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pain scores and increased satisfaction when compared with either method alone (Hee et al,
2003 Level III‐2; Ekbom et al, 2005 Level III‐2).
Non‐pharmacological strategies such as distraction, hypnosis and combined cognitive‐
behavioural interventions reduced needle‐related pain and distress in children and
adolescents (Uman et al, 2006 Level 1). Positioning the child vertically and being held by
a parent reduced distress in children during IV cannulation (Sparks et al, 2007 Level II).
Combination of hypnosis with EMLA® reduced pain, anxiety and distress associated with
venipuncture, and was more effective than either intervention alone (Liossi et al, 2009 Level II).
Lumbar puncture and bone marrow aspiration
Addition of fentanyl to propofol sedation improved analgesia (Nagel et al, 2008 Level II) and
satisfaction (Cechvala et al, 2008 Level II) in children with leukaemia undergoing bone marrow
aspirations and lumbar punctures. Oral transmucosal fentanyl reduced pain scores (Schechter
et al, 1995 Level IV). Oral or IV ketamine was associated with less distress during lumbar
puncture and /or bone marrow aspiration in children with cancer (Tobias et al, 1992 Level III‐3;
Evans et al, 2005 Level IV). For some patients, general anaesthesia is preferred to sedation, and
has been associated with less distress and pain for children requiring multiple procedures
(Crock et al, 2003 Level III‐3) (see also 10.1.8). Topical anaesthesia with EMLA® was effective for
lumbar puncture (Juarez Gimenez et al, 1996 Level II). Anticipatory and procedure‐related anxiety
and pain was reduced when hypnosis was combined with EMLA® (Liossi et al, 2006 Level II).
Urethral catheterisation and micturating cystourethrogram
Local anaesthetic lubricant reduced pain when administered 10 minutes (Gerard et al, 2003
Level II) but not 2 to 3 minutes (Vaughan et al, 2005 Level II) prior to urethral catheterisation.
N 2O reduced pain and distress in children undergoing urethral catheterisation for micturating
cystourethrogram investigation (Zier et al, 2007 Level III‐2). Preparing the child for the procedure
using a story booklet or play preparation reduced distress (Phillips et al, 1998 Level III‐2; Butler et
al, 2005 Level II), as did hypnosis (Butler et al, 2005 Level II).
Chest drain removal
IV morphine, topical anaesthesia with EMLA®, and N 2O reduced pain but did not provide
adequate analgesia for chest drain removal in children (Rosen et al, 2000 Level III‐2; Bruce et al,
2006 Level III‐2).
CHAPTER 10 Nasogastric tube insertion causes pain and distress in children (Juhl & Conners, 2005 Level IV).
Nasogastric tube insertion

In adults, topical anaesthesia of the nose and pharynx reduced pain associated with
nasogastric tube insertion (Singer & Konia, 1999 Level II; Wolfe et al, 2000 Level II) and nebulised
lignocaine after intranasal (IN) lignocaine gel was more effective than sprayed lignocaine
(Spektor et al, 2000 Level II). In children aged 1 to 5 years a benefit of nebulised lignocaine could
not be confirmed, but the study was terminated early due to the distress associated with
nebulisation (Babl et al, 2009 Level II).
Burns dressings
Children who have sustained burn injuries often require repeated, painful and distressing
dressing changes. Considerable interindividual variation occurs and analgesia needs to be
titrated to effect as requirements differ according to the surface area involved, the location,
and the child’s previous experiences. It is important to consider that one‐third will have post‐
traumatic stress disorder (Stoddard et al, 2006 Level IV).
Opioids are frequently required, and in the early phases general anaesthesia may be
preferred. Oral transmucosal (Robert et al, 2003 Level II) or IN fentanyl (Borland et al, 2005

344 Acute Pain Management: Scientific Evidence