Methods to Calm Babies and Children During IV Cannulation
We all know day today anxiety of doctors on the ward with regards to procedures, most common being cannulation, blood sampling via cannula, needle or even heel prick. This is also a significant anxiety, fear and discomfort for child and parents. There is enough evidence about the short and long term impact of painful procedures on Neonates, Infants and Children. That is the reason we must make utmost efforts to make them as comfortable as possible so that the effect of pain is minimized. Here are some of the methods which can be used in children. I have tried to categorise them according to their age as well. Where possible I have tried to provide the evidence.
Painful procedures demand a sympathetic approach: staying calm, kind and reassuring with every neonate, infant, young person and parent or carer so we can regulate their distress and improve the experience. Believe me our success of the procedure also significantly depends on this principle. Not only this, explaining the procedure beforehand is our responsibility but it helps with the success of the procedure as well.
Many of the standard guidelines recommend these procedures, (Please check your own Hospital or Institution guidelines, if there isn't any why not take a lead and write one?
(I am excluding Lumbar Puncture from this, as it needs a different approach)
Methods to Calm Babies and Children During IV Cannulation.
1. Preparation and Age‑Appropriate Explanation is very important.
It helps with building rapport with the child and parents or carers. Remember calm parents means a calmer child and higher the success of the procedure. Explaining not only to Parents and carers but where appropriate to child as well (For children >3 years, anxiety drops significantly when they know what to expect.)
2. Sweet Solutions (Sucrose or Glucose)
Sucrose or glucose given just before the procedure significantly reduces crying, pain scores, and distress. Neonatal cannulation guidelines explicitly recommend sucrose analgesia or expressed breast milk before IV insertion. It is one of the most consistently proven analgesics for minor painful procedures in neonates.
Mechanism: Activates endogenous opioid pathways → rapid calming effect.
3. Breastfeeding or bottle feeding and or Skin‑to‑Skin Contact
Those who have worked with children would know that children are most comfortable with their parents or carers. Breastfeeding during procedures or holding the baby skin‑to‑skin reduces pain and stabilises heart rate.
Standard Neonatal guidelines emphasise ensuring the baby is comfortable and supported before and after cannulation.
Mechanism : Warmth + parental regulation + oxytocin release → calmer infant and easier cannulation.
4. Swaddling, Containment & Comfort Positioning
Gentle containment (hands around shoulders/hips) or swaddling reduces distress and improves procedural success.
Mechanism: Reduces startle reflex, keeps limbs still, lowers sympathetic arousal.
5. Distraction Techniques (Toddlers & Older Children)
This is actually widely practiced in many units. It is not only highly effective for children over ~2 years, but can be used in younger children and children who are differently able.
Bubbles
Light‑up toys
Videos on a phone
Guided breathing
“Blow out the pain” technique (blowing bubbles or pinwheels)
(you can device your own methods and practice)
6. Parental Presence
Whenever possible we should allow parents to be present. It does not just relieve their anxiety but they are a great help in calming the child. They can also help
Tip: Give parents a role: “Hold their hand and help them blow bubbles.”
7. Use of Validated Tools (DIVA Score) to Reduce Multiple Attempts
This is something completely new to me, I found out about it today only. A Difficult Intravenous Access (DIVA) Score is a clinical prediction rule developed and validated to identify children who are likely to need multiple attempts at IV cannulation.
It helps clinicians decide when to escalate early to ultrasound‑guided cannulation or a vascular access expert.
The score was originally validated by Riker et al., Academic Emergency Medicine, 2011
8. Warmth & Environmental Control
Warm limbs = better veins = more likely success.
Neonatal guidelines emphasise keeping babies warm and comfortable before procedures.
Warmth reduces crying and improves success.
9. Clinician Calmness & Regulation
You will probably agree - “The calmer we are, the smoother the procedure becomes. Good communication, thoughtful preparation, and a confident approach make all the difference”.
Quick - Age Related Approach-
All ages- Clear explanation to parents and appropriate age child. Good preparation.
Please scroll down to see the picture after References (from AI)
Reference :
1. Meta‑analyses on Painful Procedures in Neonates
Hemmi et al., 2011 — Meta‑analysis (Neonatal regulatory problems → later behavioural issues
Title: Associations between problems with crying, sleeping and/or feeding in infancy and long‑term behavioural outcomes in childhood: A meta‑analysis Journal: Archives of Disease in Childhood Key relevance: Shows that early distress (often triggered by pain, discomfort, dysregulation) is linked to later behavioural problems. DOI: 10.1136/adc.2010.191312
Stevens et al., 2016 — Meta‑analysis (Sucrose for procedural pain)
Title: Sucrose for analgesia in newborn infants undergoing painful procedures Journal: Cochrane Database of Systematic Reviews Key relevance: Strong evidence that sucrose significantly reduces pain responses in neonates during procedures like heel lance and venepuncture. Cochrane Review Number: CD001069
Pillai Riddell et al., 2015 — Meta‑analysis (Non‑pharmacological pain management)
Title: Non-pharmacological management of infant and young child procedural pain Journal: Pediatrics Key relevance: Shows strong evidence for breastfeeding, skin‑to‑skin, distraction, and parental involvement.
🔵 2. Cochrane Reviews on Neonatal Pain
Cochrane Review — Sweet solutions for procedural pain (Neonates)
Title: Sweet tasting solutions for reduction of pain in neonates Authors: Harrison et al. Key relevance: Confirms sucrose/glucose is effective for minor painful procedures. Cochrane ID: CD001069
Cochrane Review — Kangaroo care for procedural pain
Title: Skin‑to‑skin contact for procedural pain in neonates Authors: Johnston et al. Key relevance: Strong evidence that skin‑to‑skin contact reduces pain scores during procedures.
Cochrane Review — Non‑nutritive sucking
Title: Non‑nutritive sucking for procedural pain in neonates Key relevance: Pacifier use reduces behavioural pain responses.
🔵 3. Meta‑analyses on Infants (1–12 months)
Pillai Riddell et al., 2019 — Systematic review & meta‑analysis
Title: Infant pain responses and regulatory behaviours Journal: PAIN Key relevance: Shows infants have consistent behavioural and physiological pain responses; repeated pain affects regulation.
🔵 4. Meta‑analyses & Reviews on Children (1–12 years)
Taddio et al., 2012 — Needle fear meta‑analysis
Title: Reducing pain during vaccine injections: A systematic review Journal: Clinical Therapeutics Key relevance: Demonstrates that early painful procedures can lead to long‑lasting needle fear and healthcare avoidance.
Birnie et al., 2014 — Psychological interventions meta‑analysis
Title: Psychological interventions for needle‑related pain and distress in children and adolescents Journal: Clinical Journal of Pain Key relevance: Strong evidence for distraction, breathing techniques, and preparation.
🔵 5. Cochrane Reviews on Children
Cochrane Review — Distraction for needle pain in children
Title: Distraction for acute pain in children Key relevance: Shows distraction significantly reduces pain and distress during cannulation and injections.
Cochrane Review — Topical anaesthetics (EMLA, Ametop)
Title: Topical anaesthetics for needle procedures in children Key relevance: Confirms EMLA and Ametop reduce pain during cannulation.
