A recent review from Canada upsets many of our long-held views regarding pain and children. It was noted that medical procedures frequently are painful and distressing for children and their parents. Painful procedures involving needles are common for both children who are healthy and children who are ill. For many years, there has been considerable debate about whether parents should be present during their children's painful medical procedures. More recently, it has been suggested that the mere presence or absence of a parent is not nearly as important as what the parent does while present. A common approach adopted by parents during their children's medical procedure is to reassure. Parental reassurance is intended to alleviate the child's pain and distress. However, does the parent communicate comfort or increase distress when reassuring a child during a painful medical procedure?

The behavior of parents during their children's painful procedures is significantly related to the amount of pain and distress the children experience. One study, for example, found that maternal behavior accounted for 53% of the variance in child distress during immunizations. Parental behaviors associated with decreases in child distress include humor, commands to use coping strategies, and talking about something other than the procedure. Humor and talking about non-procedural matters are considered distraction. These types of behaviors are referred to as coping promoting behaviors. In contrast, empathy, criticism, apologies, giving control to the child, and reassurance have been linked with increased child distress and are referred to as distress promoting behaviors. Of the distress promoting behaviors, the most common is reassurance. The purpose of this commentary was to raise awareness of what is known about the relationship between parental reassurance and child distress during medical procedures and to suggest potential mechanisms that could account for this relationship.

Reassurance has been defined as procedure-related comments that are directed towards the child with the intent of reassuring the child about his/her conditions, or the course of the procedure. Examples include, Don't worry. I'll hold your hand?; You're okay?; You can do this. Reassuring comments account for more than one quarter of the content of spontaneous adult (ie, parent and medical staff) vocalizations to children during procedures. Even when parents are trained in a variety of potential pain/distress promoting behaviors, parents make twice as many reassuring comments as any other distress promoting behaviors. Although this link between reassurance and child distress seems counterintuitive, it has been a fairly consistent finding in research.

So why might parental reassurance hurt? Parents reassure with the belief that they are being helpful to their child. Reassurance may be an ingrained response because training parents in distraction does not entirely eliminate parental tendencies to reassure. Three mechanisms could help explain the counterintuitive link between reassurance and child distress. First, reassurance may serve as a warning to the child that the caregiver is anxious, knows something bad is about to happen, or both. This quote from a children's book captures the idea well: "If an adult tells you not to worry and you weren't worried before, you better hurry up and start because you're already running late." Second, reassurance, or other forms of comfort, may reinforce distress behavior in the child. The child showing signs of apprehension may trigger the caregiver to reassure and provide attention, which in turn could increase the likelihood of expression of apprehension and distress by the child. Finally, parental reassurance may give the child permission to overtly express his or her distress; the parents' use of a soothing tone may facilitate the release of negative emotions on the part of the child. Regardless of the specific mechanism through which reassurance may contribute to child distress, its message may be conveyed in facial expression, vocal intonation, the specific content of the words, or all three.

So much for using the line, "This will hurt me more than you," when attempting to reassure your child during a medical procedure.