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Children very often experience multiple painful procedures in the course of their emergency department visit, as a part of investigation and treatment. The pain associated with these procedures can cause both long and short-term sequelae. Minimizing procedure-related pain should be a routine part of emergency department care for children.

BROWSE EVIDENCE REPOSITORY

 

Bottom Line Recommendations

Recommandations de Base: Douleur procédurale

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French Bottom line recommendations for the treatment and management of procedural pain. Published online: March 2017.

Bottom Line Recommendations: Procedural Pain

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Ali, S, Drendel A & TREKK Network

Bottom line recommendations for the treatment and management of procedural pain. Published online: November 2016.

Bottom Line: Pain Ease(R): Topical anesthetic skin refrigerant (for children 4 years and older)

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BC Children's Hospital

Purpose: Pain Ease spray is a vapocoolant (skin refrigerant) intended for topical application to skin and minor open wounds. It controls pain associated with injections (venipunctures, IV start) and minor surgical procedures (eg. irrigating laceration/abrasions).

Bottom Line: Sucrose as a procedural analgesic for infants up to 12 monts of age

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BC Children's Hospital

Purpose: Oral sucrose and other sweet tasting solutions have been used for management of pain in infants for centuries. Studies done since the early 1990's have demonstrated that the administration of sucrose and non-nutritive sucking are effective non-pharmacological interventions for relief of procedural pain in neonates and infants and may help reduce pain in infants up to 12 months of age. Sucrose and non-nutritive sucking are thought to elevate pain thresholds via endogenous opioid pathways.

Bottom Line: Psychological Interventions

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BC Children's Hospital

Even with sedation, the success of a procedure is equally reliant upon careful consideration of psychosocial aspects as it is reliant on physical aspects. A sense of mastery and control experienced by parents and children is crucial to their confidence in managing any future procedures. Reducing both pain and anxiety will facilitate effective coping.

Clinical guidelines

Clinical Practice Guideline: Prevention and Management of Procedural Pain in the Neonate: An Update

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Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine

This statement updates previous recommendations with new evidence on the prevention, assessment, and treatment of neonatal procedural pain.

Video: Managing Procedural Anxiety in Children

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Krauss BS, Krauss BA, Green SM.

This video describes the signs of acute anxiety in children and demonstrates approaches to interacting with children that minimize anxiety and maximize cooperation. Published: April 2016.

Video: It Doesn't Have to Hurt

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Centre for Pediatric Pain Research

Kids upset about the pain and distress of getting a needle? It doesn't have to be this way. Watch the Centre for Pediatric Pain Research's 2-minute video to learn some tips about how it can be easier for everyone. And the best news? These tips are all backed by scientific research! 

Clinical Practice Guideline: Good practice in postoperative and procedural pain management

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Association of Paediatric Anaesthetists of Great Britain and Ireland

This themed issue starts with an outstanding review of the history of Pediatric Regional Anesthesia (PRA), written by an equally outstanding second-wave pioneer and promoter of this particular facet of pediatric anesthesia, Professor Emeritus Kester Brown.

Clinical Practice Guideline: Evidenced-based clinical practice guideline for management of newborn pain

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Spence K, Henderson-Smart D, New K, Evans C, Whitelaw J, Woolnough R

Aim: To facilitate the uptake of evidence and to reduce the evidence practice gap for management of newborn pain through the development of a clinical practice guideline.

Clinical Practice Guideline: Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline

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Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan...

Our objective was to develop a clinical practice guideline, based on systematic reviews of the literature, as interpreted by experts, to assist clinicians in managing procedure-related pain and distress among children undergoing vaccine injections.

Clinical Practice Guideline: The recognition and assessment of acute pain in children

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Royal College of Nursing

The guideline is aimed at a range of professional groups, patients and carers who may be involved in the assessment and management of childrens pain. The primary aims of this guideline are to: identify reliable and valid measures of pain intensity appropriate for neonates and preverbal infants, and verbal and non-verbal children, through a systematic search and appraisal of the literature; describe these tools to help practitioners select from these in different clinical settings; and make recommendations regarding timing and triggers for formal pain assessment.

Clinical Practice Guideline: Guidelines for procedural pain in the newborn

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Lago P, Garetti E, Merazz, D, Pieragostini L, Ancora G, Pirelli A, Bellieni CV

Our aim was to develop guidelines based on evidence and clinical practice for preventing and controlling neonatal procedural pain in the light of the evidence-based recommendations contained in the SIGN classification.

Summaries of systematic reviews

Cochrane Summary: Psychological interventions for needle-related procedural pain and distress in children and adolescents

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Uman LS, Birni, KA, Noel M, Parker JA, Chambers CT, McGrath PJ, Kisely SR

Psychological interventions (for example, distraction, hypnosis, coping skills training) are treatments used to reduce pain and distress (anxiety and fear, or both) that children and adolescents experience while undergoing medical procedures involving needles. There is strong evidence that distraction and hypnosis are effective in reducing the pain and distress that children and adolescents experience during needle procedures. Distraction techniques can often be quite simple, such as reading the child stories, watching television, listening to music, or talking about something other than the needle. Sometimes parents or nurses are involved in helping to distract the child, although that is not always necessary. Interventions such as hypnosis may require someteachingby a trained professional for a child to learn. Other psychological treatments, such as explaining what is going to happen before or during the procedure (labelled 'providing information or preparation or both'), using virtual reality (for example, interactive video equipment, goggles, computers showing images, games, stories), or a combination of various strategies have been tested. Moreresearchis needed to know whether they are effective for reducing children's pain and distress during needles.

Cochrane Summary: Sucrose for analgesia in newborn infants undergoing painful procedures

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Stevens B, Yamada J, Lee GY, Ohlsson A

Healthcare professionals need strategies to reduce newborn babies' pain. Sucrose (sugar) provides pain relief for newborn babies having painful events such as needles or heel pricks. Pain medicine is usually given for major painful events (such as surgery), but may not be given for more minor events (such as taking blood or needles). Pain medicine can be used to reduce pain but there are several other methods including sucking on a pacifier (dummy) with or without sucrose. Researchers have found that giving sucrose to babies decreases their crying time and behaviours such as grimacing. Moreresearchis needed to determine if giving repeated doses of sucrose is safe and effective, especially for very low birthweight infants or infants on respirators.

Cochrane Summary: Sweet-tasting solutions for needle-related pain in infants up to one year of age

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Kassab M, Foster JP, Foureu M, Fowle C

The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months (Appendix 4). In thisreviewwe were interested in whether giving babies sugar-based solutions to taste when the needle breaks the skin will help reduce their pain. We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings. Overall, the studies show that different types of sugar-based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain. We did find some evidence that babies may not cry for as long if given sugar-based solutions. Thisreviewis broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.

Cochrane Overview: The Cochrane Library and procedural pain in children: an overview of reviews

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Curtis S, Wingert A, Ali S

Objective: To summarize Cochrane reviews assessing the effects of various interventions used for pain in non-neonatal children undergoing painful medical procedures.

Cochrane Summary: Breastfeeding or breast milk for procedural pain in neonates

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Shah PS, Herbozo C, Aliwalas LL, Shah VS

Breastfeeding provides pain relief for newborn babies undergoing painful procedures. Medicine for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick orvenepuncture). There are different forms of non-pharmacological strategies that may be used to reduce pain in babies, such as holding, swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in babies have shown that breastfeeding is a good way to reduce the pain babies feel when subjected to minor painful procedures. These studies have been done in full-term babies and they have shown that breastfeeding is effective by demonstrating that it reduces babies' crying time and reduces different pain scores that have been validated for babies. Breast milk given by syringe has not shown the sameefficacyas breastfeeding itself. No studies have been done in premature babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain.

Cochrane Summary: Non-pharmacological interventions for acute pain in infants

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Pillai Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L, Ah...

We examined 13 different types of commonly investigated non-pharmacological treatments (excluding breastmilk, sucrose, and music) to determine theirefficacyfor pain reactions after an acutely painful procedure (right after the needle ('pain reactivity') and less immediate pain reactions ('immediate pain-related regulation').Fifty-onerandomizedcontrolled trials were included involving 3396 participants. For preterm infants, there was sufficient evidence to recommend kangaroo care, sucking-related interventions, and swaddling/facilitated tucking interventions for both pain reactivity and immediate pain-related regulation. For neonates, there was sufficient evidence to recommend sucking-related interventions as an effective treatment for pain reactivity and immediate pain-related regulation.Rocking/holding was also found to be efficacious for neonatal immediate pain-related regulation.For older infants, there were no treatments reviewed that demonstrated sufficient evidence. Due to significant differences in the magnitude of treatment effects among studies (heterogeneity), some analyses that found a lack of treatment effect need to be interpreted with caution.

Cochrane Summary: Venepuncture versus heel lance for blood sampling in term neonates

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Shah V, Ohlsson A

In most countries, a blood sample from newborn babies is needed forscreeningtests. A heel lance is the standard way of taking blood, but it is a painful procedure with no optimal method of pain relief known. Thisreviewof trials found evidence thatvenepuncture, when done by a trained practitioner, caused less pain than heel lance. The use of a sweet tasting solution given to the baby prior to the event reduced pain further. The evidence includedoutcomemeasures using pain scales, how long the baby cried and how the mother rated their baby's pain.

Cochrane Summary: Sweet solution taste to ease injection needle pain in children aged one to 16 years

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Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B

This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. We re-ran the search in October 2014. Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non-sweet solutions, or other interventions such as non-nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction? Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain-reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain-reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years. Search date: We searched the literature for published and unpublished studies up to October 2014. Study characteristics: We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles. For older school-aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school-aged children, further studies of sweet taste for pain management in school-aged children are not warranted. Study funding sources: Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state-wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant. The two studies including school-aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.

Cochrane Summary: Local anaesthesia (numbing medicine) that is directly applied to the skin may be used to provide pain control for repair of lacerations

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Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB

Paincontrolfor suturing of torn skin is conventionally achieved by injecting medication into the skin, which may itself cause pain. Topical anaesthetics are directly applied to the skin and are painless to administer. Cocaine was one of the first anaesthetics to be successfully applied topically. Concerns overadverse effectswith cocaine and the administrative burdens of dispensing a controlled substance led to the development of cocaine-free anaesthetics. There are numerous cocaine-free topical anaesthetics and these were found to be effective for enabling repair of dermal lacerations. We included 23randomizedcontrolled trials involving 3128 patients in thisreview. The small number of trials in each comparison group and theheterogeneityofoutcomemeasures precluded quantitativeanalysisofdatain all but oneoutcome, pain scores using a visual analogue scale. Additional studies are necessary to directly compare theeffectivenessof different formulations of topical anaesthetics. No serious side effects were reported in the studies included in thereviewfollowing use of cocaine-containing or cocaine-free topical anaesthetics.

Cochrane Summary: Tissue adhesives for traumatic lacerations in children and adults

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Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N

Cuts (lacerations) often need to be closed to ensure proper healing, and prevent infection or unattractivescarring. Wounds may be closed with stitches (sutures), staples, tapes or glue (tissueadhesive). Thereviewfound that glue is an excellent substitute for stitches, staples or tapes to close simple cuts. Glue causes less pain, is quicker and needs no follow up for removal. A slightly higher number of cuts may break open (dehisce) after being glued, compared to cuts closed with stitches, staples or tapes. Though there are a few different types of glue available, no one glue seems to be superior.

Systematic reviews

Systematic Review: Pediatric clinical practice guidelines for acute procedural pain: a systematic review

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Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B

Objective: To systematically review the quality of existing practice guidelines for acute procedural pain in children and provide recommendations for their use.

Systematic Review: A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults

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Hogan ME, Smart S, Shah V, Taddio A

Our aim was to systematically review the literature regarding the analgesic effectiveness of vapocoolants in children and adults.

Cochrane Systematic Review: Psychological interventions for needle-related procedural pain and distress in children and adolescents

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Uman LS, Birnie KA, Noel M, Parker JA, Chambers CT, McGrath PJ, Kisely SR

Objectives: To provide an update to our 2006 review assessing the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

Cochrane Systematic Review: Sucrose for analgesia in newborn infants undergoing painful procedures

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Stevens B, Yamada J, Lee GY, Ohlsson A

Objective: To determine the efficacy, effect of dose and safety of oral sucrose for relieving procedural pain in neonates.

Cochrane Systematic Review: Breastfeeding or breast milk for procedural pain in neonates

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Shah PS, Herbozo C, Aliwalas LL, Shah VS

Objectives: The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

Cochrane Systematic Review: Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age

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Kassab M, Foster JP, Foureur M, Fowler C

Objectives: To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods.

Review: Relief of pain and anxiety in pediatric patients in emergency medical systems

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Fein JA, Zempsky WT, Cravero JP, Committee on Pediatric Emergency Medicine an...

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction.

Cochrane Systematic Review: Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years

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Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B

Objectives: To determine the efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age.

Cochrane Systematic Review: Topical anaesthetics for repair of dermal laceration

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Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB

Objectives: To compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for repair of dermal lacerations and to evaluate the efficacy and safety of various single or multi-component topical anaesthetics to identify cocaine-free topically applied local anaesthetics that may provide equivalent analgesia to those containing cocaine.

Cochrane Systematic Review: Non-pharmacological management of infant and young child procedural pain

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Pillai Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L, Ah...

Objectives: To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation).

Review: Needle pain in children: contextual factors

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Walco GA

Pediatric pain experiences result from a complex interplay of genetic, experiential, and developmental factors. These elements, as they relate to needle-stick procedures and other relevant painful phenomena, are explored in this article so that the context of possible interventions may be more fully appreciated. Clinical implications are discussed incorporating ethical perspectives.

Review: Clinical implications of unmanaged needle-insertion pain and distress in children

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Kennedy RM, Luhmann J, Zempsky WT

This review summarizes the evidence for the importance of managing pediatric procedural pain and methods for reducing venous access pain.

Review: Pharmacologic approaches for reducing venous access pain in children

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Zempsky WT

A variety of pharmacologic options are available to clinicians who want to provide effective and safe topical local anesthesia to children undergoing venous access procedures. These options can be distinguished on the basis of how they deliver active drug through the impermeable outer layer of skin, the stratum corneum, to pain receptors located in the dermis and epidermis. Three general methodologies are typically used to bypass the stratum corneum: direct injection of local anesthetics, usually via a small-gauge hypodermic syringe; passive diffusion from topical creams or gels; and active needle-free drug strategies that enhance the rate of drug passage into the dermis and epidermis.

Systematic Review: Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials

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Klassen JA, Liang Y, Tjosvold L, Klassen TP, Hartling L

Objective: The aim of this study was to conduct a systematic review of the efficacy of music therapy (MT) on pain and anxiety in children undergoing clinical procedures.

Cochrane Systematic Review: Venepuncture versus heel lance for blood sampling in term neonates

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Shah V, Ohlsson A

Objectives: To determine whether venepuncture or heel lance is less painful and more effective for blood sampling in term neonates.

Cochrane Systematic Review: To determine whether venepuncture or heel lance is less painful and more effective for blood sampling in term neonates

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Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N

Objectives: To summarize the best available evidence for the effect of tissue adhesives in the management of traumatic lacerations in children and adults.

Key studies

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

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Lunoe MM, Drendel AL, Levas MN, Weisman SJ, Dasgupta M, Hoffmann RG, Broussea...

Study Objective: The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray.

Key Study: Music to reduce pain and distress in the pediatric emergency department: a randomized clinical trial

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Hartling L, Newton AS, Liang Y, Jou H, Hewson K, Klassen TP, Curtis S

Objective: To compare music with standard care to manage pain and distress.

Key Study: Needle-free jet injection of lidocaine for local anesthesia during lumbar puncture: a randomized controlled trial

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Ferayorni A, Yniguez R, Bryson M, Bulloch B

Lumbar puncture (LP) is an essential procedure in the emergency department (ED) for the evaluation of meningitis. Subcutaneous injection of lidocaine before LP for local anesthesia is not a pain-free procedure. The J-Tip device allows an intradermal needle-free jet injection of 1% buffered lidocaine. This study compares needle-free jet injection of lidocaine to saline in reducing pain before LP in infants.

Key Study: A comparison of amethocaine and liposomal lidocaine cream as a pain reliever before venipuncture in children: a randomized control trial

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Poonai N, Alawi K, Rieder M, Lynch T, Lim R

Objective: Although the use of anesthetic creams before intravenous (IV) insertion has been shown to be both safe and effective in decreasing pain during IV cannulation, the use of any single agent based on efficacy is not yet considered the standard of care in children. We sought to compare a commonly used preparation, 4% liposomal lidocaine (Maxilene), with 4% amethocaine (Ametop), a newer agent with reportedly good efficacy and an intrinsic vasodilatory effect.

Key Study: Equimolar nitrous oxide/oxygen versus placebo for procedural pain in children: a randomized trial

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Reinoso-Barbero F, Pascual-Pascual SI, de Lucas R, Garca S, Billot C, Dequenn...

Objective: This randomized, single-dose, double-blind, Phase III study was designed to compare the level of procedural pain after use of premixed equimolar mixture of 50% oxygen and nitrous oxide (EMONO) or placebo (premixed 50% nitrogen and oxygen).

Key Study: Epidemiology and management of painful procedures in children in Canadian hospitals

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Stevens BJ, Abbott LK, Yamada J, Harrison D, Stinson J, Taddio A, Barwick M, ...

We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management.

Key Study: Impact of Parent-Provided Distraction on Child Responses to an IV Insertion

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McCarthy AM, Kleiber C, Hanrahan K, Zimmerman MB, Westhus N, Allen S

This study evaluates the impact of parent-provided distraction on children's responses (behavioral, physiological, parent, and self-report) during an IV insertion.

Key Study: A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department

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Auerbach M, Tunik M, Mojica M

Objectives: The objectives were to determine whether pretreatment with needleless jet-delivered lidocaine decreases self-reported pain in children undergoing needle insertion in the emergency department (ED) and to explore whether pretreatment with a jet device decreases self-reported pain in children undergoing needle insertion in the ED.

Key Study: Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial

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Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK

Objective: Comparison of the anesthetic effectiveness of J-Tip needle-free jet injection of 1% buffered lidocaine to the anesthetic effectiveness of topical 4% ELA-Max for PIV catheter insertion.

Key Study: Risk factors for traumatic or unsuccessful lumbar punctures in children

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Nigrovic LE, Kuppermann N, Neuman MI

Study Objective: Traumatic and unsuccessful lumbar punctures can cause substantial diagnostic ambiguity that may lead to unnecessary antibiotic use and hospitalization, in addition to patient discomfort. Risk factors for obtaining traumatic and unsuccessful lumbar punctures have been studied in a limited fashion only. We sought to determine patient, physician, and procedural factors associated with traumatic and unsuccessful lumbar punctures in children.

Key Study: A randomized controlled trial of sucrose and/or pacifier as analgesia for infants receiving venipuncture in a pediatric emergency department

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Curtis SJ, Jou H, Ali S, Vandermeer B, Klassen T

Although sucrose has been accepted as an effective analgesic agent for procedural pain in neonates, previous studies are largely in the NICU population using the procedure of heel lance. This is the first report of the effect of sucrose, pacifier or the combination thereof for the procedural pain of venipuncture in infants in the pediatric emergency department population.

Key Study: Lumbar puncture success rate is not influenced by family-member presence

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Nigrovic LE, McQueen AA, Neuman MI

Objective: Our goal was to evaluate the association between family-member presence and lumbar puncture success rates.

Key Study: A randomized, controlled trial of sucrose analgesia in infants younger than 90 days of age who require bladder catheterization in the pediatric emergency department

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Rogers AJ, Greenwald MH, Deguzman MA, Kelley ME, Simon HK

Objectives: To determine whether an oral sucrose solution improves pain response for infants undergoing bladder catheterization in an emergency department (ED) population.

Key Study: A comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient

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Jimenez N, Bradford H, Seidel KD, Sousa M, Lynn AM

Placement of IV catheters is a painful and stressful procedure for children. J-Tip is a needle-less Food and Drug Administration approved injection system that can be used for delivery of local anesthetic before IV cannulation. In this study, we compared the effectiveness of J-Tip versus eutectic mixture of local anesthetics (EMLA) to facilitate IV cannulation and provide adequate analgesia before IV placement.

Key Study: Local anesthetic and stylet styles: factors associated with resident lumbar puncture success

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Baxter AL, Fisher RG, Burke BL, Goldblatt SS, Isaacman DJ, Lawson ML

Objective: To assess the effects of procedural techniques, local anesthetic use, and postgraduate training level on lumbar puncture (LP) success rates.

Key Study: A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children

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Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM

Objectives: Ketamine provides effective and relatively safe sedation analgesia for reduction of fractures in children in the emergency department. However, prolonged recovery and adverse effects suggest the opportunity to develop alternative strategies. We compared the efficacy and adverse effects of ketamine/midazolam to those of nitrous oxide/hematoma block for analgesia and anxiolysis during forearm fracture reduction in children.

Key Study: Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial

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Taddio A, Soin HK, Schuh S, Koren G, Scolnik D

Historically, children have been undertreated for their pain, and they continue to undergo painful cutaneous procedures without analgesics. A new topical anesthetic, liposomal lidocaine 4% cream (Maxilene, RGR Pharma, Windsor, Ont.), has become available. It has pharmacologic properties that are superior to other topical anesthetics, including an onset of action of only 30 minutes. We sought to determine the success rate of cannulation, analgesic effectiveness, procedure duration and rate of adverse skin reactions when liposomal lidocaine is used before intravenous cannulation of children.

Key Study: A comparison of buffered lidocaine versus ELA-Max before peripheral intravenous catheter insertions in children

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Luhmann J, Hurt S, Shootman M, Kennedy R

Objective: To compare the reduction of pain and anxiety during peripheral intravenous catheter insertion provided by subcutaneous buffered 1% lidocaine or topical ELA-Max in children.

Key Study: Application of topical local anesthetic at triage reduces treatment time for children with lacerations: a randomized controlled trial

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Priestley S, Kelly AM, Chow L, Powell C, Williams A

Study Objectives: We determine whether application of topical local anesthetic at triage reduces total treatment time for children with simple lacerations.

Key Study: Effects of chewing gum on responses to routine painful procedures in children

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Lewkowski MD, Barr RG, Sherrard A, Lessard J, Harris AR, Young SN

In infants, sweet taste and sucking on a pacifier both have analgesic effects. Animal studies suggest that sweet taste may involve opioids, while rhythmic oral movements, as with a pacifier, increase the release of serotonin, which is involved in the gating of nociceptive afferents. The present study was designed to see if these effects produce an analgesic effect in children. Two studies were performed, during blood draws in a pediatric test center in 7- to 12-year-old children, and during vaccination at school in 9- to 11-year-old children.

Key Study: Buffered lidocaine: analgesia for intravenous line placement in children

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Klein EJ, Shugerman RP, Leigh-Taylor K, Schneider C, Portscheller D, Koepsell T

Objectives: To evaluate the effectiveness of intradermal buffered lidocaine as analgesia before intravenous line (i.v.) placement in children.