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Evidence Repository

Procedural Anxiety and Fear

Developed by:ARCHE, & TREKK

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EVIDENCE REPOSITORIES

This evidence repository is a collection of best available resources and evidence collated by a knowledge synthesis team at Alberta Research for Health Evidence (ARCHE) and the clinical content team.

The knowledge synthesis team utilizes a pyramid-shaped framework, built upon the “4S” hierarchy of evidence model, to provide detailed evidence appropriate to meet stakeholders’ needs. They search a combination of databases (Cochrane Library, PubMed, TRIP Database) and web-based search engines (Google, Google Scholar) to locate evidence for the knowledge pyramids. Publication types sought in the initial topic searches are organized into five levels that determine the order in which resources are presented:

  1. Bottom Line Recommendations
  2. Clinical Practice Guidelines and Pathways
  3. Overviews and Summaries of Systematic Reviews
  4. Systematic Reviews
  5. Key Studies

Where applicable resources for families and parents are also listed.

Key Studies

The knowledge synthesis team collaborates with the clinical content team to select the most relevant guidelines, reviews, and key studies, which can be found below. This evidence repository is not intended to be an exhaustive list of resources for a topic, but rather a curated list of current, evidence-based resources, based on expert consensus of relevance and usability for a general emergency department setting. Every effort is made to identify resources that are open access (i.e. publicly available, free of charge, not requiring a subscription).

More information about the creation of our evidence repositories can be found here.

Content Team

Thank you to the following clinical content experts and Knowledge Synthesis team who led the development of this evidence repository.

Samina Ali, MD, FRCPC Professor, Department of Pediatrics and Adjunct Professor, Department of Emergency Medicine, University of Alberta

Naveen Poonai, MSC, MD, FRCPC Professor, Pediatrics, Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry Scientist, Child Health Research Institute

Kathryn Birnie, PhD RPsych Associate Professor, Cumming School of Medicine, Department of Anesthesiology, Perioperative and Pain Management, and Department of Community Health Sciences, University of Calgary

Samantha Guitard, MSc Evidence Synthesis Scientist, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta

Sarah Elliott, PhD Assistant Director, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta

References in bold correspond to those used in the Bottom Line Recommendations.

Clinical Practice Guidelines And Pathways

  1. Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, Chauvin-Kimoff L, Baerg K, Ali S. Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures. Can Paediatr Soc. Updated 2025.
  2. Solutions for Kids in Pain (SKIP), Health Standards Organization (HSO). CAN/HSO 13200:2023 – Pediatric Pain Management. Updated 2023.
  3. McMurtry CM, Taddio A, Noel M, et al. Exposure-based interventions for the management of individuals with high levels of needle fear across the lifespan: A clinical practice guideline and call for further research. Cogn Behav Ther. 2016;45(3):217-35.
  4. Taddio A, McMurtry CM, Shah V, et al. Reducing pain during vaccine injections: Clinical practice guideline. CMAJ. 2015;187(13):975-82.

Systematic Reviews And Other Reviews

  1. Wang L, Fang L, Zhou Y, et al. Efficacy and safety of vapocoolant spray for vascular puncture in children and adults: A systematic review and meta-analysis. PLoS One. 2023;18(2):e0279463.
  2. Robinson N, Delorenzo A, Howell S, et al. Pediatric distraction tools for prehospital care of pain and distress: A systematic review. Pediatrics. 2023;152(1):e2022059910.
  3. Poonai N, Creene C, Dobrowlanski A, et al. Inhaled nitrous oxide for painful procedures in children and youth: A systematic review and meta-analysis. CJEM. 2023;25(6):508-28.
  4. Goren K, Cen Y, Montemurri V, et al. The impact of music, play, and pet therapies in managing pain and anxiety in paediatric patients in hospital: A rapid systematic review. Paediatr Child Health. 2023;28(4):218-24.
  5. Zaki HA, Elarref MA, Iftikhar H, et al. Efficacy of EMLA (eutectic mixture of local anaesthetics) and let (lidocaine, epinephrine, tetracaine) for topical use in wound management for children: A systematic review and meta-analysis. Cureus. 2022;14(11):e31447.
  6. Taddio A, McMurtry CM, Logeman C, et al. Prevalence of pain and fear as barriers to vaccination in children – systematic review and meta-analysis. Vaccine. 2022;40(52):7526-37.
  7. Lluesma-Vidal M, Carcelén González R, García-Garcés L, et al. Effect of virtual reality on pediatric pain and fear during procedures involving needles: Systematic review and meta- analysis. JMIR Serious Games. 2022;10(3):e35008.
  8. Kyriakidis I, Tsamagou E, Magos K. Play and medical play in teaching pre-school children to cope with medical procedures involving needles: A systematic review. J Paediatr Child Health. 2021;57(4):491-9.
  9. Cozzi G, Valerio P, Kennedy R. A narrative review with practical advice on how to decrease pain and distress during venepuncture and peripheral intravenous cannulation. Acta Paediatr. 2021;110(2):423-32.
  10. Poonai N, Spohn J, Vandermeer B, et al. Intranasal dexmedetomidine for procedural distress in children: A systematic review. Pediatrics. 2020;145(1):e20191623.
  11. Lambert V, Boylan P, Boran L, et al. Virtual reality distraction for acute pain in children. Cochrane Database Syst Rev. 2020;10(10):CD010686.
  12. Gates M, Hartling L, Shulhan-Kilroy J, et al. Digital technology distraction for acute pain in children: A meta-analysis. Pediatrics. 2020;145(2):e20191139.
  13. Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle- related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;10(10):CD005179.
  14. McMurtry CM, Noel M, Taddio A, et al. Interventions for individuals with high levels of needle fear: Systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin J Pain. 2015;31(10 Suppl):S109-23.
  15. Taddio A, Ilersich AL, Ipp M, et al. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: Systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin Ther. 2009;31(Suppl 2):S48-76.

Key Studies

  1. Ali S, Hudson S, Rajagopal M, et al. A Randomized Controlled Trial of Commercially Available Virtual Reality for Intravenous Cannulation-Related Distress in Children. J Pediatr. 2026;288:114803.
  2. Tsze DS, Woodward HA, McLaren SH, et al. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025;179(9):979–86.
  3. Wang JY, Speechley K, Anderson KK, et al. Intranasal midazolam for procedural distress in children in the emergency department: a systematic review and meta-analysis. CJEM. 2024;26(9):658-70.
  4. Wong CL, Choi KC. Effects of an immersive virtual reality intervention on pain and anxiety among pediatric patients undergoing venipuncture: A randomized clinical trial. JAMA Netw Open. 2023;6(2):e230001.
  5. Scribner-O’Pray M, Taylor ED, Krause E, Nickel A, Bergmann KR. Factors associated with low procedural pain scores among 1- to 5-year-old patients undergoing facial laceration repair. Pediatr Emerg Care. 2023;39(3):135-41.
  6. Poonai N, Sabhaney V, Ali S, et al. Optimal dose of intranasal dexmedetomidine for laceration repair in children: A phase ii dose-ranging study. Ann Emerg Med. 2023;82(2):179-90.
  7. Kleye I, Sundler AJ, Karlsson K, Darcy L, Hedén L. Positive effects of a child-centered intervention on children’s fear and pain during needle procedures. Paediatr Neonatal Pain. 2023;5(1):23-30.
  8. Siembieda J, Heyming T, Padlipsky P, Young KD. Triple versus single application of lidocaine, epinephrine, and tetracaine for laceration repair in children. Pediatr Emerg Care. 2022;38(2):e472-4.
  9. Moline RL, Constantin K, Chambers CT, et al. A brief mindfulness intervention for parents and children before pediatric venipuncture: A randomized controlled trial. Children (Basel). 2022;9(12):1869.
  10. Lee HN, Hwang S, Jung JY, et al. Tablet personal computer distraction during intravenous placement for young children in the pediatric emergency department: A pilot study. Pediatr Int. 2022;64(1):e15150.
  11. Kammerer E, Eszczuk J, Caldwell K, et al. A qualitative study of the pain experiences of children and their parents at a Canadian children’s hospital. Children (Basel). 2022;9(12):1796.
  12. Cozzi G, Cognigni M, Busatto R, et al. Adolescents’ pain and distress during peripheral intravenous cannulation in a paediatric emergency setting. Eur J Pediatr. 2022;181(1):125-31.
  13. Braithwaite FA, Noel M, Jones HG, et al. Reframe the pain: Divided attention and positive memory reframing to reduce needle pain and distress in children-a feasibility randomized controlled trial. Eur J Pain. 2022;26(8):1702-22.
  14. Osmanlliu E, Trottier ED, Bailey B, et al. Distraction in the emergency department using virtual reality for intravenous procedures in children to improve comfort (DEVINCI): A pilot pragmatic randomized controlled trial. CJEM. 2021;23(1):94-102.
  15. Lunoe MM, Bolin AE, Drendel AL. An evaluation of high preprocedural anxiety and venipuncture pain experienced by young children. Pediatr Emerg Care. 2021;37(10):e621-4.
  16. Ali S, Manaloor R, Ma K, et al. A randomized trial of robot-based distraction to reduce children’s distress and pain during intravenous insertion in the emergency department. CJEM. 2021;23(1):85-93.
  17. Ali S, Ma K, Dow N, et al. A randomized trial of iPad distraction to reduce children’s pain and distress during intravenous cannulation in the paediatric emergency department. Paediatr Child Health. 2021;26(5):287-93.
  18. Oommen S, Shetty A. Does parental anxiety affect children’s perception of pain during intravenous cannulation? Nurs Child Young People. 2020;32(3):21-4.
  19. Chumpitazi CE, Caviness AC, Grawe GH, Camp EA, Shah M. Evaluation of hydrocodone/acetaminophen for pediatric laceration repair: A randomized trial. Plast Reconstr Surg. 2020;145(1):126e-34e.
  20. Schinkel MG, Boerner KE, Chambers CT, McMurtry CM. Adult judgments of children’s pain and fear during venipuncture: The impact of adult and child sex. Can J Pain. 2018;2(1):292-301.
  21. Gouin S, Gaucher N, Lebel D, Desjardins MP. A randomized double-blind trial comparing the effect on pain of an oral sucrose solution vs. Placebo in children 1 to 3 months old undergoing simple venipuncture. J Emerg Med. 2018;54(1):33-9.
  22. Olsen K, Weinberg E. Pain-less practice: Techniques to reduce procedural pain and anxiety in pediatric acute care. Clin Pediatr Emerg Med. 2017;18(1):32-41.
  23. Neville DNW, Hayes KR, Ivan Y, McDowell ER, Pitetti RD. Double-blind randomized controlled trial of intranasal dexmedetomidine versus intranasal midazolam as anxiolysis prior to pediatric laceration repair in the emergency department. Acad Emerg Med. 2016;23(8):910-7.
  24. McMurtry CM, Pillai Riddell R, Taddio A, et al. Far from “just a poke”: Common painful needle procedures and the development of needle fear. Clin J Pain. 2015;31(10 Suppl):S3-11.
  25. Hartling L, Newton AS, Liang Y, et al. Music to reduce pain and distress in the pediatric emergency department: A randomized clinical trial. JAMA Pediatr. 2013;167(9):826-35.
  26. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013;25(2):161-167.
  27. Stevens BJ, Abbott LK, Yamada J, et al. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ. 2011;183(7):e403-10.
  28. Babl FE, Goldfinch C, Mandrawa C, et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics. 2009;123(6):1548-55.

Other

  1. Solutions for Kids in Pain. Procedural pain management in children & youth: A toolkit for health professionals. 2023. [Accessed Jan 2026].
  2. Poonai N SV, Ali S, Stevens H, et al. Infographic: Optimal dose of intranasal dexmedotomidine for laceration repair in children: A phase ii dose-ranging study using the bayesian continual reassessment method. 2023.
  3. Poonai N CD, McDowell D, Mistry R, et al. Infographic: Analgesia & sedation of paediatric ileocolic intussusception: A global multicentre study. 2023.
  4. Trottier E, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S. Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures – CPS podcast. Stollery Children’s Hospital: Peds Cases. 2019.
  5. Krauss BA, Krauss BS. Managing the frightened child. Ann Emerg Med. 2019;74(1):30-5.
  6. Krauss BS, Krauss BA, Green SM. Videos in clinical medicine. Managing procedural anxiety in children. N Engl J Med. 2016;374(16):e19.