In the last Pain in Childhood SIG blog, Dr Stefan J. Friedrichsdorf provided a review of safe and effective integrative therapies that are currently be used for pain and symptom management at the Children’s Hospital of Minnesota (Minneapolis/St. Paul, MN, USA): http://www.childrensMN.org. In this blog, he will share with you how parents and clinicians can incorporate these integrative therapies into pain management programs and will discuss the four “non-negotiable” components of managing pain related to needle pokes in children.

You can meet Dr Friedrichsdorf in Australia. Registrations for the 2014 FPM/ANZCA Spring Meeting (Sept 5-7, 2014, Blue Mountains, NSW) are now open.

Reducing and eliminating procedural pain related to needles:

The Four essential (non-negotiable) components

A recent survey among all our inpatients and their parents at the Children’s Hospitals and Clinics of Minnesota revealed that “hands down” needle-pokes for intravenous (IV) access, lab-draws or vaccination were the most painful event in the previous 24 hours. Up to one quarter of adults display a fear of needle procedures that was developed during their childhood, resulting in avoidance of health care and non-adherence with vaccination schedules (Taddio et al 2010 & 2009). Untreated procedural pain in children is associated with significant adverse consequences throughout the age continuum from infancy to adolescence. Repetitive procedural pain in preterm infants is associated with reduced early body growth and head circumference, after accounting for multiple medical confounders (Vinall, et al 2012). Repeated pain exposure in neonates induces long term changes in pain sensitivity (Grunau et al 2007, Hohmeister et al 2010) and in the developing brain (Anand et al 2000) and has serious short and long term consequences, with each painful event causing immediate physiological and behavioral instability (Holsti et al, 2004). Inadequate analgesia for initial procedures in children diminishes the effect of adequate analgesia in subsequent procedures (Weisman et al, 1998) and memory of a previous painful experience has great influence on the pain experience during subsequent procedures (Versloot et al, 2008).

Due to this research, and as a result of our survey findings, a hospital wide, three-year Toyota Lean quality improvement initiative on reducing pain was commenced. It led us to target pain management for needle pokes as the first area of focus. Improving needle procedure pain management practices undertaken by our lab technicians impacts approximately 60,000 children per year, half of them in the outpatient laboratory setting. Using Lean methodology, one-week events (i.e., rapid process improvements) were initiated in November 2013 in Children’s Hospital of Minnesota outpatient laboratories and in April 2014 in inpatient medical-surgical units. Mandatory protocols for distraction, positioning, topical anaesthesia (plus sublingual sucrose for infants), were implemented.

The four essential (non-negotiable) components of reducing and eliminating procedural pain relating to needles are as follows:

1. Numbing with Topical Anaesthesia
2. Sucrose for children 0-12 months of age
3. Positioning for Comfort
4. Distraction

Essential component #1: Numbing with Topical Anaesthesia

Topical local anaesthetics (e.g. topical lidocaine), which effectively numb the skin, are the single most important interventions in our toolbox and must always be offered for painful procedures. Obviously children and especially teenagers may decline the offer. Alternatively, in life threatening events we may forgo the administration, but otherwise every single needle procedure protocol must include a topical local anaesthetic.

Topical anaesthesia and local anaesthetics are critically important to the overall effectiveness of managing procedural pain and reducing the child’s anxiety. Large doses of the medications may have their own sedating effects and, thus, enhance sedative effects when used in combination with other sedatives or opioids. Furthermore, these agents are cardiac depressants so the maximum allowable safe dosage should be calculated before administration to avoid overdose.

Again, evidence captured for vaccination procedures hold true for other needle procedures as well. To reduce pain at the time of injection, encourage parents to use topical anaesthetics during needle procedures of children.

Topical anaesthetics are considered safe for children of all ages. However, be aware that administration of excessive doses and/or prolonged application times can lead to serious adverse effects, including irregular heartbeat, seizures and difficulty breathing.

The choice of topical anaesthetic depends on clinical scenario. The most important issue is to administer the topical local anesthetic for needle procedure in the first place; the choice of the medication may depend of application time (EMLA: 60 minutes, Lidocaine 4% [LMX]: 30 minutes; AnGel: 30 minutes), on practicability (over the counter versus prescription) and costs.

In Australia, the two most commonly administered topical creams are EMLA Cream (lidocaine 2.5% and prilocaine 2.5 and AnGel (4% amethocaine gel), but in the US the commonly used lidocaine 4% cream is also available over the counter.

What about efficacy? All creams work well, however AnGel (4% amethocaine) in a Cochrane Review was marked slightly better: “Although EMLA is an effective topical anaesthetic for children, amethocaine is superior in preventing pain associated with needle procedures.”

For children undergoing needle procedures, there is insufficient evidence for or against the use of skin-cooling techniques (vapocoolants, ice, cool/cold packs) to reduce pain at the time of injection (grade I recommendation, based on conflicting level I evidence).

EMLA® in Neonates

In neonates, EMLA reduces the behavioral pain response to venipuncture but not heel lance. Single doses in neonates have not been associated with methemoglobinemia and EMLA has shown to be effective for neonates greater than 34 weeks gestation for lumbar puncture.

Buffered subcutaneous Lidocaine

Buffered (non-buffered lidocaine is painful during administration) intradermal and subcutaneous Lidocaine has been shown to be effective for preventing pain during IV insertion in children. However, it may occasionally be difficult explaining to a child that he or she needs several needle sticks to not feel the needle procedures. Having said this, pain from a 30 gauge needle stick may be barely noticeable, especially when distraction is used during the needle stick administration of the lidocaine.

Needleless Lidocaine Injectors

Although not currently in use in Australia, the J-tip is a single-use, disposable, carbon-dioxide-powered, needleless lidocaine injector. Despite it’s significant cost this device proves to be very popular among children and paediatric providers in situation where waiting for 30 minutes (using a Ela-Max LMX or amethocaine gel) appears not to be feasible. Noise of activation might startle children and although the administration doesn’t hurt, there is usually a tiny drop of blood at the point where it injects the lidocaine, which might make younger children cry when they see it. If using this device for a needle procedure, the clinician has to be very precise in its use (only a 3mm zone will be numb). The device can drive the lidocaine quite deep, for example, on the back of a hand, not only might it numb the spot on the skin but might cause digital nerve block lasting nearly an hour. An example of the J-tip in use can be seen here:

Essential component #2: Sucrose for children 0-12 months of age

Administering sucrose is effective in managing mild to medium procedural pain in children 0-12 months of age (i.e. not only in newborns). The administration reduces pain and cry during painful procedure, such as venipuncture. Endogenous opioids seem to play an important role, as the mu-opioid receptor antagonist naloxone blunts the analgesic effect.

The effective dose of sucrose (24%) is 0.05 – 0.5 mL (= 0.012 – 0.12 g), administrated (e.g. with a pacifier/dummy) 2 minutes prior to a mild to moderately painful procedure. The duration of analgesia is about 4 minutes.

Consider additional analgesia and sedation

If the above strategies (positioning, integrative therapies and topical anaesthesia) cannot guarantee excellent procedural pain management in the individual child and/or for the individual procedure then the next steps would be to consider either systemic opioids by different routes of administration (e.g. intranasal, sublingual, buccal, intravenous, oral). Sedation may also be considered depending on the child and procedure (mild to moderate to deep sedation) using agents such nitrous gas, ketamine, or propofol.

There is data, which supports the intranasal administration of fentanyl for procedural pain in children. A clinical practice guideline, including clinical indications for use, is available form the Royal Children’s Hospital in Melbourne here http://www.rch.org.au/clinicalguide/guideline_index/Intranasal_fentanyl/

Essential component #3: Positioning for Comfort

When a child is undergoing a procedure while awake, positioning and holding are key to the procedure going well. A child that feels comforted and supported is more likely to be cooperative, while the child who feels held down is likely to resist. Positioning for comfort helps the infant or young child feel secure and close to the parent while keeping them still and quiet for the procedure. For simple procedures it is often helpful to gently hold the infant or toddler in the parent’s lap, facing the parent. If the infant needs to lie down then swaddling has been shown to be effective.

Positioning for comfort:

• Is appropriate for infants and toddlers, as well as for many older children.
• Will increase the child’s sense of support.
• Decreases the chances of the child resisting the procedure.

If the young child can sit in the parent’s lap for the procedure the following hold works well:

• The parent holds the child on his/her lap.
• One of the child’s arms embraces the parent’s back under the parent’s arm.
• The other arm is controlled by the parent’s arm and hand. For infants, the parent can control both arms with one hand.
• The child’s feet are held between the parent’s thighs, anchoring the child’s legs. The parent can also use his/her arm to control the legs.

The excellent recommendations for vaccination pain in children (refer to the “It Doesn’t Have To Hurt” video below) also hold true for most other painful procedures, such as blood draw, venous access, finger/heel stick etc. To reduce pain at the time of injection, do not place children in a supine position during needle pokes, including vaccination.

As mentioned previously, whenever feasible, offer choice of position to the child including the caregiver’s lap.

Excellent examples of positioning a child for comfort are available from the Royal Children’s Hospital in Melbourne, Australia. Review this here: http://www.rch.org.au/comfortkids/

Essential component #4: Distraction

There is significant evidence utilising integrative therapies for painful procedures in children. In a Cochrane review of 28 trials with 1951 children aged 2-19 years undergoing needle procedures (immunisations and injections), the following strategies proved to be effective:

• Distraction
• Hypnosis
• Combined cognitive behavioral interventions

In addition, the following was promising but had more limited evidence:

• Information/preparation
• Nurse coaching plus distraction
• Parent positioning plus distraction
• Distraction plus suggestion

To reduce pain at the time of injection among children four years of age and older, offer to rub or stroke the skin near injection site with moderate intensity before and during vaccination or other needle procedures (grade B recommendation, based on level II-1 evidence).

Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E843-55. Download here: http://www.cmaj.ca/content/182/18/1989.full

Consider parent coaching, by brochure or in person. Certain types of parental behaviors (nonprocedural talk, suggestions on how to cope, humour) have been related to decreases in children’s distress and pain. However, other behaviors, such as reassurance or apologies, have been related to increases in children’s distress and pain.

Distraction minimises children’s fear, anxiety and pain. The mechanism by which distraction works is not fully understood but is likely a combination of diverting attention away from painful and distressing stimuli, focusing the brain and reducing the capacity for awareness of noxious stimuli, and engaging in a pleasurable activity that releases endorphins.

Children will vary in their desire to either watch a procedure or to look away. If a child wishes to watch and is forced to look away s/he may become more distressed. Many children will choose a distraction but periodically look back at the procedure in progress. It helps to have a staff member comment on how well it is going, provide praise to the child on his/her cooperation and to do a time check, such as “we are half-way done”. In general, strategies that reinforce the child’s capacity for self-control will contribute to more successful procedural experiences.

Many children, especially young children, can be distracted with stories or books read aloud, the more familiar the better. The storyteller or reader should engage the child by asking questions, such as “what do you think will happen next?” or “what is this character’s name?” This is a good role for parents if they are comfortable being helpers. Other distracters are puppets, therapy animals or blowing bubbles.

Older children and teens can be quite distracted by video games. Some procedures such as wound debridement or dressing changes, might lend to the child playing a video game. Additionally there are biofeedback programs, which measure levels of relaxation, such as decreased muscle tension or lowered heart rate that can be used during procedures when the child is awake. Examples would include electrodes that measure muscle tension or finger sensors for pulse or temperature. Devices can be simple (skin thermometers) or complex (laptop computers). As the child focuses on breathing or relaxation they watch the device to see how it changes. This can reinforce the child’s sense of mastery and control.

What about Apps?

My personal favourite for managing pain remains teaching children self-hypnosis. However, in addition, I am increasingly using Apps in my clinical practice (inpatient, clinic and home visits) on my iPhone or iPad. My Top 10 Apps for Pain & Symptom Management in Children can be found here: http://noneedlesspain.org/?p=8

If the abovementioned four strategies (namely positioning, integrative therapies, topical anaesthesia and systemic analgesics) are not adequate to provide excellent analgesia for a certain procedure in an individual child, then the child must be sedated in a safe environment.

There are occasions that require sedation to safely manage procedures. These may complex procedures, or situations where the child’s ability to cope has seriously deteriorated. Sedation is also a helpful strategy to minimise the burden of painful procedures, like bone marrow aspiration, for example. There are different levels of sedation, and in general, using the lightest sedation to ensure comfort and achieve the necessary results is desired. When sedation is required for procedures, careful planning is important.

Holding down a crying child to perform a painful procedure cannot be tolerated anymore in the 21st century.

In conclusion, state of the art paediatric pain management requires the integration of non-pharmacologic, integrative strategies. At a recent prospective cross sectional survey among all our inpatients at our Institution undertaken on one day, we found that needle related pain was the single most painful event in the previous 24 hours. Interestingly children in pain perceived several integrative strategies, including patient and caregiver participation, infant comfort, distraction and positioning as more helpful than medications in reducing commonly caused pain.

In addition to the videos above aimed at clinicians, Children’s Hospitals and Clinics of Minnesota have also prepared information for families and patients. Watch the introduction video and then select the film for the appropriate age group of your child or young person.

Baby

Toddler

School Aged

Teenager

Stefan J. Friedrichsdorf, MD, FAAP

Stefan is the Medical Director
Department of Pain Medicine, Palliative Care & Integrative Medicine
Children’s Hospitals and Clinics of Minnesota
Associate Professor of Pediatrics, University of Minnesota

www.childrensMN.org/PainAndPalliativeCare

Twitter: @NoNeedlessPain

The 10 videos embedded in this blog (non-YouTube links) have been kindly authorised for publication by Children’s Hospitals and Clinics of Minnesota.

Copyright remains with Children’s Hospitals and Clinics of Minnesota.