Page 391 Acute Pain Management

10.4.1 Procedural pain in the neonate

Blood sampling and intravenous cannulation
Neonates in intensive care often require frequent blood sampling. Heel lance produced more
pain than venipuncture (Shah & Ohlsson, 2007 Level I), but fewer attempts were required and
less pain behaviour was exhibited with spring loaded automated devices for heel lance (Shah
et al, 2003 Level II). Topical local anaesthesia reduced the physiological and behavioural
response to venipuncture (Taddio et al, 1998 Level I). Sucrose (Stevens et al, 2004 Level I) and
breastfeeding (Shah et al, 2006 Level I) reduced pain responses to venipuncture. The optimal
dose of sucrose, its efficacy and the safety of repeated doses have not been determined.
Background morphine infusions in ventilated neonates had limited efficacy for acute
procedural interventions in intensive care (Bellu et al, 2008 Level I). IV morphine bolus with
topical amethocaine provided more effective analgesia than morphine or amethocaine alone
for peripheral central venous line placement in preterm neonates (Taddio et al, 2006 Level II).
Lumbar puncture
EMLA® (eutectic mixture of lignocaine and prilocaine) reduced the physiological and
behavioural response with needle insertion for lumbar puncture in preterm and term
neonates (Kaur et al, 2003 Level II).
Urine sampling
EMLA® reduced pain scores in neonates and young infants undergoing suprapubic aspiration
(Nahum et al, 2007 Level II). Transurethral catheterisation after the urethral application of 2%
lignocaine (lidocaine) was less painful than suprapubic aspiration after the topical application
of EMLA® (Kozer et al, 2006 Level II). Sucrose reduced pain scores during transurethral
catheterisation in neonates (Rogers et al, 2006 Level III‐2).
Ocular examination for retinopathy of prematurity
Screening for retinopathy of prematurity in neonates is painful (Belda et al, 2004 Level IV).
Topical local anaesthesia reduced pain scores (Marsh et al, 2005 Level II), and sucrose in addition
to topical local anaesthetic had a greater effect (Gal et al, 2005 Level II, Mitchell et al, 2004
Level II).
10.4.2 Procedural pain in infants and older children
Venipuncture and intravenous cannulation
Venipuncture causes pain and significant distress in many children (Humphrey et al, 1992
Level IV). Topical local anaesthesia reduced pain associated with IV cannulation, but CHAPTER 10
amethocaine was more effective than EMLA® and had more rapid onset (Lander et al, 2006
Level I). Lignocaine administered by iontophoresis (Zempsky et al, 2004 Level II) or liposomal
lignocaine 4% cream (Eidelman, Weiss, Lau et al, 2005 Level I) had a more rapid onset and was as
effective as EMLA® for venipuncture and IV cannulation. A needleless device that delivers 1%
buffered lignocaine under high pressure from a compressed carbon dioxide gas cartridge was
effective within 3 minutes, and produced more effective skin anaesthesia than EMLA® (Jimenez
et al, 2006 Level II).
Vapocoolant sprays have variably been reported to be ineffective (Costello et al, 2006 Level II) or
reduce pain (Farion et al, 2008 Level II) associated with IV cannulation, and to be as effective as
topical amethocaine in children undergoing venipuncture (Davies & Molloy, 2006 Level III‐1).
Nitrous oxide (N 2O) reduced pain and anxiety associated with IV cannulation (Henderson et al,
1990 Level II). Use of 70% N 2O in oxygen was more effective that 50% (Furuya et al, 2009 Level II).
The combination of N 2O and topical EMLA® for IV cannulation was more effective in reducing
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