fear of pain (perceived or actual) or recollection of similar, negative experiences. The range of anxiety-provoking procedures may include having a diaper removed, getting weighed or positioned on an exam table, lab draws, vaccinations, line placement, tube replacement, catheterization, interventional radiology or other diagnostic studies, oxygenation or ventilation, getting suctioned, wound debridement, being hospitalized, or having surgery. It is important that clinicians ask caregivers about how anxious they believe the child will be during the procedure and that they help prepare the child.
Consider the following:
  • Build a rapport with the child through playful interaction.
  • Address any parental anxiety and outline ways in which caregivers can help the child, or offer to let the parent leave the room if they prefer.
  • If Child Life specialists are available, their expertise may reduce or eliminate the need for medical analgesia and anesthesia.
  • Consider non-pharmacological relaxation approaches to help children before and during procedures. These may include aromatherapy, music, massage, and local application of vibration or ice to dull sensation to the skin that will be poked. Infants may benefit from breastfeeding or suckling, oral sucrose, and warmth from placing the baby skin-to-skin (“kangaroo care”) or under a radiant warmer.
  • When possible, engage parents in holding the child in positions of comfort and distracting the child with cartoons, relaxation apps, songs, bubbles, etc.
  • Plan ahead for the appropriate level of analgesia and anesthesia. Consider options such as ice, vibration, and/or topical anesthetics to dull sensation to the area. Consider pre-administration of over-the-counter analgesics like ibuprofen or acetaminophen.
  • In the outpatient setting, benzodiazepines are generally not necessary except in severe situations. For extreme anxiety, such as severe needle phobia, the primary care clinician can consider having caregivers administer small doses of oral or intranasal midazolam (Versed) or lorazepam (Ativan) 30-60 minutes before receiving immunizations or drawing labs. Due to the risk of respiratory depression and paradoxical reactions, it is strongly recommended to use benzodiazepines only in a clinical setting where monitoring and interventions are readily available.
  • Simple rewards such as fun Band-Aids, stickers, colorful casts, or a popsicle can help kids feel better after the procedure. Praise children for being courageous.
Families should know what degree of pain to expect after the procedure and how they can help the child. Encourage the family to familiarize themselves with resources (see below) that help with anxiety or pain.

Resources

Information & Support

For Professionals

Managing Procedural Anxiety in Children (NEJM)
Ten-minute video that presents a thoughtful, step-wise approach to reducing anxiety during clinic visits and medical procedures; New England Journal of Medicine.

Vulnerable Patients (APA)
A brief article discussing distraction, exposure therapy, and other approaches to reducing pediatric anxiety in the medical setting; American Psychological Association.

Helping Children and Families Cope with Needle Sticks (Children's National) (PDF Document 504 KB)
Behavioral strategies that help to mitigate anxiety about needles and needle‐related pain.

For Parents and Patients

Getting a Shot: You Can Do It! (Sid the Science Kid/PBS)
A 28-minute YouTube video for kids about why and how we get vaccinations.

Medical Procedures and Pain: Helping Your Child (University of Michigan)
Concise guide to help families understand and reduce their child's anxiety and pain in during shots and procedures.

A Fun Way to Ease Kids’ Anxiety About Medical Procedures (University of Michigan)
An introduction to medical play.

Preparing Your Child (Duke Children's Hospital & Health Center) (PDF Document 288 KB)
A stepwise approach, organized by age of the child, for parents to prepare children for hospitalizations and procedures.

Using Comfort Positions During Stressful Events (St. Jude Children's Research Hospital)
Show family members how to hold children in comfort positions during medical procedures.

Relaxation Workbook (Primary Children's Hospital) (PDF Document 407 KB)
Self-administered relaxation exercises and pages for reflection.

Pain Management Workbook (Primary Children's Hospital) (PDF Document 408 KB)
Self-administered pain management exercises and pages for reflection.

Practice Guidelines

Fein JA, Zempsky WT, Cravero JP.
Relief of pain and anxiety in pediatric patients in emergency medical systems.
Pediatrics. 2012;130(5):e1391-405. PubMed abstract
An AAP guideline to pediatric analgesia and anxiolysis in the EMS and emergency department settings, including information relevant to children with developmental disabilities. Reaffirmed Nov 2015.

Patient Education

Hablemos Acerca De: Cómo Ayudar a Su Hijo a Sobrellevar Procedimientos Médicos (Intermountain Healthcare) (PDF Document 1.6 MB)
A printable handout in Spanish about preparing and supporting the child during painful procedures. Illustrates comfort positions for parents holding their child and gives examples of encouraging words.

Let's Talk About: Counterstimulation Techniques Using Sensory Distraction (Intermountain Healthcare) (PDF Document 1.5 MB)
A 2-page printable handout with simple examples of counterstimulation techniques using sight, sound, smell, taste, and touch.

Let's Talk About: Helping Your Child Cope with Medical Procedures (Intermountain Healthcare) (PDF Document 1.9 MB)
A printable handout about preparing and supporting the child during painful procedures. Illustrates comfort positions for parents holding their child and gives examples of encouraging words.

Let's Talk About: Pain Management Techniques for Special Needs Children (Intermountain Healthcare) (PDF Document 1.7 MB)
A 2-page printable handout with tips for identifying potential sources of pain in a child who is unable to tell you what is wrong and how to manage pain without medications.

Authors & Reviewers

Last update/revision: January 2019; initial publication: August 2016
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Authoring history
2018: update: Mary Steinmann, MDA
2016: first version: Douglas Nelson, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer