medical procedures

Section 4

Medical Procedures

Contents

4.1 General Principles of Procedural Pain Management4.2 Procedural Pain in the Neonate

4.2.1 Blood Sampling4.2.2 Percutaneous Central Venous Catheter Insertion

(PICC)4.2.3 Ocular Examination for Retinopathy of Prematurity4.2.4 Lumbar Puncture4.2.5 Urine Sampling4.2.6 Chest Drain (tube) Insertion and Removal (see 4.2.3)4.2.7 Nasogastric Tube Placement (see 4.2.5)

4.3 Procedural Pain in Infants and Older Children4.3.1 Blood Sampling and Intravenous Cannulation4.3.2 Lumbar Puncture4.3.3 Chest Drain (Tube) Insertion and Removal4.3.4 Urine Sampling4.3.5 Insertion of nasogastric tubes4.3.6 Immunization and Intramuscular Injection4.3.7 Repair of Lacerations4.3.8 Change of Dressings in Children with Burns

4.1 General principles of procedural painmanagement

Routine medical care involving blood sampling and

other painful diagnostic and therapeutic procedures

can cause great distress for children and their

families. When such procedures are essential, it is

important that they should be achieved with as

little pain as possible. For many children who have

chronic illness, procedures often need to be repeated

and this can generate very high levels of anxiety and

distress if their previous experience has been poor.

The general principles, which apply to the manage-

ment of all procedures at any age, are listed below.

Evidence based recommendations for the general

and specific management of common procedures are

described in Section 4.2 for neonates and Section 4.3

for infants and older children.

• Infants and children of all ages, including pre-

mature neonates are capable of feeling pain and

require analgesia for painful procedures.

• Developmental differences in the response to pain

and analgesia should be considered when choos-

ing analgesia.

• Consider if the planned procedure is necessary, and

how the information it will provide might influence

care? Avoid multiple procedures if possible.

• Are sedation or even general anesthesia likely to be

required for a safe and satisfactory outcome?

• Would modification of the procedure reduce pain?

For example, venepuncture is less painful than

heel lance.

• Is the planned environment suitable? Ideally this

should be a quiet, calm place with suitable toys

and distractions.

• Allow sufficient time for analgesic drugs and

other analgesic measures to be effective.

• Ensure that appropriate personnel are available,

and enlist experienced help when necessary.

• Formulate a clear plan of action should the

procedure fail or pain become unmanageable

using the techniques selected.

Good practice pointPain management for procedures should be planned

taking into account the general principles (outlined

above) and include both pharmacological and non-

pharmacological strategies whenever possible.

4.2 Procedural pain in the neonate

Premature neonates are able to perceive pain but the

response to both pain and analgesia is dependant on

developmental age. Because of this, pain assessment

in this age group is particularly difficult (see Section

3), and the low sensitivity of many pain measurement

tools can complicate the interpretation of evidence.

Clinically, neonates appear to be sensitive to the

adverse effects of many drugs, including analgesics;

however, reductions in the response to pain have

been observed following nontraditional analgesia

such as sucrose and to physical and environmental

measures, e.g. suckling or tactile stimulation, which

are currently not known to have potentially harmful

effects. A number of documents including reviews,

guidelines, and policy statements have been pub-

lished recently on the subject of procedural pain

management in the neonate (1–3). On the basis of the

currently available evidence the following measures

can be generally recommended for the management of

procedural pain in the neonate:

Pediatric Anesthesia 2008, 18 (Suppl. 1), 19–35 doi:10.1111/j.1460-9592.2008.02430.x

� 2008 The AuthorsJournal compilation � 2008 Blackwell Publishing Ltd 19

RecommendationsBreast-feeding mothers should be encouraged tobreastfeed during the procedure, if feasible:Grade A (4,5)

Non-nutritive sucking (NNS) and ⁄or the use ofsucrose or other sweet solutions should be usedfor brief procedures: Grade A (4–14)

Evidence

Neonatal procedural pain has been relatively well

studied. Evidence relating to the specific management

of a number of common procedures listed in Sections

4.2.1 to 4.2.7. Evidence for the benefit of sweet tasting

solutions in the management of brief pain in the

neonate has been accumulating over the last decade

(13,14). It is becoming increasingly clear that other

modalities may also modify the response to pain:

especially NNS. Sucrose seems to be effective through-

out the neonatal period, but the efficacy of NNS using a

pacifier has not been established in the preterm infant.

Preterm infants are born without a highly developed

suck reflex: this develops around 32–34 weeks gesta-

tion and may reduce the effectiveness of interventions

involving sucking at this age (9). The difference

between the effect of NNS and sucrose may therefore

be a feature of gestational age – this is an area that

needs further elucidation. The optimum dose of sweet

tasting solutions has yet to be determined: studies

have used sucrose and glucose in different concentra-

tions and have used different assessment methods;

1 ml of 30% glucose was more effective than 1 ml of

either 10% glucose or 1 ml of breast milk in a study of

newborns having heel prick tests who were not

sucking (13). Two milliliters of 30% glucose was more

effective than 0.4 ml of the same solution prior to

venepuncture in term newborns (6). Studies using

validated assessment methods for preterm infants

e.g. NFCS and PIPP (see Section 3) have found that

0.012–0.12 g, i.e. 0.2–2.0 ml of 12% sucrose, is effec-

tive (14). Recent consensus guidelines have recom-

mended that 0.1–2.0 ml 24% solution be used in the

lowest effective volume 1–2 min prior to the pro-

cedure; upper dose limits of 0.5, 1.0, and 2.0 ml for ages

27–31, 32–36, and 37+ weeks, respectively, were

also suggested (15). The interaction of other inter-

ventions such as pacifiers, touch, and sensory

stimulation is unclear for all circumstances and

therefore requires further study (7,14). Long-term

outcomes following the use of repeated doses of

sucrose in preterm infants are currently unknown.

See Section 6.7 for advice on dosage and administra-

tion of sucrose.

20 MEDICAL PROCEDURES

� 2008 The AuthorsJournal compilation � 2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18 (Suppl. 1), 19–35

4.2.1 Blood sampling in the neonate

Blood sampling, particularly where frequent sam-

ples are needed in NICU, has been identified in

many studies as a significant cause of pain and

morbidity. Where sampling from indwelling venous

access is not possible either heel lancing (heel stick)

or venepuncture are options. They are not equiva-

lent. Venepuncture pain appears to be more easily

managed than pain from heel lance, but pain from

heel lance can be reduced by technique modification.

Venepuncture can be technically more difficult than

heel lance and is therefore sometimes impractical:

capillary samples are collected for blood sugars,

bilirubin, newborn screening tests, and capillary

blood gases. Please also see Sections 4 and 4.2 on the

general management of procedural pain.

RecommendationsSucrose or other sweet solutions should be used:Grade A (4–14)

Venepuncture is preferred to heel lance as it isless painful: Grade A (12,16,17)

Topical local anesthetics alone are insufficient forheel lance pain: Grade A (18)

Topical local anesthetics can be used for vene-puncture pain: Grade A (18–20)

Morphine alone is insufficient for heel lance pain:Grade B (21)

Sensory stimulation including tactile stimulation,such as holding or stroking, can be used orcombined with sucrose where feasible, as it mayfurther reduce the pain response: Grade B (7,22)

(See also Sections 4 and 4.2)

Evidence

Blood sampling in the neonate has been relatively

well investigated; evidence for the use of sweet

tasting solutions in venepuncture and heel lance

pain has been accumulating over the last decade –

see Section 4.2 Many studies have used venepunc-

ture as the pain stimulus: this appears to be less

painful than heel lance and so when practical it is the

preferred option (12,16). Topical local anesthesia can

reduce the pain of venepuncture (20). However, the

response to heel lance or insertion of PICC lines in

preterm infants does not appear to be reduced with

topical analgesia alone and this needs further study

see Section 4.2.2 (23). Tactile stimulation has been

associated with reductions in the pain response in

neonates; ‘kangaroo care’ reduced heel lance pain in

those aged 32–36 weeks (22) and a combination of

‘multisensory stimulation’– massage, aural stimula-

tion, and eye contact – with glucose + pacifier was

more effective than glucose + pacifier alone in

another study (7).

Heel lance pain can be reduced by procedure

modification, e.g. the use of special spring-loaded

devices. Studies have compared automated devices:

while some types may improve blood collection and

reduce the number of punctures required there does

not seem to be a reduction in pain if collection

involves squeezing of the heel (24,25). The develop-

ment of local hypersensitivity from repeated sam-

pling is reduced by widening the area of the

sampling site (Table 1; 26).

Table 1

Blood sampling in the neonate

Direct evidence

Local anesthesia Topical 1+a

Sucrose 1++Breast feeding 1+a

Non-nutritive sucking 1+Tactile stimulation 1+b

Procedure modifications 1+c

aVenepuncture only; bHeel lance only; cVenepuncture by trainedphlebotomist, spring loaded heel-lance device.

MEDICAL PROCEDURES 21


4.2.2 Percutaneous central venous catheterinsertion (PICC) in the neonate

Percutaneous central venous catheters are inserted

for long-term venous access; the procedure can be

technically difficult. Infants requiring PICC line

insertion are often unwell and may be receiving

ventilatory support; these infants are also likely to be

receiving morphine by intravenous infusion and are

the group that have been mostly studied.

RecommendationTopical LA with tetracaine alone is insufficient toabolish pain of PICC line insertion; Tetracaineplus morphine is superior (in ventilated infants):Grade B (23,27)

Evidence

In comparison with simple blood sampling or

temporary venous cannulation, infants undergoing

PICC line insertion need to be held in position for

longer and this may contribute to the high levels of

perceived distress reported in studies. There has

been only limited study of this procedure, but a

combination of morphine and topical local anesthe-

sia appears to be superior to either alone in venti-

lated infants (23,27). There is little evidence to guide

practice in an infant who is not ventilated: morphine

in this situation may produce respiratory depres-

sion. General anesthesia should be considered in

situations where such facilities are available. Indirect

evidence would suggest that a combination of

topical anesthesia and sucrose before the initial

venepuncture, with the use of NNS in the infant

who is able to suck, may be helpful in reducing pain

and distress (Table 2).

4.2.3 Ocular examination for retinopathy ofprematurity

Preterm infants ‘at risk’ for retinopathy (ROP)

should have regular ocular examination. An eyelid

speculum is inserted to hold the eye open and the

retina is examined by indirect fundoscopy through a

dilated pupil.

RecommendationsInfants undergoing ROP exam should receivelocal anesthetic drops: Grade B (28)

Infants should be offered a pacifier: Grade B(29,30)

Sucrose may contribute to pain response reduc-tion: Grade B (30,31)

Evidence

A combined analgesic approach using LA, a pacifier

and the addition of a sweet solution is likely to be

most effective for ROP examination pain. Sucrose

may have a role in reducing this pain – the

frequency of dosing, and the relationship to the

use of a pacifier needs further exploration. Studies of

pain reduction for needle related pain suggest that

sucrose is effective 2 min prior to the painful

stimulus (14). However, examination for ROP is

longer in duration that either venepuncture or heel

lance. For ROP, 2 ml of 24% sucrose was of some

benefit in one study (31), but 1 ml of 33% sucrose

was not different than placebo in another (29).

The use of local anesthesia, a pacifier, and three

doses of sucrose were found to reduce pain scores

more than LA, pacifier, and water (30). See Section

6.7 for further information on the use of sucrose

(Table 3).

Table 3

Examination for retinopathy of prematurity

Direct evidence Indirect evidence

Local anesthesia Topical 1+Sucrose 1+Non-nutritive sucking 1+Tactile stimulation 1+

Table 2

Percutaneous central venous catheter insertion

Directevidence

Indirectevidence

Local anesthesia Topical 1+a

Opioids Intravenous 1+a

Sucrose 1++Non-nutritive sucking 1+Tactile stimulation 1+

aCombined.



4.2.4 Lumbar puncture in the neonate

Sampling of cerebrospinal fluid is often regarded as

a minor procedure in infants; nevertheless it is

associated with pain which can be reduced by

suitable analgesia (32).

RecommendationTopical local anesthesia is effective in reducingLP pain: Grade A (32)

Evidence

There have been few studies directly investigating

LP pain in the neonate (Table 4). Topical local

anesthetic has been found to be effective (32).

Indirect evidence suggests that subcutaneous infil-

tration of LA would also be effective, but it has not

been ‘consistently’ shown to be superior to placebo

in the neonate, in contrast to positive effects in older

children and adults (1). Sucrose, NNS, and other

strategies have not been investigated but are also

likely to be effective – see Section 4.2.

4.2.5 Urine sampling in the neonate

Urine sampling is important to detect urinary tract

infection in infants and must be collected so as to

avoid sample contamination. Direct catheterization

of the urethra or catheterization of the bladder by the

percutaneous suprapubic route are often preferred

because some types of urine collection bags have

a high rate of contamination, and ‘clean catch’

specimens can be difficult or time consuming to

collect.

RecommendationTransurethral catheterization with LA gel is pre-ferred as it is less painful than suprapubicaspiration using topical LA: Grade B (33)

Evidence

Pain responses were observed in neonates and

infants having either urethral or suprapubic cathe-

terization with local anesthesia (Table 5; 33). Tran-

surethral catheterization appeared to be less painful

(33). Sucrose analgesia immediately before bladder

catheterization in neonates and infants up to 3

months old was not effective at abolishing pain

responses; however, a reduction in response was

observed in a subgroup of those less than 30 days

old (34). Indirect evidence also suggests that sucrose,

NNS, and other strategies may be effective at

reducing pain especially if used in combination with

LA but this has not been directly studied – see

Sections 4.2 and 6.7 for advice on the use and

administration of sucrose.

Table 4Lumbar puncture in the neonate

Agent Technique Direct evidence Indirect evidence

Local anesthesia Topical 1+Infiltration 1+a

Sucrose 1++Tactile stimulation 1+

aOlder children and adults.

Table 5

Urine sampling in the neonate

Directevidence

Indirectevidence

Local anesthesia: topical, lubricant gela 1+Sucrose 1+Non-nutritive sucking 1+Procedure modification 1+Tactile stimulation 1+

aUrethral catheterization.



4.2.6 Chest drain (tube) insertion andremoval

The management of his procedure in the neonate is

discussed with that of older children in Section 4.3.3.

4.2.7 Nasogastric tube placement

The management of his procedure in the neonate is

discussed with that of older children in Section 4.3.5.

4.3 Procedural pain in infants and olderchildren

Painful procedures are often identified as the most

feared and distressing component of medical care

for children and their families. See Section 4.2 for a

general introduction on the management of proce-

dural pain, and Section 4.2.1 for the management

of procedural pain in the neonate. When managing

procedural pain in infants, older children, and

adolescents special emphasis should given not

only to proven analgesic strategies but also to

reduction in anticipatory and procedural anxiety

by suitable preparatory measures. Families, play

therapists, nursing staff, and other team members

play key roles in reducing anxiety by suitable

preparation. The personality, previous experience

and analgesic preferences of the child will influ-

ence management strategies. Analgesia-sedation

with ENTONOX (nitrous oxide ⁄ oxygen), by super-

vised self-administration should be considered

where indicated, especially in children older than

6 years who can cooperate: see Section 6.6. Seda-

tion (see SIGN Guideline 58, available at: http://

www.sign.ac.uk) or general anesthesia may be

needed for complex, invasive or multiple proce-

dures. For recent reviews and guideline statements

on the management of procedural pain in infants

and older children, see (35,36).

Good practice pointsChildren and their parents ⁄ carers may benefit from

psychological preparation prior to painful proce-

dures.

Pain management for procedures should include

both pharmacological and nonpharmacological

strategies where possible.

Entonox should be considered for painful procedures

in children who are able to cooperate with self-

administration.

Sedation or general anesthesia should be considered,

particularly for invasive, multiple, and repeated

procedures.



4.3.1 Blood sampling and intravenouscannulation in children

For most children venepuncture or intravenous

cannulation may be a ‘one off’ event but children

with chronic illness are likely to require multiple

procedures and this can be very distressing for the

child, the family, and the medical team. When

managing such pain in infants, older children, and

adolescents, special emphasis should given not only

to proven analgesic strategies but also to reduction

in anticipatory anxiety by suitable preparatory mea-

sures. Venepuncture or intravenous cannulation

maybe technically difficult – practitioners should

not continue to try multiple cannulation sites unless

the procedure is urgent or a more experienced

practitioner is not available. In non-urgent cases

consider whether the test can be rescheduled, and

enlist the help of a more experienced practitioner.

See also Section 4, general management of proce-

dures, and Section 4.3, procedural pain in infants,

older children, and adolescents.

RecommendationsTopical local anesthesia should be used forintravenous cannulation: Grade A (37–41)

Psychological strategies e.g. distraction or hyp-nosis, to reduce pain and anxiety should be used:Grade A (42)

Nitrous oxide is effective for pain reduction invenous cannulation: Grade B (38,43)

Evidence.

Topical LA, such as EMLA or AMETOP, has an

established place in the management of venous

cannulation with high quality evidence for efficacy

(37–39,41). Newer preparations such as liposomal

encapsulated LA or newer LA delivery systems may

offer advantages in some situations. Buffered in-

jected LA (e.g. lidocaine + bicarbonate 10 : 1),

administered with a fine 30 g needle subcutaneously

prior to cannulation is faster in onset and may be as

acceptable and effective as topical preparations

(37,41,44).

Nitrous oxide (50–70%) inhalation has been used

in children older than 6 years who can self-administer

during venepuncture. 50% Nitrous oxide and

EMLA have been shown to be equally effective for

venepuncture with further improvements in pain

reduction using a combination of the two (38,43).

The efficacy of vapocoolant topical spray has not

been clearly established, but in a study of children’s

preferences children who had experienced both

methods selected both ethyl chloride and AMETOP

equally (45). Vapocoolant spray was not effective in

reducing pain in a study of intravenous cannulation

(46). Psychological strategies, particularly distraction

and hypnosis, and combinations of such methods

including both cognitive and behavioral elements

have been shown to be effective for needle-related

pain in a systematic review (42).

For a summary of evidence levels see Table 6.

Table 6

Blood sampling and IV cannulation in children

Direct evidence

Local anesthesia Topical 1+Infiltration 1++

ENTONOX (nitrous oxide) 1+Psychological preparation 1-Psychological intervention 1+



4.3.2 Lumbar puncture in children

Lumbar puncture (LP) is necessary in acutely ill

children in whom meningitis is suspected. These

children are likely to be unwell and anxious and they

may also undergo other painful procedures such as

venepuncture as part of diagnosis and treatment.

Other children require ‘elective’ or ‘planned’ LP:

this may be for diagnostic reasons, such as evalua-

tion of possible raised intracranial pressure, or for

intrathecal treatments such as chemotherapy.

Positioning of the child is very important for

success and it is helpful to have assistance from

trained staff with experience of correct positioning.

Children who require multiple LPs may cope better

with the addition of sedation (see SIGN Guideline

58, available at: http://www.sign.ac.uk) or general

anesthesia. See also Sections 4 and 4.3 on the general

management of painful procedures.

RecommendationsPsychological techniques of pain managementshould be used to reduce LP pain: Grade A (42,47)

Topical LA and LA infiltration are effective for LPpain and do not decrease success rates: Grade B(37,48,49)

Inhaled Entonox (50% nitrous oxide in oxygen)should be offered to children willing and able tocooperate: Grade C (50)

Evidence

Few studies have directly examined the efficacy of

analgesics in awake children undergoing lumbar

puncture. Most commonly, local anesthesia is com-

bined with sedative agents such as midazolam, or

psychological techniques such as distraction, hyp-

nosis or other cognitive-behavioral interventions

(42,47,48,51). Entonox is effective for LP pain, and

may also be used in combination with LA (either

topical or infiltration) and other strategies (50).

Ketamine analgesia-sedation or general anesthesia

are used in emergency departments and oncology

units with appropriate facilities (52–54). It seems

likely that older children, especially those who

may only need to undergo this procedure once,

may tolerate LP with appropriate behavioral tech-

niques and local anesthesia. Whereas, children

requiring multiple LPs should be offered sedation

or GA (51).


Table 7Lumbar puncture in children

Directevidence

Indirectevidence

Local anesthesia Topical 1+Infiltration 1)

Nitrous oxide 2+Psychological interventions 1++



4.3.3 Chest drain (tube) insertionand removal

Chest drains are necessary in children with pneu-

mothorax, empyema, pleural effusions, following

chest trauma and surgery. Pediatricians are most

likely to need to insert chest drains in the Neonatal

Intensive Care Unit for infants with pneumothorax.

This procedure is becoming increasingly rare be-

cause of improvements in the management of

respiratory distress syndrome, e.g. the use of sur-

factant and ventilating infants at lower pressures.

Older children require drains for management of

empyema or for pneumothorax. Chest drains have

become easier to insert recently with the develop-

ment of small-bore Seldinger type drains that reduce

the need for blunt dissection of the chest wall. They

are available for both neonates and older children.

Sedation (see SIGN guideline 58 available at:

http://www.sign.ac.uk) or general anesthesia

should be considered for chest drain insertion;

however in an emergency some children may

tolerate this procedure using buffered infiltrated LA.

Studies agree that chest drain removal also causes

significant pain. No single analgesic strategy has

been shown to satisfactorily alleviate this pain in

children and it is likely that the optimum effects will

be achieved using a combination of strategies.

See also Sections 4 and 4.3 for advice on the

general management of painful procedures.

Good practice pointsFor chest drain insertion consider general anesthesia

or sedation combined with subcutaneous infiltration

of buffered lidocaine. Selection of appropriate drain

type may reduce pain by facilitating easy insertion.

For chest drain removal a consider combination of

two or more strategies known to be effective for

painful procedures such as psychological interven-

tions, sucrose or pacifier (in neonates), opioids,

nitrous oxide, and NSAIDs.

Evidence

There is little published evidence looking at analge-

sic options for chest drain insertion or removal.

Chest drain insertion may require general anesthesia

or sedation in combination with LA infiltration

(Table 8). Analgesia for removal of chest drains has

included IV opioid, local anesthetics, and NSAIDs

but despite the use of these analgesics significant

pain is still reported (55,56). Inhalation agents such

as nitrous oxide or isoflurane may have a role in

these procedures but further study is needed (57,58)

(NB: nitrous oxide is contraindicated in the presence

of pneumothorax and therefore cannot be recom-

mended for chest drain insertion for this indication).

Multimodal therapy, e.g. i.v. morphine, inhalation

analgesia, topical LA, and a NSAID, is likely to be

superior to a single agent but such combinations,

although in clinical use, have not been studied. It is

important to allow enough time for the chosen agent

to reach its peak effect and to use adequate doses

(55).


Table 8Chest drain insertion and removal

Directevidence

Indirectevidence

Local anesthetic: bufferedlidocaine infiltration (insertion)

1++

Local anesthetic: topical (removal) 1+a

Opioids (removal) 1+a

NSAIDS (removal) 1+a

Entonox (removal)b 1)a,b

Psychological interventions 1++Procedure modification (insertion) 3

aMay reduce but not abolish pain of chest drain removal;bContraindicated in presence of pneumothorax.



4.3.4 Bladder catheterization and relatedurine sampling procedures in children

Urine specimens are usually obtained by ‘clean

catch’ or midstream specimen (MSU). Bladder cath-

eterization may be required for radiological or other

investigation of the renal tract e.g. micturating

cystogram (MCUG) also known as voiding cystou-

rethrogram (VCUG). Consider if MCUG is really

necessary – it is a distressing procedure for the child

and other less invasive techniques such as dynamic

renal scanning may provide the same information.

Bladder catheterization may also be required in

children who develop urinary retention, particularly

those receiving epidural analgesia postoperatively.

Very ill patients in ICU may also require catheter-

ization to monitor urine output. For children who

are to receive postoperative epidural opioids after

major surgery consider ‘prophylactic’ bladder cath-

eterization under general anesthesia at the time of

surgery.

Sedation may also be indicated for some children

see: SIGN guideline 51 available at: http://

www.sign.ac.uk for advice on sedation practice,

and Sections 4 and 4.3 on the general management

of procedural pain.

Good practice pointLubricant, containing local anesthesia, should be

applied to the urethral mucosa prior to bladder

catheterization.

RecommendationPsychological preparation and psychological andbehavioral interventions should be used duringbladder catheterization and invasive investiga-tions of the renal tract: Grade B (59,60)

Evidence

Bladder catheterization has been shown to cause

significant pain and distress but analgesia is not part

of routine care in many institutions (61). More

complex interventions, which include bladder cath-

eterizations such as MCUG or VCUG, have also been

shown to cause significant distress, which can be

reduced, by psychological preparation, and psycho-

logical pain management techniques such as dis-

traction or hypnosis (59,60). Local anesthetics

incorporated into lubricant gels are frequently used

in adults to reduce the pain and discomfort of

catheterization but this has not been well studied in

children. Pretreatment of the urethra with lidocaine

10 min before catheterization reduced pain in a

group of children (16 girls and 4 boys) with a mean

age of 7.7 years (62). However, in younger children

(mean age 2 years) application of lidocaine gel to

the ‘genital mucosa’ for only 2–3 min before the

procedure and its subsequent use as a lubricant did

not decrease pain (61). Techniques combining

adequate preparation, local anesthesia, and psycho-

logical interventions are likely to be more effective

(63).


Table 9

Bladder catheterization and urine sampling in children

Directevidence

Indirectevidence

Local anesthesia Topical gel 1+a

ENTONOX (50% nitrous Oxide) 1+Psychological preparation 1+Psychological intervention 1+

aApplied 10 min before catheterization.



4.3.5 Nasogastric tube insertion

Nasogastric tube (NGT) insertion is a painful and

distressing procedure frequently performed with

little attention to pain relieving strategies (64). Infants

who are unwell and unable to feed, particularly those

with respiratory problems such as bronchiolitis, may

need to be ‘tube fed’ for a short period. Nasogastric

tubes are often maintained in the postoperative

period and may need to be re-inserted if they become

displaced. Older children may also be fed via NGT,

e.g. in cystic fibrosis patients who sometimes require

supplementary feeding on multiple occasions.

Clearly it is particularly important to optimize pain

management in those patients who are likely to need

repeated NGT placement.

Passing a NGT is a skilled procedure and in the UK,

the Department of Health have published guidelines

(CMO Update no. 39, publ. DoH, UK), which should

be followed. See also Sections 4, 4.2, and 4.3 for advice

on the general management of painful procedures in

neonates, infants, and children.

Good practice pointTopical local anesthetics such as lidocaine contain-

ing lubricant gel or atomized or nebulized 4–10%

lidocaine applied prior to placement are likely to

reduce the pain and discomfort of NGT insertion.

Evidence

Nasogastric tube insertion has been little studied in

children. In the adult, topical local anesthesia and

lubricants have been shown to reduce pain and

facilitate placement (65–67). 10% nebulized lido-

caine is effective but may also slightly increase the

incidence of epistaxis (68). The additional use of

vasoconstrictors such as topical phenylephrine may

reduce this risk. These findings have not been

confirmed in children. Indirect evidence also sug-

gests that the use of psychological ⁄ behavioral tech-

niques may be of benefit in older children, and that

sucrose, sucking, or other techniques might reduce

pain responses in neonates (Table 10).

Table 10

Nasogastric tube insertion


Topical local anesthesia (LA) 1++Sucrose 1++a

Non-nutritive sucking 1+a

Tactile stimulation 1+a

Psychological preparation 1+Psychological intervention 1+

aNeonates.



4.3.6 Immunization and intramuscularinjection

Immunization schedules result in increasing num-

bers of intramuscular injections being administered

to infants and children. At 2 and 3 months infants

are offered diptheria, tetanus, pertussis, hemophilus

(Hib), and polio immunization as one vaccination,

with a separate meningococcal or pneumococcal

vaccine. All three are given at 4 months. Children

receive further immunizations at 1 year and

15 months, again at preschool and finally at school

leaving (www.immunisation.org.uk/Immunisation_

Schedule). Intramuscular administration of aspara-

ginase to children with leukemia, and long-acting

penicillin therapy are other examples. The pain of

these injections is widely acknowledged and con-

tributes to anxiety in patients and their parents ⁄ ca-

rers, particularly regarding vaccinations. There is

now evidence that such pain may be reduced by a

number of strategies. Knowledge that practitioners

have considered the use of these strategies may help

parents in their decisions about immunization. It is

important that treatable pain is not a barrier to the

childhood immunization program.

See also Sections 4, 4.2, and 4.3 on the general

management of procedural pain.

Good practice pointsIntramuscular injections should be avoided in chil-

dren as part of routine care. If intramuscular injection

is unavoidable, pharmacological and nonpharmaco-

logical strategies should be employed to reduce pain.

Swaddling, breast feeding or NNS, and sucrose should

be considered in infants undergoing vaccination.

RecommendationsPsychological strategies such as distractionshould be used for infants and children undergo-ing vaccination: Grade A (42,69,70)

Consider additional procedure modificationssuch as vaccine formulation, needle size, depthof injection (25 mm 25 gauge needle), or the useof vapocoolant: Grade A (71–76)

Topical local anesthesia may reduce immuniza-tion pain in infants and older children in somecircumstances, but there is insufficient evidenceto recommend routine use: Grade B (77–80)

Evidence

There are two phases of immunization pain: the initial

pain of the needle piercing the skin and injection of a

volume of vaccine into the muscle or subcutaneous

tissue, followed by a later phase of soreness and

swelling at the vaccination site due to subsequent

inflammatory reaction. Studies have generally inves-

tigated strategies designed to deal with the former,

presumably because this is perceived to be the most

unpleasant component (Table 11). Children typically

dread needle related pain; the use of either nonphar-

macological or pharmacological pain reduction strat-

egies may reduce subsequent negative recall (70).

There is good evidence that nonpharmacological

methods, particularly distraction, can reduce immuni-

zation pain, indeed, they may be as effective as

pharmacological analgesia (42,69–71). There is also

evidence of benefit from nonpharmacological strate-

gies in infants, including swaddling, NNS, and sucrose

but further study is required, especially to clarify the

effectiveness of sucrose in older infants (81,82). See

Section 6.7 for information on the use of sucrose.

Procedure modifications may alter pain responses.

Some combined vaccine formulations (MMR-Priorix

and lower dose DTP vaccine booster Tdap) appear to

be less painful, and this requires further study

(75,83,84). Longer (25 mm) needles and deeper

intramuscular rather than subcutaneous injection

can reduce local reactivity following immunization

(72,74). Swab applied vapocoolant (fluori-methane)

was as effective as topical analgesia when both were

combined with distraction (71).

Topical local anesthesia (EMLA and AMETOP) is

clearly capable of reducing components of vaccina-

tion pain in both infants and older children but

the efficacy, and the balance of effectiveness against

cost is difficult to determine from the studies presently

available (77–80). Lidocaine local anesthesia added to

asparaginase or benzyl penicillin injection reduced

the pain response in two studies, again this approach

requires further investigation (85,86).

Table 11

Immunization and intramuscular injection


Local anesthesia Topical 1+Sucrose 1)Psychological interventions 1++Psychological preparation 1+Procedure modifications 1+



4.3.7 Repair of lacerations in children

Traumatic lacerations of the skin and scalp are

common presentations in the emergency depart-

ment. Acceptable, safe, and effective repair is often a

considerable challenge, general anesthesia or seda-

tion may be necessary (see Section 4). For minor

lacerations without general anesthesia or sedation a

combination of pharmacological and nonpharmaco-

logical techniques are likely to be most effective.

There are a number of less painful alternatives to

simple wound suture in the awake patient: tissue

adhesives in simple low-tension wounds, and the

hair apposition technique (HAT) in scalp lacerations

are examples.

Also see Sections 4 and 4.3 for general consider-

ations in procedural pain management.

Good practice pointFor extensive wounds or children who are very

anxious consider sedation or general anesthesia.

RecommendationsFor repair of simple low tension lacerations tissueadhesives should be considered as they are lesspainful, quick to use and have a similar cosmeticoutcome to sutures or adhesive skin closures:Grade A (87–89)

If sutures are needed, topical anesthetic prepara-tions e.g. LAT (lidocaine-adrenaline-tetracaine) ifavailable, can be used in preference to injectedlidocaine, as they are less painful to apply and areequi-analgesic; it is not necessary to use apreparation containing cocaine: Grade A (90–93)

Buffering injected lidocaine with sodium bicar-bonate should be considered: Grade A (44)

‘HAT’ (hair apposition technique) should be con-sidered for scalp lacerations. It is less painfulthan suturing, does not require shaving andproduces a similar outcome: Grade B (94)

If injected lidocaine is used, pretreatment ofthe wound with a topical anesthetic preparatione.g. lidocaine-adrenaline-tetracaine (LAT) gelreduces the pain of subsequent injection: GradeB (95,96)

50% nitrous oxide reduces pain and anxietyduring laceration repair: Grade B (97,98)

Evidence

Laceration repair has been relatively well studied in

children. There a number of alternatives to simple

wound suture in the awake patient. Tissue adhesives

in simple low-tension wounds, and the HAT in scalp

lacerations are less painful alternatives (88,94). A

number of topical local anesthetic mixtures are

available; they can give equivalent analgesia to

infiltrated local anesthetic and are less painful to

apply (90). A systematic review including trials in

adults and children found that ‘buffering’ local

anesthetics with sodium bicarbonate significantly

reduces the pain of injection (44). Nitrous oxide has

been shown to be effective in reducing pain, anxiety,

and distress in cooperative children (97,98). See

Section 6.6 for information on the use of nitrous

oxide. Psychological techniques such as distraction

and relaxation are also likely to be useful (42).


Table 12Repair of lacerations in children

Directevidence

Indirectevidence

Local anesthesia Topical 1++Infiltration 1++Bufferedinfiltration

1++

ENTONOX(50% nitrous oxide)

1+

Procedure modification 1++Psychological intervention 1++



4.3.8 Dressing changes in the burned child

Children with burns often require repeated, often

extremely painful dressing changes. Children with

severe burns are normally cared for in a specialist

unit but some children will be seen in Emergency

Departments. Initial dressing changes are likely to be

performed under general anesthesia, and if children

remain very distressed this option may be favored

for subsequent procedures. Sedation is sometimes

used to supplement analgesia for burns dressings

(see SiGN guideline 58 available at: http://www.

sign.ac.uk). In the early stages of burn pain man-

agement children may require continuous infusion

of potent opioids such as morphine, additional anal-

gesia will be required prior to dressing changes (99).

Both pharmacological and nonpharmacological

techniques should be used in the management of

painful dressing changes, see Sections 4, 4.2, and 4.3

for advice on the general management of painful

procedures.

RecommendationsPotent opioid analgesia given by oral, transmu-cosal, or nasal routes according to patient pref-erence and availability of suitable preparationsshould be considered for dressing changes inburned children: Grade A (100–103)

Nonpharmacological therapies such as distrac-tion, relaxation, and massage should be consid-ered as part of pain management for dressingchanges in burned children: Grade B (104–106)

Evidence

The evidence base for managing burn pain in

children is small and incomplete. Opioids are used

extensively, and should be given as necessary by

intravenous or other routes (99). There are a number

of small studies comparing different opioid formu-

lations and routes of administration, such as trans-

mucosal or intranasal fentanyl and hydromorphone,

oxycodone morphine by the oral route (100–103).

Nitrous oxide is used extensively for single painful

procedures in children who are able to cooperate,

but has not been specifically investigated for multi-

ple or frequent administration or directly in this

patient group. See Section 6.6 for more information

on the use of nitrous oxide. For a summary of

evidence levels see Table 13.

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