Behavioral methods and pharmacologic options for pain control during minor procedures (eg, venipuncture or IV placement) in children

	Start time before procedure (minutes)
Behavioral methods*
Preparation	60
Relaxation	30
Breathing	2 and during procedure
Distraction	2 and during procedure
Encourage coping	2 and during procedure
Positioning	2 and during procedure
Positive reinforcement	After procedure
Selected pharmacologic options^¶
Lidocaine/prilocaine cream (eg, EMLA®)	60
Liposomal lidocaine (eg, LMX), heated lidocaine and tetracaine patch (Synera) or tetracaine gel (eg, Ametop^Δ)	30
Lidocaine iontophoresis	15
Needle-free lidocaine delivery	2
Lidocaine infiltration	2
Vapocoolant spray	15 seconds
Nitrous oxide	<1

* All behavioral methods should be continued throughout the procedure, preferably by a dedicated child life specialist.
¶ The provider should select only one type of topical agent based upon available time prior to the procedure. Refer to UpToDate topics on topical analgesia during minor procedures. When properly maintained equipment and personnel are available and per caregiver and provider preference, nitrous oxide may be used to augment topical analgesia.
Δ Tetracaine gel is an ester type local anesthetic and is not commercially available in the United States. It is widely available elsewhere.
IV: intravenous.

Data from: Zempsky WT. Optimizing the management of peripheral venous access pain in children: Evidence, impact, and implementation. Pediatrics 2008; 122 Suppl 3:S121.

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Behavioral methods and pharmacologic options for pain control during minor procedures (eg, venipuncture or IV placement) in children