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is evidence that for long-bone fractures and abdominal pain, children of Black and Hispanic background are less likely to receive opioid analgesia than White children Furthermore, in a busy ED, physicians are often forced to concentrate on other aspects of resuscitation and care before managing pain Plans for pain control, therefore, may be overlooked because of other priorities Some physicians avoid analgesics because they not want to mask symptoms Topical anesthetics may be avoided because it is inconvenient to wait for them to take effect This can delay care, so some physicians may underuse analgesics and convince a young child that a painful procedure or repositioning of an extremity fracture will hurt only “for a minute.” Forceful restraint (instead of medication) is then used, and more pain is inflicted on an already uncomfortable child Impact of Pain and Importance of Successful Pain Management Emergency physicians must understand that pain is an individual experience and many factors contribute to the degree of pain that a child experiences for any given condition Children of all ages can experience pain; it is believed that even neonates by 26 weeks’ gestation respond to tissue injury with specific behavior and with autonomic, hormonal, and metabolic signs of distress Newborns feel pain and react to painful stimuli (e.g., circumcision) with wiggling motions and crying Young children often have an exaggerated fear of needles, while older children may be better able to understand the need for a painful procedure; they are usually less anxious and better able to tolerate the inflicted pain However, an older child may have a better understanding of the significance of an injury or an illness that could cause depression, anxiety, and more pain Similarly, parental response (anxiety or reassuring calm) may affect a child’s perception of pain Caregivers can experience elevated heart rate, blood pressure, and anxiety during painful procedures Not surprisingly, parental distress–promoting behaviors may increase childhood distress Other psychological factors, such as the child’s emotional state, personality traits, gender, or cultural background, may impact their anxiety, and this can also alter the degree of pain Some children seem to have a hypersensitivity to pain, whereas others tolerate it well Certain genotypes, such as the CYP2D6 polymorphisms and opioid receptor OPRM1, can mediate the metabolism and efficacy of certain