The Comfort Promise

Studies show that in both high-income and low-medium income countries (LMICs), needle pain is consistently rated among the most painful and least well-managed medical experiences for children. According to the U.S. Centers for Disease Control and Prevention, as many as 2 in 3 children and 1 in 4 adults suffer from a strong fear of needles. This fear, often rooted in negative experiences during childhood, leads to healthcare avoidance behaviors and is the leading reason for immunization non-compliance.

Despite WHO guidelines stating that the lack of analgesic provision for vaccination pain is inexcusable, evidence-based modalities—such as numbing cream—are still not routinely offered to all children in most clinics and hospitals worldwide.

The Impact of Needle Pain & Anxiety on Pediatric Cancer Outcomes

Pediatric cancer mortality remains alarmingly high in low- and middle-income countries (LMICs), where nearly 90% of children with malignancies do not survive their disease. Many health systems in LMICs lack central venous line (CVL) capacity, resulting in children enduring dozens to hundreds of needle pokes throughout their treatment.

Needle-related anxiety is a major reason children discontinue their cancer therapy—a devastating but preventable barrier to care.

Clinical Solutions and Global Success

Several initiatives have been successfully implemented to address this challenge, including e.g. CARD and the Comfort Promise, the latter a global program (in collaboration with St. Jude Research Children’s Hospital, Memphis, TN, USA) adopted in more than 50 hospitals across 26 countries on all six continents.

Using a Comfort Promise bundle, most children now describe their needle procedures as pain-free, thanks to five core strategies:

Topical anesthetics (e.g., 4% lidocaine cream, EMLA cream)
Sucrose or breastfeeding for infants aged 0 to 12 months
Comfort positioning, including skin-to-skin contact for infants and upright seating for older children
Age-appropriate distraction techniques
Offer Choices & Reframe the Memory

Among these interventions, topical anesthetics have been shown to be the most effective, increasing the likelihood of pain control by a 9-fold odds ratio.

Funded by the MAYDAY Foundation both at Children’s Minnesota and UCSF Benioff Children’s Hospitals we created a Comfort Promise Tool Kit including five modules as a training tool to support the role out of a “Comfort Promise” Quality Improvement project at your institution:

Module 1. Comfort Promise Introduction Download

Module 2. Evidence. Why. What. How.[Short version]Download

Module 2. Evidence. Why. What. How.[Long version]Download

Module 3. Mind the Gap Download

Module 4. Implementation Download

Module 5. Creating & Sustaining new Culture Download

Literature:

Friedrichsdorf, S. J., D. Eull, C. Weidner, and A. Postier. “A Hospital-Wide Initiative to Eliminate or Reduce Needle Pain in Children Using Lean Methodology.” Pain Rep 3, no. Suppl 1 (Sep 2018): e671. https://www.ncbi.nlm.nih.gov/pubmed/30324169.

McNeil, M. J., X. Garcia Quintero, M. Gonzalez, Y. Zheng, C. Ugaz Olivares, R. Morales, E. Boldrini, et al. “Preventing and Treating Pain and Anxiety During Needle-Based Procedures in Children with Cancer in Low- and Middle-Income Countries.” Cancers (Basel) 16, no. 5 (Mar 1 2024). https://www.ncbi.nlm.nih.gov/pubmed/38473383.

Friedrichsdorf, S. J. “Prevention and Treatment of Pediatric Pain and Anxiety Caused by Botulinum Neurotoxin a Injections: Inadmissible without Nitrous Oxide Analgesia and Sedation?“. Dev Med Child Neurol 64, no. 12 (Dec 2022): 1437-38. https://www.ncbi.nlm.nih.gov/pubmed/36089662.

Friedrichsdorf, S. J., and L. Goubert. “Pediatric Pain Treatment and Prevention for Hospitalized Children.” Pain Rep 5, no. 1 (Jan-Feb 2020): e804. https://www.ncbi.nlm.nih.gov/pubmed/32072099.

Postier, A. C., D. Eull, C. Schulz, M. Fitzgerald, B. Symalla, D. Watson, L. Goertzen, and S. J. Friedrichsdorf. “Pain Experience in a Us Children’s Hospital: A Point Prevalence Survey Undertaken after the Implementation of a System-Wide Protocol to Eliminate or Decrease Pain Caused by Needles.” Hosp Pediatr 8, no. 9 (Sep 2018): 515-23. https://www.ncbi.nlm.nih.gov/pubmed/30076160.

Friedrichsdorf, S. J. “Nitrous Gas Analgesia and Sedation for Lumbar Punctures in Children: Has the Time for Practice Change Come?”. Pediatr Blood Cancer 64, no. 11 (Nov 2017). https://www.ncbi.nlm.nih.gov/pubmed/28585713.

Friedrichsdorf, S. J., A. Postier, D. Eull, C. Weidner, L. Foster, M. Gilbert, and F. Campbell. “Pain Outcomes in a Us Children’s Hospital: A Prospective Cross-Sectional Survey.” Hosp Pediatr 5, no. 1 (Jan 2015): 18-26. https://www.ncbi.nlm.nih.gov/pubmed/25554755.

Additional Comfort Promise Information / Videos

UCSF Benioff Children’s Hospitals, Oakland and San Francisco https://www.ucsfbenioffchildrens.org/services/comfort-promise

Children’s Minnesota https://www.childrensmn.org/services/care-specialties-departments/pain-program/childrens-comfort-promise/