Dr Friedrichsdorf is challenging norms to reduce pain and fear in pediatric care.
Highlights:
- Pediatric medical care has long minimized children’s pain, especially from needle procedures, treating it as brief, unavoidable, and insignificant. However, children’s pain is real, memorable, and avoidable.
- Dr. Stefan Friedrichsdorf shifted his career after witnessing children experience unnecessary fear and suffering, particularly around needle-related procedures.
- He developed a simple, evidence-based protocol to reduce pain and anxiety during any needle procedure, from vaccinations to blood draws. These are small, low-cost interventions that can dramatically reduce fear and suffering.
- The protocol combines topical anesthetics, comfort positioning, distraction, soothing techniques (like breastfeeding or sugar water), and communication.
- Friedrichsdorf argues that reducing procedural pain should be a universal standard of care, like handwashing, and that real change must begin in medical education and culture, not just guidelines.
Stepping into the elevator of a modern medical office tower, gleaming, with spotless mirrors and metallic walls, was enough to trigger the memory. From the entrance, the smell of antiseptics and ethanol did the rest, unleashing inconsolable crying in a nearly two-year-old girl. The terror of knowing what was coming.
Going to the pediatrician usually involves the necessary dose of a vaccine, and sometimes a couple more, along with other procedures that may require the use of needles. Historically, medical culture has tended to minimize the pain children experience from these kinds of procedures.
Largely it comes down to people thinking it’s not a big deal.
Stefan Friedrichsdorf
“Largely it comes down to people thinking it’s not a big deal,” explains Dr. Stefan Friedrichsdorf, medical director of the Stad Center for Pediatric Pain, Palliative & Integrative Medicine at Benioff Children’s Hospitals. It’s assumed that it doesn’t matter, that the pain is minimal and fleeting. There’s also a belief that nothing can be done about it.
His turn toward pediatric pain medicine came when Stefan saw children being unnecessarily subjected to pain and fear, especially those in intensive care or even in palliative care. Why make them endure more pain, anxiety, and fear? “When I started working as a resident, I realized we were torturing children,” he recalls. Needle-related pain is the most common procedure in pediatrics, and also a highly traumatic one. Anxiety begins beforehand and lingers long after the poke. “So it’s not just a second,” Friedrichsdorf notes.
How can we relieve the pain and anxiety caused by painful medical procedures in all children, everywhere, always?
Seeing this accepted as normal, he decided to devote most of his career to transforming the experience of going to the doctor. “How can we relieve the pain and anxiety caused by painful medical procedures in all children, everywhere, always?” he began to ask himself. From that question, he created an efficient, easy protocol to reduce pain in any procedure that uses a needle, from blood draws for lab tests to vaccinations or catheter placement. This work led to his being named one of the one hundred most influential people in health last year.
The protocol combines several methods. “Number one, always apply a topical anesthetic cream to the skin,” at the site where the needle will be used, at least thirty minutes before the procedure. This substantially reduces pain. It’s also necessary to help the child feel calm, and for that, comfort positioning is recommended. Holding a baby chest-to-chest or seating her on her mother’s lap helps her feel safe. The priority is comfort. “Never, never, never restrain by force,” the doctor says. For him, this is the gravest mistake.
Before injecting a patient, he often puts on plastic thumbs that light up when pressed. He moves them in front of the child, making the light seem to jump from side to side. While the attention is there, the injection is given. Other age-appropriate distractions can range from singing or using a rattle to light-up toys, books, bubbles, or a stuffed animal. With older children, “of course, they’re going to use apps,” along with giving them a sense of control during the procedure. You can pause if the patient seems stressed or, in the case of children, offer simple choices: “Do you want to sit on your mom’s lap?” “Do you want to sit next to your dad?” “Do you want to sit by yourself?” You give them options.
Breastfeeding or sugar water works like a pain blocker.
Another method used during the procedure is offering breastfeeding or sugar water to help soothe infants. “Breastfeeding or sugar water works like a pain blocker,” he says.
They remember it as less painful, and when they come back, they’re less anxious.
Finally, it’s important to care for how the memory of the experience is formed. In this sense, you should ask how it felt, for example, and frame the experience positively by highlighting achievements. “They remember it as less painful, and when they come back, they’re less anxious,” he explains. There are also additional approaches supported by scientific evidence. For children who can communicate verbally, it’s helpful to explain what the procedure involves and why it’s necessary. It’s also important to avoid promising that it won’t hurt. Instead, you can anticipate that they’ll feel pressure and remind them they can rely on a distraction to get through it. Assigning a simple task is also useful, asking them, for instance, to keep their arm still or squeeze an adult’s hand gives them a goal. Added to this are breathing exercises, with slow inhalations before the procedure and long exhalations while it’s happening.
Stefan believes the protocol should be adopted with the same naturalness as handwashing. “One hundred fifty years ago, people didn’t wash their hands,” he notes. Today, it’s not debated or negotiated. It’s a rule, a standard. Period. “It can work in any setting,” he says—both in wealthy countries and in lower-resource contexts. “We’ve successfully implemented it in more than 20 countries.”
For him, change has to begin in medical education. He describes himself as a dissenter from the traditional approach, which he believes fails because it can’t change behavior. “Making suggestions, drafting guidelines, or publishing papers, as I’ve done, doesn’t change clinical practice,” he explains. The model focuses on transmitting knowledge, but it doesn’t address fear, myths, peer pressure, or beliefs. Without tackling these barriers, without creating an emotional connection and teaching practical skills, knowledge remains theoretical. The result, in this particular case, is that children’s suffering continues to be treated as something minor, acceptable, and inevitable. And it definitely isn’t.
