Review of paediatric pharmacological and non-pharmacological procedural comfort strategies

Procedural anxiety and untreated procedural pain can result in adverse clinical and behavioural outcomes. Procedural comfort is defined as the intentional, multidisciplinary management of pain, anxiety and distress before, during and after medical procedures. Strategies to provide procedural comfort can be subdivided into pharmacological and non-pharmacological.

Careful planning and preparation, involving both parent and child, and tailoring the procedural comfort strategies to the individual maximise the likelihood of a successful procedure while also minimising pain and distress. This includes determining the location for the procedure (bedside versus treatment room) and consideration of clustering procedures where appropriate. A calm environment should be maintained throughout, and the use of age-appropriate and positive language is key.

Non-pharmacological strategies such as positions for comfort, interactive (play therapy, distraction), relaxation (guided imagery, deep breathing, massage, hypnotic communication) and sensory (vibration and cold stimulation, aromatherapy, virtual reality) should be considered for all children and may be combined with sedation if deemed necessary.

The choice to sedate must always balance risks (over-sedation/paradoxical reactions) versus the benefits (increased likelihood of a successful attempt, a calmer patient and reduced patient and family distress). If a sedative is needed, the choice is made after a discussion between the medical team and the patient (if appropriate) and their family or carers.

Pharmacological strategies include local anaesthetic cream and sedatives, most commonly: benzodiazepines (midazolam and temazepam), α2-adrenoceptor agonists (dexmedetomidine and clonidine) and N-methyl-D-aspartate receptor antagonists (ketamine). Factors influencing choice of drug include the formulation, route of administration, existing comorbidities, contraindications and previous experience of the patient.

Local policy with regard to fasting should be adhered to and children who have been given sedatives should remain supervised by appropriately trained medical staff with accredited paediatric life support skills and be continuously monitored.