Tissue adhesives – Can be used for all ages. Use caution around eye area. Avoid areas of tension. Can optimize use of glue with perpendicularly-applied steri-strip adhesive bandages prior to application of glue. Do not use for bites/dirty wounds.
Absorbable sutures – Are used preferentially for most pediatric suturing in the ED (other than wounds under significant tension). Removing sutures can be associated with a high degree of distress and discomfort for children.
Lidocaine-Epinephrine-Tetracaine (LET) gel (lidocaine 4% – epinephrine 0.05% – tetracaine 0.5%) 0.18 mL/kg/ dose (MAX 3 mL/dose) for patients 3 months or older. Apply LET gel to laceration, with or without gauze, then cover with occlusive dressing (e.g., Tegaderm^®). Apply early! Application at triage is recommended as LET gel requires at least 30 minutes to be effective and a minimum of 45 minutes for joints and palmar surfaces.
Minimize lidocaine injection pain – Warm lidocaine to body temperature by rubbing vial between hands, use a 27-30 gauge needle, and use slow injection technique.
pH adjustment of injected lidocaine – Buffering lidocaine decreases the pain of injection. Add 1 mL of 8.4% sodium bicarbonate to 9 mL of 1% or 2% lidocaine (do not exceed lidocaine 4 mg/kg/dose, MAX 300 mg/dose).

Topical anesthetic creams – Can be applied in all ages. Fast-acting creams (e.g., Maxilene^®, Ametop®, L.M.X.4^®) are preferred over slow-acting ones in the ED setting. Apply 30 minutes prior to procedure for fast- acting creams/60 minutes for slow-acting creams with an adhesive dressing (e.g., Tegaderm^®).
Injected lidocaine – Topical creams only numb the superficial few millimeters of the skin. Inject the deeper area for lumbar puncture needle insertion with approximately 1-3 mL of 1-2% lidocaine (do not exceed 4 mg/kg/dose, MAX 300 mg/dose). Warm and buffer lidocaine as described above.
Oral sucrose (see above) for infants in addition to anesthetics mentioned in this section.

Pain management should involve non-opioids (ibuprofen, acetaminophen, ketorolac) as a first line, with opioids reserved for more severe pain or in anticipation of more painful procedures (e.g., diagnostic imaging).
Pain during reduction can be managed with regional anesthesia (hematoma block, intra-articular block, or regional nerve block) or using procedural sedation Bottom Line Recommendation

Lidocaine spray – Evidence is limited for lidocaine spray efficacy; multi-modal therapy is key for this procedure. Lidocaine spray can be tried if patient is 6 months or older. Atomized 4% lidocaine nasal spray (10-20 mg) or nebulized 4% lidocaine (3-5 mL). Do not exceed 4 mg/kg/dose.
Lidocaine jelly – Lubricating the nasogastric tube with 1-2 mL of 1-2% lidocaine jelly may be beneficial for minimizing post-insertion pain if patient is 6 months or older.

Topical anesthetic creams – Can be applied to all ages. Fast-acting creams (e.g., Maxilene^®, Ametop^®, L.M.X.4^®) are preferred over slow-acting ones (e.g., EMLA^®). Apply 30 minutes prior to procedure for fast-acting creams/60 minutes for slow-acting creams with an adhesive dressing (e.g., Tegaderm^®).
Vapo-coolant spray – Can be used for 3 years and older. If topical anesthetic is unavailable, vapo-coolant spray (e.g., Pain-Ease^®) may be used. Spray on intact skin for 4-10 seconds or until skin blanches prior to the skin- puncturing procedure. Immediately perform procedure as cooling effect last 45-60 seconds. May repeat x 1.¹

Consider non-invasive techniques to collect urine for screening (e.g., bag or stimulated clean catch method).
Physical and psychological methods of minimizing pain are key due to limited evidence for pharmacotherapy.
Lidocaine jelly – Limited evidence for benefit. Lubricating the catheter with 1-2 mL of 1-2% lidocaine jelly may be beneficial in treating post-insertion pain in infants/children 6 months and older.