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 can range widely, from having a diaper removed to significant interventional procedures. 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. Using a treatment room for procedures is recommended to avoid the child developing negative associations with the exam rooms used for routine patient care.
• 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 sucking on a bottle or oral sucrose. Breastfeeding and placing the baby skin-to-skin (“kangaroo care”) can help but may be more challenging for positioning.
• 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 not used except for extreme anxiety. The primary care clinician can consider a small dose of oral or intranasal midazolam (Versed) or lorazepam (Ativan) 30-60 minutes prior to a procedure. Due to the risk of respiratory depression and paradoxical reactions, use benzodiazepines only in a clinical setting where monitoring and interventions are available.
• Make a plan for what happens when the procedure ends. 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.