A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children

A prospective, observational study of a pediatric affect and cooperation scale (HRAD±) for vascular access procedures

BACKGROUND

Anxiety is common in pediatric patients, especially during vascular access procedures. Most well-studied affect and anxiety scales, including the Observation Scale of Behavioral Distress-Revised (OSBD-r), the modified Yale Preoperative Anxiety Scale (mYPAS), and the modified Induction Compliance Checklist (mICC), are too cumbersome for clinical use outside of research settings. HRAD± (Happy, Relaxed, Anxious, Distressed with yes/no to cooperation) is a clinically-efficient observational scale that evaluates pediatric procedural affect and cooperation. This study examined the clinical utility of HRAD± during vascular access procedures in children. The aims were to investigate the correlation of HRAD± to highly reliable, research-based affect and cooperation scales and to assess inter-rater reliability (IRR) between observers in this setting.

METHODS

This was a prospective, observational study conducted at Lucile Packard Children's Hospital Stanford. Inpatient participants were 1 month to 25 years old and undergoing a peripheral intravenous insertion or phlebotomy. Two trained research assistants (RAs) scored each patient independently during the vascular access procedure using HRAD±, OSBD-r, mYPAS, and mICC. Correlation analyses computed the associations between HRAD± and reference scales. IRR between RAs and vascular access providers was calculated using Fleiss' Kappa.

RESULTS

A total of 234 patients were included. HRAD± scores strongly correlated with OSBD-r and mYPAS (p < 0.0001, p < 0.0001, respectively). The cooperation assessment of HRAD± demonstrated strong correlation to mICC (p < 0.0001). IRR of HRAD± between research assistants and vascular access providers showed moderate agreement (p < 0.0001).

CONCLUSION

HRAD± demonstrated strong correlation to the reference affect and cooperation scales. This study supports the utility of HRAD± for rapid assessment of pediatric procedural anxiety and cooperation during vascular access procedures. HRAD± can serve as a practical tool for facilitating clinical decisions, and its wider incorporation into healthcare settings would importantly guide targeted interventions to reduce patient anxiety.

Comparative efficacy of pharmacological and non-pharmacological interventions for mitigating pain and anxiety associated with venipuncture: a randomised controlled trial

BACKGROUND

Venipuncture is one of the most commonly performed medical procedures in paediatric care, but it can also be one of the most painful and distressing experiences for patients. Finding effective strategies to manage pain and fear associated with venipuncture is crucial for improving the paediatric patient experience and promoting positive health outcomes. This study aimed to evaluate the efficacy of a combined approach using a topical analgesic cream (TKTX cream) and a distraction technique (Trace Image and Colouring for Kids-Book, TICK-B) in reducing pain intensity and fear levels in children undergoing venipuncture procedures.

METHODS

We conducted this randomised controlled trial among 176 children aged 6-12 years undergoing venipuncture. Participants were randomly assigned to four groups: TICK-B, TKTX cream, TICK-B+TKTX cream and a control group. Pain and fear were measured using the Wong-Baker FACES Pain Rating Scale and Children's Fear Scale. The study was carried out from 20 February 2024 to 1 June 2024 at the emergency unit of Heevi paediatric teaching hospital in the Kurdistan region of Iraq. In the intervention groups, TICK-B was applied for 2-3 min before needle insertion, and TKTX cream was applied 20 min before the venipuncture procedure. All outcome measures were evaluated 2-3 min after the completion of the venipuncture procedure.

RESULTS

The combined TICK-B (colouring book) and TKTX cream (topical anaesthetic) intervention was the most effective in reducing both pain intensity (mean score 2.80 vs 7.24 in the control, p<0.001) and fear levels (mean score 0.93 vs 2.83 in the control, p<0.001) during and after venipuncture procedures compared with individual interventions and control.

CONCLUSIONS

The combined TICK-B distraction and TKTX cream topical anaesthetic intervention was the most effective in reducing pain intensity and fear during and after venipuncture in children, providing a practical strategy for healthcare providers to optimise needle procedure management.

TRIAL REGISTRATION NUMBER

NCT06326125.

Strategies to minimize procedure-related pain and anxiety: lessons from pediatric dermatology

PURPOSE OF REVIEW

Recent studies have suggested that prolonged or repeated episodes of general anesthesia early in childhood may adversely affect neurodevelopment. This, combined with rising healthcare costs and decreasing access, has sparked interest in performing pediatric procedures in the office setting when possible. It is essential to address the physical and psychological discomfort that often accompany this experience, particularly in children.

RECENT FINDINGS

Healthcare providers performing procedures on children can draw from a spectrum of established techniques, new technology, and novel use of medications to decrease peri-procedural pain and anxiety. These techniques include distraction, optimization of local anesthesia, and mild to moderate sedation.

SUMMARY

We recommend using a combination of techniques to minimize pain and anxiety to improve safety, decrease healthcare costs, improve patient experience, and prevent childhood trauma and persistent negative perception of the healthcare system.

Optimizing pediatric periprocedural pain management part II-Adjunct therapies to support the use of infiltrative anesthetics

Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger healthcare community. We present a comprehensive review of infiltrative anesthetics, including a comparison of their mechanisms of action and relative safety and efficacy data to help guide clinical selection. We also describe the multimodal utilization of adjunct therapies-in series and in parallel-to support the optimization of pediatric periprocedural pain management, enhance the patient experience, and provide alternatives to sedation medication and general anesthesia.

Poke Plan: An Initiative to Improve Distraction and Pain Mitigation With Venous Access in Hospitalized Children

BACKGROUND

Adequate pain control and anxiety relief during peripheral intravenous cannula (PIV) placement improves patient, parental, and staff satisfaction and reduces health care-induced stress in children. We noted a low rate of analgesic/anxiolysis use (<20%) and child life utilization (3%) in our institution. This quality improvement project was initiated to increase pain mitigation strategies in hospitalized children requiring PIV access.

METHODS

From November 2020 to March 2021, we created a key driver diagram and summarized possible interventions with the aim to increase our use of pain control strategies to >40% and child life utilization to 25%. For 12 months, 8 Plan-Do-Study-Act cycles were conducted focusing on nursing education and training, improved documentation, electronic medical record optimization, easy access to analgesics and anxiolytics, family involvement, and weekly huddles. Our primary measure was the percentage use of pain medications for PIV access. The utilization of PIV experts from the ICU (advanced practice registered nurses and physicians) served as the balancing measure.

RESULTS

A total of 883 patient charts were reviewed. The use of topical anesthetics and anxiolytics increased from 16.2% at baseline to 78.9% after the implementation of the quality improvement project. Eighty percent of parents reported their child was kept comfortable during the procedure using pain mitigation and comfort measures. A slight increase from 2% to 5.8% was noted in the utilization of advanced practice registered nurses and intensivists.

CONCLUSIONS

Implementation of a standardized approach for PIV placement improved team communication and provided better preparation for pain control before needle insertions in hospitalized children.

Pharmacological and non-pharmacological interventions in management of peripheral venipuncture-related pain: a randomized clinical trial

BACKGROUND

Venipuncture is a routine nursing procedure in the pediatric ward for blood collection and transfusion. However, this procedure can cause severe pain and distress if not adequately managed.

METHODS

Children aged 3-16 years old were randomized into three groups: EMLA group, distraction group, and combined group. The primary outcome was children's self-reported pain scored using the Wong-Baker FACES® Pain Rating Scale. The parents-reported and observer-reported pain were scored using the Revised Face, Legs, Activity, Cry and Consolability Scale, and children's salivary cortisol levels, heart rate, percutaneous oxygen saturation, venipuncture duration and retaining time of IV cannulas were the secondary outcomes.

RESULTS

A total of 299 children (167 male, 55.8%, median age 8.5) were enrolled: EMLA group (n = 103), distraction group(n = 96) and combined group(n = 100). There was no statistical difference in self-reported pain (P = 0.051), parent-reported pain (P = 0.072), and observer-reported pain (P = 0.906) among the three groups. All three interventions can decrease children's pain during IV cannulations. Additionally, the distraction group's salivary cortisol levels were lower than the combined group(P = 0.013). Furthermore, no significant difference was observed in the heart rate(P = 0.844), percutaneous oxygen saturation (P = 0.438), venipuncture duration (p = 0.440) and retaining time of IV cannulas (p = 0.843) among the three groups.

CONCLUSIONS

All three groups responded with slight pain during the peripheral venipuncture procedure. Therefore, medical workers in pediatric settings can use the interventions appropriate for their medical resources and availability while involving parents and children's preferences whenever possible.

TRIAL REGISTRATION

This trial was registered on https://register.

CLINICALTRIALS

gov/ (Gov.ID NCT04275336).

Needle-Free Jet Injectors and Nanosuspensions: Exploring the Potential of an Unexpected Pair

Needle-free liquid jet injectors are medical devices used to administer pharmaceutical solutions through the skin. Jet injectors generate a high-speed stream of liquid medication that can puncture the skin and deliver the drug to the underlying tissues. In this work, we investigated the feasibility of using liquid jet injectors to administer nanosuspensions, assessing the impact of the jet injection on their pharmaceutical and physicochemical properties. For this purpose, the model drug diclofenac was used to prepare a set of nanosuspensions, stabilized by poloxamer 188, and equilibrated at different pHs. The hydrodynamic diameter and morphology of the nanocrystals were analyzed before and after the jet injection across porcine skin in vitro, together with the solubility and release kinetics of diclofenac in a simulated subcutaneous environment. The efficacy of the jet injection (i.e., the amount of drug delivered across the skin) was evaluated for the nanosuspension and for a solution, which was used as a control. Finally, the nanosuspension was administered to rats by jet injector, and the plasma profile of diclofenac was evaluated and compared to the one obtained by jet injecting a solution with an equal concentration. The nanosuspension features were maintained after the jet injection in vitro, suggesting that no structural changes occur upon high-speed impact with the skin. Accordingly, in vivo studies demonstrated the feasibility of jet injecting a nanosuspension, reaching relevant plasma concentration of the drug. Overall, needle-free jet injectors proved to be a suitable alternative to conventional syringes for the administration of nanosuspensions.

Managing acute pain in children presenting to the emergency department without opioids

Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non-pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.

Efficacy of Distraction for Reducing Pain and Distress Associated With Venipuncture in the Pediatric Posttransplant Population: A Randomized Controlled Trial

OBJECTIVE

Distraction can reduce pain and distress associated with painful procedures but has never been studied in children with solid organ transplants. We aimed to determine whether there is a difference in pain and distress associated with venipuncture in pediatric posttransplant patients who receive distraction compared with those who do not.

METHODS

Randomized controlled trial of children aged 4 to 17 years with solid organ transplants undergoing venipuncture in the outpatient setting. Patients were randomized to receive distraction or no distraction. The primary outcome was the Faces Pain Scale-Revised. Secondary outcomes were the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale. Exploratory outcomes included the number of venipuncture attempts, time to successful venipuncture, and satisfaction of phlebotomists and parents.

RESULTS

Median age of the 40 children enrolled was 11.5 years. Type of transplants included the heart (67.5%), kidney (22.5%), liver (7.5%), and more than 1 organ (2.5%). There was no difference between the Faces Pain Scale-Revised scores in distraction and no distraction groups (1.4; 95% confidence interval, 0.9-1.9; and 1.3, 95% confidence interval, 0.5-2.1, respectively). There was also no difference in the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale scores, number of venipuncture attempts, or time to successful venipuncture. Phlebotomists were more satisfied with the venipuncture when distraction was implemented.

CONCLUSIONS

In children with solid organ transplants, there was no difference in pain and distress associated with venipuncture between those who did and did not receive distraction. There was also no difference in other procedure-related outcomes except for greater phlebotomist satisfaction when distraction was implemented.

Comfort measures for peripheral I.V. catheter placement in children

ABSTRACT

I.V. catheter placement is one of the most common causes of procedural pain in children. Interventions to address this pain are readily available but inconsistently used in practice. The focus of this article is to identify and encourage best practice for pain mitigation in peripheral I.V. catheter placement in children.

A Comparison of Local Anesthetics for Intravenous Catheter Insertion in Hospitalized Pediatric Patients: A Randomized Clinical Pilot Trial

Peripheral intravenous catheter (PIVC) insertion is one of the most painful procedures pediatric patients undergo during hospitalization. To date, local anesthetics delivered via cream, patch, and needle-free injection have not been rigorously evaluated together. This study aimed to investigate feasibility and potential efficacy of local anesthetics on pain intensity during PIVC insertion in an unblinded, single-center, randomized clinical pilot trial. Between March 2017 and February 2020, 88 hospitalized children aged 12 months to 18 years in an acute pediatric unit at an academic medical center were randomized to 1 of 3 local anesthetics: 1) lidocaine/prilocaine cream, 2) lidocaine/tetracaine patch, and 3) unbuffered lidocaine needle-free injection. Feasibility outcomes were recruitment and protocol adherence. Pain intensity was measured using the Face, Legs, Activity, Cry, Consolability (age <8 years) and Verbal Numeric Rating (VNRS) scales (age ≥8 years) before, during, and after procedure. Secondary outcomes included catheterization attempts, procedure time, and parent satisfaction. Recruitment rate was acceptable (2.7 patients per month). Protocol adherence was high (92%). Preliminary clinical findings showed no significant difference in pain intensity across treatments. Procedure time to successful insertion differed in the VNRS group, favoring unbuffered lidocaine needle-free injection. Conduct of a definitive, full-scale randomized clinical trial in the hospitalized pediatric population is feasible.

An Evaluation of High Preprocedural Anxiety and Venipuncture Pain Experienced by Young Children

OBJECTIVE

The aim of this study was to determine if young children with high preprocedural anxiety experience increased pain at venipuncture.

METHODS

This was secondary analysis of prospectively obtained data from a randomized controlled trial comparing vapocoolant spray with jet-injected lidocaine for venipuncture pain. Children aged 1 to 6 years were enrolled and videotaped. Videos were reviewed and scored for anxiety using the modified Yale Preoperative Anxiety Scale score for preprocedural anxiety (score range, 23-100). High anxiety was defined as greater than 40. Pain at the time of venipuncture was scored using the Face, Legs, Activity, Cry, and Consolability scale (score range 0-10). Moderate to severe pain was defined as greater than 3. Logistic regression assessed patient factors associated with high preprocedural anxiety and evaluated the relationship between preprocedural anxiety and pain during venipuncture.

RESULTS

Two hundred five patients were enrolled; 59.5% of patients were male, and 53.7% were White. Mean age was 3.2 years. Prior to the procedure, 67% of patients had high anxiety. Patient age, race, sex, and previous venipuncture were not associated with increased odds of high anxiety. Moderate to severe pain at venipuncture was observed in 65% of children. High preprocedural anxiety was associated with increased odds of moderate to severe pain at venipuncture when controlled for patient characteristics (adjusted odds ratio, 4.62; 95% confidence interval, 2.03-8.54).

CONCLUSIONS

Most young children undergoing venipuncture experienced high preprocedural anxiety. Children with high preprocedural anxiety had increased odds of moderate to severe pain at venipuncture. Anxiety-reducing interventions should be explored to reduce pain experienced during venipuncture.

Behavioral Strategies to Minimize Procedural Distress During In-Office Pediatric Tympanostomy Tube Placement Without Sedation or Restraint

The purpose of this study was to evaluate behavioral strategies to minimize procedural distress associated with in-office tympanostomy tube placement for children without general anesthesia, sedation, or papoose-board restraints. 120 6-month- to 4-year-olds and 102 5- to 12-year-olds were treated at 16 otolaryngology practices. Mean age of children was 4.7 years old (SD = 3.18 years), with more boys (58.1%) than girls (41.9%). The cohort included 14% Hispanic or Latinx, 84.2% White, 12.6% Black, 1.8% Asian and 4.1% ‘Other’ race and ethnicity classifications. The in-office tube placement procedure included local anesthesia via lidocaine/epinephrine iontophoresis and tube placement using an integrated and automated myringotomy and tube delivery system. Behavioral strategies were used to minimize procedural distress. Anxiolytics, sedation, or papoose board were not used. Pain was measured via the faces pain scale-revised (FPS-R) self-reported by the children ages 5 through 12 years. Independent coders supervised by a psychologist completed the face, legs, activity, cry, consolability (FLACC) behavior observational rating scale to quantify children’s distress. Mean FPS-R score for tube placement was 3.30, in the “mild’ pain range, and decreased to 1.69 at 5-min post-procedure. Mean tube placement FLACC score was 4.0 (out of a maximum score of 10) for children ages 6 months to 4 years and was 0.4 for children age 5–12 years. Mean FLACC score 3-min post-tube placement was 1.3 for children ages 6 months to 4 years and was 0.2 for children age 5–12 years. FLACC scores were inversely correlated with age, with older children displaying lower distress. The iontophoresis, tube delivery system and behavioral program were associated with generally low behavioral distress. These data suggest that pediatric tympanostomy and tube placement can be achieved in the outpatient setting without anxiolytics, sedatives, or mechanical restraints.

A narrative review with practical advice on how to decrease pain and distress during venepuncture and peripheral intravenous cannulation

Venepuncture and peripheral intravenous cannulation are two of the most commonly paediatric performed medical procedures in many healthcare settings. These procedures can cause significant pain and distress at any age, during childhood, so appropriate management is strongly recommended. This review examines the evidence related to pain and distress management during venepuncture and peripheral intravenous cannulation, including preparing the environment, assessing and preparing patients, parental involvement and psychological and pharmacological interventions. It specifically refers to neonates, children with cognitive impairment and children with difficult intravenous access. We provide a brief management strategy, with easily implemented techniques to improve daily practice.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

La gestion de la douleur et de l’anxiété chez les enfants lors de brèves interventions diagnostiques et thérapeutiques

Les interventions médicales courantes utilisées pour évaluer et traiter les patients peuvent causer une douleur et une anxiété marquées. Les cliniciens devraient adopter une approche de base pour limiter la douleur et l’anxiété chez les enfants, notamment à l’égard des interventions diagnostiques et thérapeutiques fréquentes. Le présent document de principes est axé sur les nourrissons, les enfants et les adolescents qui subissent des interventions médicales courantes mineures, mais douloureuses. Il n’aborde pas les soins prodigués à l’unité de soins intensifs néonatale. Les auteurs examinent des stratégies simples et fondées sur des données probantes pour gérer la douleur et l’anxiété et donnent des conseils pour en faire un volet essentiel de la pratique clinique. Les professionnels de la santé sont invités à utiliser des façons de procéder peu invasives et, lorsque les interventions douloureuses sont inévitables, à combiner des stratégies simples de réduction de la douleur et de l’anxiété pour améliorer l’expérience du patient, du parent et du professionnel de la santé. Les administrateurs de la santé sont encouragés à créer des politiques pour leurs établissements, à améliorer la formation et l’accès aux lignes directrices, à créer des environnements propices aux enfants et aux adolescents, à s’assurer de la disponibilité du personnel, de l’équipement et des agents pharmacologiques appropriés et à effectuer des contrôles de qualité pour garantir une gestion de la douleur optimale.

Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures

Common medical procedures to assess and treat patients can cause significant pain and distress. Clinicians should have a basic approach for minimizing pain and distress in children, particularly for frequently used diagnostic and therapeutic procedures. This statement focuses on infants (excluding care provided in the NICU), children, and youth who are undergoing common, minor but painful medical procedures. Simple, evidence-based strategies for managing pain and distress are reviewed, with guidance for integrating them into clinical practice as an essential part of health care. Health professionals are encouraged to use minimally invasive approaches and, when painful procedures are unavoidable, to combine simple pain and distress-minimizing strategies to improve the patient, parent, and health care provider experience. Health administrators are encouraged to create institutional policies, improve education and access to guidelines, create child- and youth-friendly environments, ensure availability of appropriate staff, equipment and pharmacological agents, and perform quality audits to ensure pain management is optimal.

Recent advances in pain treatment for children with serious illness

Pain is a common distressing symptom in children receiving pediatric palliative care. Both in children with cancer, but especially in children with progressive neurodegenerative and chromosomal conditions with CNS impairment pain is common, and often under-recognized and undertreated. Multimodal analgesia for children with serious illness acts synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. Successful pain treatment and prevention usually include integrative 'nonpharmacological' therapies, rehabilitation, psychology and spirituality in addition to pharmacology and regional anesthesia. This review article will address these effective components of multimodal pediatric analgesia and present starting doses of basic analgesia, opioids and adjuvants analgesia in infants, children and adolescents with serious illness.

The Use of the Buzzy, Jet Lidokaine, Bubble-blowing and Aromatherapy for Reducing Pediatric Pain, Stress and Fear Associated with Phlebotomy

PURPOSE

This study aimed to investigate the effects of the Buzzy, Jet lidokaine, bubble-blowing and inhalation aromatherapy with lavender essence on pain, stress and fear in children undergoing phlebotomy.

DESIGNS AND METHODS

This study was a prospective, randomized controlled trial. The sample was comprised of children aged 5 to 10 years requiring blood tests. Children were assigned to five subgroups through randomization performed using a computer program: the Buzzy group (n = 39), Jet lidokaine group (n = 39), bubble-blowing group (n = 39), inhalation aromatherapy with lavender essence group (n = 39) and control group (n = 39). The children's levels of pain were evaluated and reported by the parents, observers and the children, who self-reported using the Oucher Pain Scale. The children's fear levels were assessed using the Children's Fear Scale, and salivary cortisol analysis was conducted to evaluate stress levels.

RESULTS

A significant difference was found between the intervention and control groups in terms of levels of pain during and after phlebotomy in favor of the Buzzy group (p < 0.05). There was a significant difference between the fear scores of the children in the intervention and control groups before phlebotomy (p < 0.05). This difference was found to be caused by the bubble-blowing method. There was a significant difference between intervention and control groups fear levels in favor of the Buzzy group during phlebotomy (p < 0.05).

PRACTICE IMPLICATIONS

It is recommended that the Buzzy and bubble-blowing be used during phlebotomy in children to reduce the severity of their pain.

Noninvasive Transdermal Delivery System of Lidocaine Using an Acoustic Droplet-Vaporization Based Wearable Patch

Current technologies for managing acute and chronic pain have focused on reducing the time required for achieving high therapeutic efficiency. Herein a wearable transdermal patch is introduced, employing an acoustic droplet vaporization (ADV) methodology, as an effective noninvasive transdermal platform, for a fast local delivery of the anesthetic agent lidocaine. The skin-worn patch consists of a flexible drug reservoir containing hundreds of micropores loaded with lidocaine, and mixed with the perfluorocarbon (PFC) emulsion. The ultrasound-triggered vaporization of the PFC emulsion provides the necessary force to breach dermal barriers. The drug release kinetics of our model was investigated by measuring the amount of lidocaine that passed through phantom tissue and pigskin barriers. The ADV platform increases the payload skin penetration resulting in shorter treatment times compared to passive diffusion or ultrasound alone, holding considerable promise for addressing the delayed therapeutic action and slow pain relief of existing delivery protocols. It is envisioned that the integration of ADV-based transdermal devices could be expanded to the depth-dependent delivery of other pain management, vaccines, and gene therapy modalities.

A hospital-wide initiative to eliminate or reduce needle pain in children using lean methodology

INTRODUCTION

Pain remains common, underrecognized, and undertreated in children's hospitals and pediatric clinics. Over 200,000 patients experience needle pain annually in our institution, caused by blood draws, intravenous access, vaccinations, and injections on all inpatient units, emergency departments, outpatient laboratories, and ambulatory clinics.

OBJECTIVES

We implemented a hospital-based, system-wide initiative called the "Children's Comfort Promise," and created a new standard of care for needle procedures that required staff to consistently offer 4 strategies: (1) topical anesthetics, (2) sucrose or breastfeeding for infants 0 to 12 months, (3) comfort positioning (including swaddling, skin-to-skin, or facilitated tucking for infants; sitting upright for children), and (4) age-appropriate distraction.

METHODS

The protocol was established system-wide in one of the largest children's hospitals in the United States using a staggered implementation approach over a 3-year period to allow for unit-specific customization and facilitation of knowledge transfer from one unit to another. All departments were required to offer all 4 strategies with appropriate education at least 95% of the time.

RESULTS

Comparison of baseline audits with continuous postimplementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed (eg, concerns about wait times and success rates of venipuncture after topical anesthesia).

CONCLUSION

This is the first report of a successful system-wide protocol implementation to reduce or eliminate needle pain, including pain from vaccinations, in a children's hospital across all inpatient units, emergency departments, outpatient laboratories, and ambulatory clinics through consistent use of topical anesthesia, sucrose/breastfeeding, positioning, and distraction.

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

OBJECTIVES

Pain in hospitalized children remains under-assessed and undertreated. With this study, we aim to describe results from a repeat single-day, hospital-wide survey of children's pain and its treatment after the initiation of a hospital-wide quality improvement initiative used to reduce or eliminate pain caused by needle procedures.

METHODS

All patients and parents listed on the inpatient morning census, in emergency department and outpatient surgery registration lists, were invited to participate in a brief single-day point prevalence survey of their experience with pain and its management in the hospital setting. Results were compared with a survey conducted 2 years earlier, before implementation of a system-wide Children's Comfort Promise needle pain treatment and prevention protocol.

RESULTS

A total of 194 children and their parents participated in the current survey. A higher percentage of children reported having no pain compared with the previous survey (33% vs 24%; P = .07; not significant) and fewer experienced severe pain (score ≥7 out of 10). Fewer children identified pain caused by needles as the cause of the worst pain (21% vs 30%), although it remained the highest reported cause of the most painful experience overall. The number of pain management strategies administered and offered to children with needle pain (distraction, positioning, numbing cream, and sucrose and/or breastfeeding for infants) increased.

CONCLUSIONS

The implementation of a mandatory Comfort Promise protocol used to minimize or prevent pain caused by elective needle procedures was associated with a significant reduction in overall pain prevalence and improved use of evidence-based practices for needle pain management.

Pediatric Pain Management

Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.

A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus Topical Anesthesia for Infant Lumbar Puncture

OBJECTIVES

Lumbar punctures (LPs) are commonly performed in febrile infants to evaluate for meningitis, and local anesthesia increases the likelihood of LP success. Traditional methods of local anesthesia require injection that may be painful or topical application that is not effective immediately. Recent advances in needle-free jet injection may offer a rapid alternative to these modalities. We compared a needle-free jet-injection system (J-Tip) with 1% buffered lidocaine to topical anesthetic (TA) cream for local anesthesia in infant LPs.

METHODS

This was a single-center randomized double-blind trial of J-Tip versus TA for infant LPs in an urban tertiary care children's hospital emergency department. A computer randomization model was used to allocate patients to either intervention. Patients aged 0 to 4 months were randomized to J-Tip syringe containing 1% lidocaine and a placebo TA cream or J-Tip syringe containing saline and TA. The primary outcome was the difference between the Neonatal Faces Coding Scale (NFCS) before the procedure and during LP needle insertion. Secondary outcomes included changes in heart rate (HR) and NFCS throughout the procedure, difficulty with LP, number of LP attempts, provider impression of pain control, additional use of lidocaine, skin changes at LP site, and LP success.

RESULTS

We enrolled 66 subjects; 32 were randomized to J-Tip with lidocaine and 34 to EMLA. Six participants were excluded from the final analysis due to age greater than 4 months, and the remaining 58 were analyzed in their respective groups (32 J-Tip, 34 TA). There was no difference detected in NFCS between the two treatment groups before the procedure and during needle insertion for the LP (p = 0.58, p = 0.37). Neither HR nor NCFS differed among the groups throughout the procedure. Median perception of pain control by the provider and the need for additional lidocaine were comparable across groups. LPs performed with a J-Tip were twice as likely to be successful compared to those performed using TA (relative risk = 2.0; 95% confidence interval = 1.01-3.93; p = 0.04) with no difference in level of training or number of prior LPs performed by providers.

CONCLUSIONS

In a randomized controlled trial of two modalities for local anesthesia in infant LPs, J-Tip was not superior to TA cream as measured by pain control or physiologic changes. Infant LPs performed with J-Tip were twice as likely to be successful.

Acute Pediatric Pain Management in the Primary Care Office

Pain is a chief complaint in children seeking medical care, yet it may also be experienced in evaluation and treatment during office visits. Inadequate relief of children's procedural pain and distress not only affects the experience of the children and their parents, but also adversely affects procedural outcomes. Despite increasing awareness and research, management of procedural pain and anxiety in children is often inadequate. In addition, parent and patient satisfaction is often tied to pain management. Development of a pain management plan must be systematic, individualized, and multimodal. We present a review of nonpharmacologic modalities, topical and oral analgesic agents, and intranasal adjuncts for use in routine outpatient practice. [Pediatr Ann. 2018;47(3):e124-e129.].

Comparison of Children's Venipuncture Fear and Pain: Randomized Controlled Trial of EMLA® and J-Tip Needleless Injection System®

PURPOSE

Needle procedures, like venipuncture and intravenous (IV) catheter insertion, are recognized as a common cause of pain and fear for children in hospitals and emergency departments. The purpose of this study was to compare children's self-reported pain and fear related to IV insertion with administration of either the topical local anesthetic EMLA® or 1% buffered lidocaine delivered with the J-Tip Needleless Injection System® (J-Tip®).

DESIGN AND METHODS

In this prospective, randomized trial, 150 consecutive pediatric patients 8 to 18years of age undergoing IV insertion were randomly assigned 1:1 to treatment group. Participants self-reported procedural pain using a Visual Analog Scale, and procedural fear using the Children's Fear Scale.

RESULTS

Procedural pain scores were significantly lower in the EMLA® group (mean score 1.63+1.659) vs. the J-Tip® group (2.99±2.586; p<0.001). Post-procedure fear scores were significantly lower than pre-procedure fear scores in both treatment groups (p<0.002), but there was no difference in fear scores between the two treatment groups (p=0.314).

CONCLUSION

EMLA® provided superior pain relief for IV insertion compared to J-Tip®.

PRACTICE IMPLICATIONS

Although EMLA® use resulted in lower self-reported pain scores compared to J-Tip®, pain scores for both treatments were low and fear scores did not differ. When IV insertion can be delayed for 60-90min, EMLA® should be used. When a delay is contraindicated, J-Tip® may be a reasonable alternative to minimize procedural pain of IV insertion.

Needle-Free Jet Lidocaine Administration for Preinjection Anesthesia in Trigger Finger Injection: A Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of needle-free jet lidocaine (J-tip) administration for pain reduction in trigger finger corticosteroid injection compared with simultaneous lidocaine injection with corticosteroid.

METHODS

A prospective randomized clinical trial was performed in which patients received either 0.25 mL of 2% lidocaine administered by J-tip just prior to 0.5 mL of corticosteroid injection by needle or 0.5 mL of 1% lidocaine and 0.5 mL of corticosteroid administered simultaneously through a needle for the treatment of trigger finger. Both the expected pain preinjection and the actual pain experienced postinjection were measured with a visual analog scale (VAS). Pain catastrophizing scale (PCS) scores were recorded before injection.

RESULTS

The use of the J-tip demonstrated a lower mean actual pain, 3.3 VAS, compared with the control group, 4.6 VAS. Both study groups anticipated more pain than they actually experienced. The PCS did not correlate to pre- or post-injection scores.

CONCLUSIONS

Needle-free jet administration of lidocaine reduces the pain associated with trigger finger injection. Patients anticipate more pain than they experience with trigger finger injection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Increasing ED Use of Jet Injection of Lidocaine for IV-Related Pain Management

BACKGROUND AND OBJECTIVE

Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement-related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months.

METHODS

We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) order set changes, (2) online education, (3) hands-on workshops, (4) improved accessibility, (5) standing order policy revision, and (6) reminders. We collected biweekly data on IV placements for all ED patients, except level 1 (critical) triage patients. We used standard quality improvement methodology and statistical process control for statistical analysis.

RESULTS

JIL use with IV placement increased to 54% over 7 months and has remained >50% for >12 months. For all eligible IV placements (n = 12 791), 76.4% of those where JIL was used were successful on the first attempt compared with 75.8% without JIL (χ²_{1degrees of freedom} = 0.33, P = .56), with no significant difference in the success at IV placement.

CONCLUSIONS

We sustainably increased JIL use with IV placement. The use of JIL was not associated with a difference in first-attempt IV placement success rates. We are expanding the project to other parts of the institution.

Managing Pediatric Pain in the Emergency Department

Far more attention is now given to pain management in children in the emergency department (ED). When a child arrives, pain must be recognized and evaluated using a pain scale that is appropriate to the child's development and regularly assessed to determine whether the pain intervention was effective. At triage, both analgesics and non-pharmacological strategies, such as distraction, immobilization, and dressing should be started. For mild pain, oral ibuprofen can be administered if the child has not received it at home, whereas ibuprofen and paracetamol are suitable for moderate pain. For patients who still require pain relief, oral opioids could be considered; however, many EDs have now replaced this with intranasal fentanyl, which allows faster onset of pain relief and can be administered on arrival pending either intravenous access or definitive care. Intravenous opioids are often required for severe pain, and paracetamol or ibuprofen can still be considered for their likely opioid-sparing effects. Specific treatment should be used for patients with migraine. In children requiring intravenous access or venipuncture, non-pharmacological and pharmacological strategies to decrease pain and anxiety associated with needle punctures are mandatory. These strategies can also be used for laceration repairs and other painful procedures. Despite the gaps in knowledge, pain should be treated with the most up-to-date evidence in children seen in EDs.

Vapocoolants (cold spray) for pain treatment during intravenous cannulation

BACKGROUND

Intravenous cannulation is a painful procedure that can provoke anxiety and stress. Injecting local anaesthetic can provide analgesia at the time of cannulation, but it is a painful procedure. Topical anaesthetic creams take between 30 and 90 minutes to produce an effect. A quicker acting analgesic allows more timely investigation and treatment. Vapocoolants have been used in this setting, but studies have reported mixed results.

OBJECTIVES

To determine effects of vapocoolants on pain associated with intravenous cannulation in adults and children. To explore variables that might affect the performance of vapocoolants, including time required for application, distance from the skin when applied and time to cannulation. To look at adverse effects associated with the use of vapocoolants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Latin American Caribbean Health Sciences Literature (LILACS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Institute for Scientific Information (ISI) Web of Science and the http://clinicaltrials.gov/, http://www.controlled-trials.com/ and http://www.trialscentral.org/ databases to 1 May 2015. We applied no language restrictions. We also scanned the reference lists of included papers.

SELECTION CRITERIA

We included all blinded and unblinded randomized controlled trials (RTCs) comparing any vapocoolant with placebo or control to reduce pain during intravenous cannulation in adults and children.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data, contacted study authors for additional information and assessed included studies for risk of bias. We collected and analysed data for the primary outcome of pain during cannulation, and for the secondary outcomes of pain associated with application of the vapocoolant, first attempt success rate of intravenous cannulation, adverse events and participant satisfaction. We performed subgroup analyses for the primary outcome to examine differences based on age of participant, type of vapocoolant used, application time of vapocoolant and clinical situation (emergency vs elective). We used random-effects model meta-analysis in RevMan 5.3 and assessed heterogeneity between trial results by examining forest plots and calculating the I(2) statistic.

MAIN RESULTS

We found nine suitable studies of 1070 participants and included them in the qualitative analyses. We included eight studies of 848 participants in the meta-analysis for the primary outcome (pain during intravenous cannulation). Use of vapocoolants resulted in a reduction in pain scores as measured by a linear 100 mm visual analogue scale (VAS 100) compared with controls (difference between means -12.5 mm, 95% confidence interval (CI) -18.7 to -6.4 mm; moderate-quality evidence). We could not include in the meta-analysis one study, which showed no effects of the intervention.Use of vapocoolants resulted in increased pain scores at the time of application as measured by a VAS 100 compared with controls (difference between means 6.3 mm, 95% CI 2.2 to 10.3 mm; four studies, 461 participants; high-quality evidence) and led to no difference in first attempt success compared with controls (risk ratio (RR) 1.00, 95% CI 0.94 to 1.06; six studies, 812 participants; moderate-quality evidence). We documented eight minor adverse events reported in 279 vapocoolant participants (risk difference (RD) 0.03, 95% CI 0 to 0.05; five studies, 551 participants; low quality-evidence).The overall risk of bias of individual studies ranged from low to high, with high risk of bias for performance and detection bias in four studies. Sensitivity analysis showed that exclusion of studies at high or unclear risk of bias did not materially alter the results of this review.

AUTHORS' CONCLUSIONS

Moderate-quality evidence indicates that use of a vapocoolant immediately before intravenous cannulation reduces pain during the procedure. Use of vapocoolant does not increase the difficulty of cannulation nor cause serious adverse effects but is associated with mild discomfort during application.