FOREWORD: Making Children Comfortable in the Emergency Room

By Heather ErlemannHealth Humanities, Special Issue: ER Observations, 2019



In this foreword to articles by Burri, Holmes, and Piekarski, Heather Erlemann looks at how the hectic environment of emergency departments can make children feel overwhelmed, as well as potential strategies for making them more comfortable.


The emergency room is loud, hectic and at times completely wild. This chaotic environment and the accompanying feelings of stress on patients is amplified in pediatric patients. According to a study done by the American College of Emergency Physicians (2014), nearly 12 million pediatric patients under the age of eighteen visit the emergency room each year. Children are often not given enough amenities and their pain is evaluated inaccurately as doctors and the setup of emergency rooms are more adequately prepared to handle adult cases. Many factors can lead to unnecessary elevated discomfort for kids in the emergency room. Some of these factors include children’s perception of time, which makes waits seem longer, and hospitals’ lack of age appropriate games and distractions in the waiting room (Parra, C., Vidiella, N., Irene Marin, I., Trenchs, V., & Luaces, C., 2017, p.1266). There are also many ongoing efforts and studies with the goal to change practices that cause pediatric patients avoidable distress.

Different researchers have many different approaches to making children more comfortable in the emergency department. One major theme is distraction. The idea is that children focus more on the distraction than their pain or the wait time. One study tested this by the use of dish soap bubbles (Longobardi, C., Prino, L. E., Fabris, M. A., & Settanni, M., 2019). Researchers randomly assigned the 74 subjects into a control group, who got no distraction, and an experimental group, which played with soap bubbles while awaiting an examination. Self-reported scores assessed the result. Children reported their state of anxiety and fear three times throughout the experiment, before the experiment, after the administering of the soap bubble protocol (experiment group) and after the medical exam. The experimental group that played with bubbles reported much less fear and pain. The concept of keeping children busy seems to aid in their discomfort, and hospitals can lack the tools necessary for children to distract themselves; in another study, conducted in 2017, 40.5% of children reported “no” to the question, “Was there enough for you to do when you were waiting to be seen (such as toys, games and books)?” (Parra, C., Vidiella, N., Irene Marin, I., Trenchs, V., & Luaces, C., 2017, p.1265). Hence, the simple task of providing a wider selection of activities in the waiting room could potentially increase a child’s comfort.

Another approach taken by investigators to ease the process of visiting the ER is evaluating and improving patient pain management. There are two parts to this issue, do caregivers block children from receiving proper pain medication, or doctors not prescribe proper pain medication? One study looked directly at this issue; researchers found that most caregivers follow doctors’ advice and caregivers are not obstacles to proper pain management for pediatric patients (Whiston, C., Ali, S., Wright, B., Wonnacott, D., Stang, A., Thompson, G., . . . Poonai, N., 2018). The study evaluated 743 cases of children who entered into the ER with a painful condition, collecting data across two hospitals using questionnaires and by reviewing charts. This study showed that ED personal are the primary barrier to lessening children’s discomfort when it comes to pain management, by failing to accurately measure and distribute pain medication. Another study set out with a similar goal of seeing if doctors prescribe the correct amount of painkillers when they do decide to issue anesthetics (Milani, G., Benini, F., Dell’Era, L., Fossali, E., Silvagni, D., Podestà, A., Mancusi, R.L., & Fossali, E.F., 2017). Milani et al. (2017) focused on the two main medicines prescribed for children, ibuprofen and acetaminophen. The study reviewed 1471 cases across 17 different centers. It found that children were prescribed an under- dosage in 893 cases (60.7%), 577 of which were prescribed both ibuprofen and acetaminophen. A surprising feat the study found was that the same issue of under-prescription was similar in centers with guidelines for child pain management and those without guidelines. This study displayed the shortcomings of ED doctors in prescribing sufficient pain medication. The issue of medicine dosage is a fine balance between making the patient comfortable and making sure the patient is safe. With young children, administering pain medication can be very risky as their developing brains react differently than those of adults. However, resolving the issue of refusal and under-dosage of medication has the potential to greatly improve pediatric patient experience in the emergency room. Pain makes the experience very unpleasant and only amplifies the other environmental chaos of the emergency room.

The last common approach is training staff to better recognize and handle children patients. One experiment focused on the training of nurses to better identify children’s verbal and non-verbal pain cues and how to react (Ramira, M. L., Instone, S., & Clark, M. J., 2016). There are many factors that contribute to making the evaluation a child’s pain a difficult task. These factors include a child’s age and cognitive development stage. The study explores the effectiveness of giving nurses more training and fixed guidelines. In the study, 100 nurses were given exact criteria to determine a child’s pain and a set medicine to reduce it. Results were determined by the examining of medical charts and discharge questionnaires. The article supports that administering training to nurses is effective. The time it took nurses to react and administer pain relief decreased significantly. Also, the pain felt by patients at discharge declined considerably. This provides some insight into effectively training emergency room staff to better quantify and react to children’s conditions.

Overall, the care for children in the emergency room is adequate, but many studies, such as those mentioned above, show that it is a work in progress. Making children comfortable in the ER is a complex challenge that is different than that of adult patients. Children are all different and their communication skills are often not developed enough to effectively convey their discomfort. Doctors have taken several methods to try to lessen pediatric patients’ distress including distraction techniques, improving medication, and training healthcare professionals to better understand child behavior. These tried techniques have had success in studies and are continuing to be developed in the healthcare community (Longobardi, C., Prino, L. E., Fabris, M. A., & Settanni, M., 2019; Milani, G., Benini, F., Dell’Era, L., Fossali, E., Silvagni, D., Podestà,…Fossali, E.F., 2017; Ramira, M. L., Instone, S., & Clark, M. J., 2016).

In conclusion, we must make progress in the effort to take care of children in the emergency department. Pediatric patients are many times lumped in with how adult patients are processed, which induces further stress on the children. In the articles by Burri, Holmes, and Piekarski, there are personal accounts of what exactly life’s like in the chaotic world of emergency medicine. These articles give only a small look into the emergency department, but it is valuable to illustrate just how hectic practices are and how easily it can be for children’s comfort to be an afterthought. We need to invest in further studies and the results of the studies; if studies show that distraction activities calm nervous children, hospitals need to invest in distraction activities in waiting rooms. Making Emergency Rooms more comfortable for children is an important initiative that anyone who cares for the future of healthcare, or the future health of our society alone, needs to stand behind.



Longobardi, C., Prino, L. E., Fabris, M. A., & Settanni, M. (2019). Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the pediatric emergency room: A pilot study. Child: Care, Health & Development.

Marcin, J. P., Romano, P. S., Dharmar, M., Chamberlain, J. M., Dudley, N., Macias, C. G., … Pediatric Emergency Care Applied Research Network. (2018). Implicit review instrument to evaluate quality of care delivered by physicians to children in emergency departments. Health Services Research, 53(3), 1316–1334.

Milani, G., Benini, F., Dell’Era, L., Fossali, E., Silvagni, D., Podestà, A., … PIERRE GROUP STUDY. (2017). Acute pain management: acetaminophen and ibuprofen are often under-dosed. European Journal of Pediatrics, 176(7), 979–982.

Nearly 12 Million Kids Visit the ER Each Year For Injuries. (2014, July 7). Retrieved from

Parra, C., Vidiella, N., Marin, I., Trenchs, V., & Luaces, C. (2017). Patient experience in the pediatric emergency department: do parents and children feel the same? European Journal of Pediatrics, 176(9), 1263–1267.

Ramira, M. L., Instone, S., & Clark, M. J. (2016). Quality Improvement. Pediatric Pain Management: An Evidence-Based Approach. Pediatric Nursing, 42(1), 39–49. Retrieved from

Remick, K., Gausche-Hill, M., Joseph, M. M., Brown, K., Snow, S. K., & Wright, J. L. (2018). Pediatric Readiness in the Emergency Department. Pediatrics, 142(5), 1–15.

Whiston, C., Ali, S., Wright, B., Wonnacott, D., Stang, A., Thompson, G., . . . Poonai, N. (2018). Is caregiver refusal of analgesics a barrier to pediatric emergency pain management? A cross-sectional study in two Canadian centres. CJEM, 20(6), 892-902. doi:10.1017/cem.2018.11

Zhang, A., Yocum, R. M., Repplinger, M. D., Broman, A. T., & Kim, M. K. (2018). Factors Affecting Family Presence During Fracture Reduction in the Pediatric Emergency Department. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 19(6), 970–976.


Heather Erlemann