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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

 

Summaries of systematic reviews English (10) French All (10)

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

Visit

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: 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.

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

Visit

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 Summary: Sucrose for analgesia in newborn infants undergoing painful procedures

Visit

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

Visit

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

Visit

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

Visit

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

Visit

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

Visit

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

Visit

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: Venepuncture versus heel lance for blood sampling in term neonates

Visit

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: Tissue adhesives for traumatic lacerations in children and adults

Visit

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.

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