If a wound is not closed initially, delayed primary closure (tertiary closure) can be considered after the risk of infection decreases, about to days later This is recommended for selected heavily contaminated wounds and those associated with extensive damage These uncommon wounds in pediatrics might include high-velocity missile injuries, crush injuries, explosion injuries of the hand, industrial wounds, those occurring on a farm, and some extensive bite wounds The wound should be cleaned and debrided and covered at the time of initial presentation, then reassessed in a few days for infection A contaminated but healing wound may gradually gain sufficient resistance to infection to permit uncomplicated closure at a later time This approach may reduce discomfort and lead to a better cosmetic result than no repair Tertiary closure is used rarely in pediatrics because children have few severely contaminated wounds Preparing the Child and Family It is important to reassure the child and the family that everything will be done to care for the wound appropriately and to relieve the patient’s pain and anxiety In many cases, early removal of blood and foreign material from the surface of the wound is reassuring Also, carefully chosen words will reduce fear for the procedure The provider must honestly warn the patient of an impending painful stimulus but may leave open the possibility that it may not hurt as much as the child thinks Appearing unhurried and confident, giving the child some control of the situation, and explaining the upcoming procedure seem to help reduce anxiety and pain for many patients The parent(s) and child should be informed that steps will be taken to make the procedure as quick and painless as possible, such as with the use of topical anesthetics The clinician should provide an age-appropriate empathic explanation, to reduce anxiety Prepare instruments that may be frightening, such as needles and scalpels, away from the child Distraction techniques, such as allowing the child to listen to music or view age-appropriate, entertaining videos during the procedure can be quite effective (see Chapter A General Approach to the Ill or Injured Child ) Child life specialists, if available, are also a good resource Inviting the parent to be in the room increases their level of confidence in the provider and can improve their overall satisfaction with the visit Most parents want to be present during wound repair in the ED, and most can be a stabilizing force if properly oriented The parent can reassure or distract the child with a story while maintaining physical contact under necessary drapes and restraints It is usually best if the parent is sitting down and focusing on the child, rather than directly observing the procedure