Procedural Pain

Procedural pain is the discomfort children and adults experience during medical procedures like needle sticks, blood draws, and other medical interventions. While these procedures may be brief, their impact can extend far beyond the moment, affecting future healthcare experiences and overall well-being.

Table of contents

• What is Procedural Pain?
• How Common is Procedural Pain?
• Health and Emotional Consequences
• Factors That Influence Pain Experience
• How Pain is Assessed
• Long-Term Effects of Poorly Managed Pain
• The Caregiver Perspective

What is Procedural Pain?

Procedural pain refers to the pain that people, especially children, experience during medical procedures. These procedures include common interventions such as immunizations (vaccinations), blood draws through needles called venipunctures, intravenous line insertions (placing a needle into a vein to deliver fluids or medications), circumcision (surgical removal of foreskin), bone marrow aspirations (removing bone marrow for testing), and lumbar punctures (also called spinal taps, where fluid is collected from around the spinal cord)^[1].

The most common source of procedural pain is needle-related procedures. These include not only vaccinations and blood tests but also more complex procedures performed in emergency departments and hospitals^[2].

How Common is Procedural Pain?

Children undergo numerous medical procedures as part of routine medical care throughout childhood. Needles are used everywhere in healthcare to prevent, diagnose, treat, and monitor a wide variety of conditions and diseases. In fact, between 8 to 12 billion vaccinations are given worldwide every year^[1].

For children who are hospitalized, the frequency of painful procedures is particularly high. Children in hospitals undergo approximately 4 procedures per day, and research shows that their pain is often not treated adequately^[1]. Even in emergency departments, where half of all visits result from painful conditions, about 78% of patients experience pain during their stay^[5].

While the pain from a needle procedure may seem brief, lasting only moments, the consequences can extend far beyond the actual procedure itself^[1].

Health and Emotional Consequences

When procedural pain and fear are not properly managed, they can lead to both immediate and lasting problems. In the short term, inadequately controlled pain can result in increased time needed to complete the procedure, the need to physically restrain the child, worsening pain and fear during the procedure, dizziness and fainting, and potential for injury^[1].

The immediate effects can also be distressing for everyone involved. Painful procedures without proper management can lead to increased distress for patients and families, and can make the entire emergency department or hospital experience more difficult^[3].

Beyond the procedure itself, poorly managed pain can create negative memories that lead to increased pain and fear at future medical appointments. This can result in children and their families delaying or completely avoiding necessary procedures in the future, including situations like vaccine hesitancy (reluctance or refusal to be vaccinated). Some patients may also need higher doses of pain-relieving medications to achieve the same effect in future procedures^[1].

Factors That Influence Pain Experience

Many different factors affect how much pain a child experiences during a medical procedure. These factors fall into three main categories: biological, psychological and social, and procedural factors^[1].

Biological factors include characteristics like the child’s sex. Psychological and social factors include the child’s level of anxiety before and during the procedure, as well as how parents and caregivers behave during the procedure. Research shows that when caregivers experience anxiety and distress around their child’s procedure, this can actually increase the child’s perceived pain^[5].

Procedural factors include how invasive the procedure is (how much it involves entering or disrupting the body) and the environmental setting where it takes place^[1].

How Pain is Assessed

Pain is a personal and subjective experience, meaning it feels different to each person. Because of this, whenever possible, asking the person directly about their pain is considered the most important part of pain assessment. For children between the ages of 4 or 5 and 12 years, healthcare providers often use the Faces Pain Scale-Revised, which shows different facial expressions representing increasing levels of pain. For children and adolescents age 8 years and older, a simple 0-10 Numerical Rating Scale is also recommended, where 0 means no pain and 10 means the worst pain imaginable^[1].

When children are unable to report their pain themselves—for example, if they are very young, have cognitive impairment, or are sedated—parents, caregivers, and healthcare professionals use observation scales to assess pain based on behaviors like crying, facial expressions, and body movements^[1].

It is also important to screen for needle fear before procedures. Negative experiences with needles can lead to very high levels of needle fear, which may spread to fears and avoidance of medical procedures more broadly. People with high levels of needle fear need different types of help before they can fully benefit from standard pain management strategies. Screening helps healthcare providers identify which children have low to moderate fear levels and which have high fear, so they can provide the most appropriate support^[1].

Long-Term Effects of Poorly Managed Pain

When pediatric pain is not adequately treated, it can lead to serious physical and psychological consequences. Research over multiple decades has documented both short-term and long-term effects from poorly treated pediatric pain, especially in younger children^[2].

Evidence suggests that early painful experiences might permanently change the nerve pathways in the spinal cord that process pain signals. One important theory, called the neuromatrix theory of pain, proposes that pain is a complex experience produced by specific patterns of nerve signals generated by a widely distributed network in the brain and nervous system. These patterns are influenced not only by the physical sensation itself but also by mental and emotional factors such as psychological distress^[2].

For neonates (newborns) and infants, repeated and poorly treated painful episodes can lead to lasting changes in how sensitive they are to pain later in life. This heightened sensitivity, called hypersensitivity, can persist as children grow^[6].

In the preoperative setting (before surgery), a child who has already experienced multiple painful procedures may arrive at the operating room with intense anxiety, fear, and distress. This can lead to a greater pain response after the surgery is complete^[3].

The Caregiver Perspective

Caregivers of children experiencing procedural pain have identified important information needs and concerns. They report that they most value receiving information directly from their healthcare provider, rather than from other sources. They also believe that healthcare providers should direct information about the procedure to their child, not just to the adults, and have identified specific strategies to help involve children in their own care^[5].

Many caregivers want to be empowered to ask informed questions of their healthcare providers. They want to understand what will happen during procedures and what options are available to help manage their child’s pain and anxiety^[5].

Unfortunately, caregivers have reported negative experiences with procedures for their children, particularly when procedures take place at non-pediatric centers (hospitals or clinics that do not specialize in children’s care). These negative experiences can have lasting impacts on both the child and the family’s willingness to seek medical care in the future^[5].

Caregivers themselves may experience anxiety and distress when their child undergoes a procedure. This anxiety can, in turn, increase the child’s perceived pain, creating a cycle where the caregiver’s stress affects the child, and the child’s distress further increases the caregiver’s anxiety^[5].