Can Indian classical instrumental music reduce pain felt during venepuncture?

Objective  Local anesthetic agent is not usually used to reduce pain experienced by children undergoing venepuncture. This study was undertaken to determine comparative efficacy of local anesthetic cream, Indian classical instrumental music and placebo, in reducing pain due to venepuncture in children. Methods  Children aged 5–12yr requiring venepuncture were enrolled in a prospective randomized clinical trial conducted at a tertiary care center. They were randomly assigned to 3 groups: local anesthetic (LA), music or placebo (control) group. Eutactic mixture of local anesthetic agents (EMLA) and Indian classical instrumental music (raaga-Todi) were used in the first 2 groups, respectively. Pain was assessed independently by parent, patient, investigator and an independent observer at the time of insertion of the cannula (0 min) and at 1- and 5 min after the insertion using a Visual Analog Scale (VAS). Kruskal- Wallis and Mann-Whitney U tests were used to assess the difference amongst the VAS scores. Results  Fifty subjects were enrolled in each group. Significantly higher VAS scores were noted in control (placebo) group by all the categories of observers (parent, patient, investigator, independent observer) at all time points. The VAS scores obtained in LA group were lowest at all time points. However, the difference between VAS scores in LA group were significantly lower than those in music group only at some time-points and with some categories of observers (parent: 1min; investigator: 0-, 1-, 5 min and independent observer: 5 min). Conclusion  Pain experienced during venepuncture can be significantly reduced by using EMLA or Indian classical instrumental music. The difference between VAS scores with LA and music is not always significant. Hence, the choice between EMLA and music could be dictated by logistical factors.     

Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations

Local anesthetic infiltration of wounds causes pain which distresses children. A painless topical anesthetic solution containing tetracaine, adrenaline, and cocaine (TAC) may reduce this distress. We hypothesized that the use of TAC for anesthesia may reduce the utilization of sedation for laceration repair. We performed a retrospective review of all pediatric emergency department (PED) patients receiving parenteral meperidine, promethazine, and chlorpromazine (DPT) during the period after TAC became routinely available. For comparison, data from a recent retrospective study of DPT (preTAC) use in the same PED were used. There was a reduction in the percent of total PED patients receiving DPT, from 1.7% preTAC to 1.2% during the TAC period (P less than 0.05). During the TAC period, there were no significant changes in patient volume or case-mix indicators. Of the major indications for DPT, there was no significant change in the percent receiving DPT for fractures, abscesses, burns, foreign body removal, or head injuries. However, there was a significant reduction in the percent of patients with lacerations receiving DPT during the experimental period, from 12% to 7.6% (P less than 0.05). There were no significant differences in laceration frequency (119/mo and 116/mo), length (2.7 and 2.7 cm), location (85% and 93% total for face and digits), or complexity (64% and 63%) for preTAC and TAC periods, respectively. We conclude that TAC used for local anesthesia may reduce the need for sedation in PED patients with lacerations that require suturing.     

Half-strength TAC topical anesthetic. For selected dermal lacerations

A prospective evaluation of 75 consecutive children with lacerations of the face, lip, and scalp who received TAC (tetracaine, epinephrine [adrenalin], cocaine) topical anesthetic for the repair of their wound was performed. The TAC preparation contained one-half the conventional concentration of cocaine (5.9%) and tetracaine (0.25%) previously used in other studies that have evaluated its anesthetic efficacy. A maximal dosage of 3 ml of TAC (containing 175 mg cocaine and 7.5 mg tetracaine) was applied to each laceration. The diluted TAC preparation provided complete anesthesia for approximately 95% of the more than 400 sutures placed. No adverse reactions were noted in any patient who received TAC, and in no instance did a complication of wound healing occur. The original formulation of TAC was arbitrarily composed, and the maximum concentration per dosage of the potentially toxic component medications of TAC that can be "safely" applied to dermal lacerations in children remains to be defined. Utilization of this diluted preparation will diminish the risk of potential systemic toxicity from the absorbed component medications of TAC without compromising anesthetic efficacy.     

A comparison of Likert scale and visual analogue scales as response options in children's questionnaires

AIM: To examine which response options children prefer and which they find easiest to use, and to study the relative reliability of the different response options. METHODS: A consecutive group of unselected children (n = 120) filled out three questionnaires in a paediatric outpatient clinic. Each questionnaire included seven similar questions, but had different response options: the Likert scale, the Visual Analogue Scale (VAS) and the numeric VAS. In general, the questions were not related to the children's particular diseases, but dealt with the frequency of simple activities, their feelings and opinions. The pages with the three different response options were offered in random order. Afterwards, the children rated their preference and ease of use of the different response options on a scale from one to 10. RESULTS: Children preferred the Likert scale (median mark 9.0) over the numeric VAS (median mark 8.0) and the simple VAS (median 6.0). They considered the Likert scale easiest to fill out (median mark 10 vs 9 and 7.5 for the numeric and simple VAS, respectively). Results of the different response options correlated strongly with each other (rho = 0.67-0.90, p < 0.05). CONCLUSION: Children prefer the Likert scale over the numeric and simple VAS and find it easiest to complete. The Likert scale, the simple VAS and the numeric VAS are of comparable reliability. The Likert scale is recommended for use in questionnaires for children, although research into larger and more diverse samples is needed.     

Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children

To determine whether the tetracaine component traditionally used in tetracaine-adrenaline-cocaine (TAC) is necessary to obtain effective topical anesthesia, a prospective study was performed to compare TAC and adrenaline-cocaine preparations for the repair of facial lacerations in children. Physicians were "blind" to which preparation was being used. Of 55 patients studied, 24 received TAC (103 sutures placed) and 31 received adrenaline-cocaine (151 sutures placed). The anesthetic efficacy of each preparation was approximately 95%; there were no adverse reactions related to administration of either medication or complications of wound healing noted in either group. The tetracaine component of TAC is superfluous for obtaining topical anesthesia of minor dermal lacerations of the face in children. The TAC formulation can be simplified by omitting tetracaine without compromising anesthetic efficacy.     

Comparing wound closure using tissue glue versus subcuticular suture for pediatric surgical incisions: a prospective,randomised trial

Tissue adhesives have gained favour for quicker and painless closure of lacerations. To compare the tissue adhesive 2-octylcyanoacrylate with our current standard subcuticular suture for closure of surgical incisions in children, looking at outcome measures of time efficiency, cosmesis, and wound complications, a prospective, randomised, controlled trial was conducted at our institution's ambulatory surgery centre. All healthy patients undergoing unilateral or bilateral herniotomies were recruited prospectively with informed consent and randomly allocated to suture or glue. The exclusion criteria were neonates or children with allergy to tissue glue. Time of wound closure was measured from the subcutaneous layer to application of the dressing. An independent, blinded observer assessed cosmesis at 2 to 3 weeks using a validated wound scale ranging from worst (0) to best (6). Parent satisfaction with wound appearance was recorded on a 100-mm visual analogue scale (VAS). A total of 59 patients were recruited into the study with 26 in the glue group and 33 in the suture group. There was no difference in mean time of closure (glue 181 +/- 62 s vs suture 161 +/- 45 s, P = 0.18). Two patients in each group had a suboptimal Hollander wound score of 5 (7.7% glue, 6.1% suture). There was also no difference in parent satisfaction (VAS: glue 78 +/- 19 mm vs suture 81 +/- 15 mm, P = 0.68). No patient reported any rash, wound infection, or dehiscence. Tissue glue is easy to use with no complications and has equivalent cosmetic results, but is not faster than a subcuticular suture.     

Perception of exercise induced asthma by children and their parents.

BACKGROUND: Exercise induced asthma (EIA) plays an important role in clinical evaluation. There has been little previous work validating EIA as reported directly by children and indirectly by their parents. AIMS: (1) To determine the strength of the association between children's symptoms of EIA and their physiological response to exercise in a laboratory setting. (2) To compare parents' perception of EIA with that of their children. (3) To seek factors influencing the perception of EIA. METHODS: Forty three asthmatic children and their parents answered a questionnaire, which included measures of symptom perception in EIA using visual analogue (VAS) and Likert scales. The children underwent a standardised treadmill exercise challenge, using spirometry to measure the physiological outcome, after which they and their parents independently completed the symptom scores. Twenty four subjects agreed to return for a second visit, in order to assess repeatability. RESULTS: The VAS and Likert scales were highly correlated. Children's symptom perception as measured by change in VAS scores related weakly to change in FEV(1) after exercise, and was unaffected by confounding factors such as age, gender, medication, and habitual exercise. Parents' perception of symptoms was unrelated to any physiological measure. There was no significant relation between parent and child VAS scores after exercise, and there was poor agreement between the Likert scale scores after exercise. The repeatability of the perception of change in FEV(1) after exercise was poor for both parents and children. CONCLUSION: Physicians should obtain reports of EIA from children rather than parents, but be aware of their limited accuracy and repeatability.     

Perception of exercise induced asthma by children and their parents

Background: Exercise induced asthma (EIA) plays an important role in clinical evaluation. There has been little previous work validating EIA as reported directly by children and indirectly by their parents. Aims: (1) To determine the strength of the association between children''s symptoms of EIA and their physiological response to exercise in a laboratory setting. (2) To compare parents'' perception of EIA with that of their children. (3) To seek factors influencing the perception of EIA. Methods: Forty three asthmatic children and their parents answered a questionnaire, which included measures of symptom perception in EIA using visual analogue (VAS) and Likert scales. The children underwent a standardised treadmill exercise challenge, using spirometry to measure the physiological outcome, after which they and their parents independently completed the symptom scores. Twenty four subjects agreed to return for a second visit, in order to assess repeatability. Results: The VAS and Likert scales were highly correlated. Children''s symptom perception as measured by change in VAS scores related weakly to change in FEV₁ after exercise, and was unaffected by confounding factors such as age, gender, medication, and habitual exercise. Parents'' perception of symptoms was unrelated to any physiological measure. There was no significant relation between parent and child VAS scores after exercise, and there was poor agreement between the Likert scale scores after exercise. The repeatability of the perception of change in FEV₁ after exercise was poor for both parents and children. Conclusion: Physicians should obtain reports of EIA from children rather than parents, but be aware of their limited accuracy and repeatability.     

Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective,randomized trial

OBJECTIVE: The purpose of this study is to compare the cosmetic outcome of scalp wound closure with staples to traditional skin sutures. METHODS: A prospective, randomized trial was conducted using a convenience sample of children (aged 1-16 y) with simple scalp lacerations admitted to the pediatric emergency department. After parental consent was obtained, patients were randomly assigned to either a stapling or suturing procedure. A trained attending physician completed the procedure following a standard protocol. Based on previously published data, a sample size of 18 patients per group was calculated to give 85% power to detect a 10% difference on a visual analogue scale (VAS) score (two-sided alpha 0.05). Initial outcome of wound healing at 7 to 10 days and final cosmetic outcome after 6 to 18 months were estimated using a VAS. Cosmetic outcome was assessed by a physician blinded to the procedure. Data were analyzed using SPSS (Version 8.02; SPSS Inc., Chicago, IL). The VAS scores for the two treatment groups were compared using the two-tailed Student t test. Analysis of age, race, mode of injury, time interval, and size of the wound were performed to estimate the strength of the association of VAS score with the treatment, adjusted for the covariates. RESULTS: A total of 42 patients were enrolled. Of the 42, 38 (90.5%) finished the initial follow-up and 31 of those 38 (81.6%) finished the final follow-up. There were no significant demographic differences between groups at recruitment and first follow-up. Among those patients who completed the final follow-up, 15 underwent stapling, and 16 underwent suturing. There were no significant demographic or baseline differences between the groups. Procedure time was significantly lower in the stapling group (P = 0.001). Final follow-up evaluations were completed in 12 +/- 4 months. The mean VAS scores at first and final follow-up were 78.75 +/- 16.16 and 96.31 +/- 8.06 for the suturing group and 86.67 +/- 9.76 and 97 +/- 7.02 for the stapling group (P = 0.17). There remained no significant difference in the final follow-up VAS score between groups when adjusted for covariates. CONCLUSION: Stapling appears to be a fast and cosmetically acceptable alternative to suturing for simple scalp lacerations.     

Pediatric pain measurement using a visual analogue scale: a comparison of two teaching methods

The goals of this study were to evaluate the validity of the visual analogue scale (VAS) for young children and to compare a newly developed method of teaching children to use a VAS with one used in our previous studies. It was hypothesized that the new method would increase the number of children who understand the VAS and correctly mark their responses on the VAS line. The association between child's age and ability to understand the VAS was also evaluated. One hundred-six children with a laceration requiring sutures and receiving a lidocaine injection for local anesthesia participated in the study. They ranged in age from 5 to 14 years. Two outcome measures were used to assess the baseline and lidocaine injection pain: a 5-point Likert scale and a VAS. A calibration study was used to determine whether the subjects were able to use the VAS to make proportional judgments about their perceptions. Teaching method had no effect on the number of subjects who could correctly mark their responses on the VAS line, nor did it significantly increase the number of subjects who could understand the concept of the VAS. Subjects who were able to understand the VAS were significantly older (mean = 9.8 years, SD = 2.8) than those who did not (mean = 8.2 years, SD = 2.5). Overall, only about one third of the subjects were able to correctly mark the VAS and understand the concept of the VAS. Other measures of pain that are better understood by young children may be more valid indicators of pain than the VAS.     

Topical anesthetics in children: agents and techniques that equally comfort patients, parents, and clinicians.

Topical anesthetics are increasingly important, as the number of outpatient surgeries for dermatologic problems in infants and children is steadily growing. This noninvasive modality of anesthetic delivery in conjunction with a reassuring environment may minimize the discomfort of otherwise painful procedures. Since the 1880s, when cocaine was first used as a topical ophthalmologic anesthetic, many ester-and amide-based local anesthetics have been developed for a variety of simple and complex procedures. The pediatric dermatologist's arsenal of topical anesthetic preparations is increasing with the development of novel vehicles of transdermal delivery and the use of anesthetics in combination. Eutectic mixture of local anesthetics is currently the most frequently prescribed topical agent, though the use of ELA-max, another lidocaine-containing preparation, is gaining momentum, especially in the neonatal population. Amethocaine, tetracaine, iontophoresis, and the S-caine patch, a product on the horizon for use in the pediatric population, also are included in this discussion.     

A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children

A randomized, prospective, double-blind study comparing three formulations of the topical anesthetic solution TAC for laceration repair was undertaken in 250 children. The children's wounds were anesthetized with either TAC I (original formulation--0.5% tetracaine, 1:2000 Adrenalin, 11.8% cocaine), TAC II (1.0% tetracaine, 1:4000 Adrenalin, 7.0% cocaine), or TAC III (1.0% tetracaine, 1:4000 Adrenalin, 4.0% cocaine) prior to repair. The solutions were compared with respect to efficacy, acceptability, wound complications, and side effects. We found comparable efficacy of the three formulations, with similar efficacy to 1% lidocaine infiltration for facial and scalp wounds. Anesthesia for extremity wounds was adequate in only 39.9% of cases, regardless of TAC strength. Wound complications and side effects were within expected and acceptable limits. Our findings support use of TAC for face and scalp lacerations and a change to a less concentrated TAC preparation, such as our "TAC III," which is presumably safer for widespread use.     

New concepts in wound management

Children with lacerations and other minor wounds are among the most often encountered in the ED. The steps in management of these patients are well-known and often well-researched, but dogma still permeates the process. Local anesthetics are effective, and several choices are available. New topical creams and expanded indications for the currently available anesthetics will enhance patient comfort during laceration cleaning and repair. Irrigation with tap water is a safe, effective and economic method of cleaning wounds, and perhaps even the use of sterile gloves is superfluous in preventing wound contamination. Several alternative wound-closure materials are currently available including tissue adhesive in an array of applicators and formulations, adhesive strips, staples, and nonabsorbable as well as absorbable suture material. Finally, prophylaxis for tetanus is a simple, if possibly underused, technique. Further research into new materials and procedures will only improve our care of patients who have sustained skin trauma.     

Efficacy of TAC topical anesthetic for repair of pediatric lacerations

A prospective evaluation of 103 consecutive children who received TAC (tetracaine, epinephrine [adrenaline], cocaine) liquid topical anesthetic for the repair of their minor dermal lacerations was performed. A unique method of TAC application was used that consisted of applying the medication to the inner margins of the wound cavity and allowing it to stand for several minutes prior to the application of a TAC-saturated gauze pad to the wound surface. Of 670 sutures placed, 637 (95%) were done without eliciting pain. The TAC topical anesthetic was more than 95% effective in providing complete anesthesia for wounds located on the face and lip; it was equally efficacious in anesthetizing larger wounds (greater than or equal to 5 cm in length and/or greater than or equal to 5 mm in depth). No adverse reactions resulted from the application of TAC. A single wound healing complication occurred in 103 patients. TAC is a safe, effective method for anesthetizing minor lacerations of the skin in children. Its painless method of application relieves patient discomfort and maximizes patient compliance during the repair procedure, both of which enhance the accurate approximation of lacerated tissue.     

Updates in wound management for the pediatrician

Lacerations are common in children, and skills in wound management, especially laceration repair, are important. The minimization of pain and anxiety should be considered an essential part of the procedure. Newer techniques using topical anesthetics and tissue adhesives have significantly simplified the process of laceration repair promoting application in office, clinic, and emergency department settings. In situations inappropriate for topical anesthesia and closure, the use of buffered lidocaine and attention to the technique of infiltration are important. Although infection is the most common complication, the percentage of lacerations, which become infected in children, is low. Antibiotic prophylaxis is seldom needed. Human and animal bites raise special concerns in the assessment for primary repair and prophylactic antibiotic use.     

Pilot evaluation of an instrument to measure quality of life in British children with inflammatory bowel disease

The IMPACT questionnaire was developed in Canada to measure quality of life in children with inflammatory bowel disease (IBD). In the present study, 20 children with IBD completed 2 versions of the IMPACT questionnaire with a Likert scale or visual analog scale (VAS), 5 of whom expressed problems with language or phrasing. Difficult words included "restrictions," "moderate," "diarrhea," "school break," and the abbreviation "IBD." Fifteen children preferred the Likert scale to the VAS (chi = 20, P < 0.01). Rewording the difficult words and using a Likert scale should facilitate completion of the IMPACT questionnaire in the United Kingdom. Further validation is needed to ensure that the instrument is reliable and valid.     

Comparison of two benzodiazepines used for sedation of children undergoing suturing of a laceration in an emergency department

OBJECTIVES: (1) To determine if oral diazepam (POD) is as effective in sedating children less than 6 years of age for laceration repair as oral midazolam (POM) or intranasal midazolam (INM); and (2) To determine if patients stayed longer in the department after sedation when given POD for sedation. DESIGN/METHODS: Block-randomized, single-blind trial. SETTING: Tertiary pediatric emergency department. PARTICIPANTS: Patients 1 to 5 years old with a laceration requiring sutures were enrolled. INTERVENTIONS: All patients had topical anesthetic applied to the wound and were randomly assigned to POD 0.5 mg/kg, POM 1.0 mg/kg, or INM 0.4 mg/kg for sedation. RESULTS: One hundred twenty-nine patients were enrolled, 42 POD, 45 POM, and 42 INM. Each group was similar at baseline for age, heart rate, respiratory rate, blood pressure, oxygen saturation, previous laceration or sedation, anxiety score, and site of laceration. POM and POD were better tolerated than INM (P = 0.05 and 0.034), respectively. Time to sedation was significantly longer in POD (31.0 +/- 9 min) than INM (26.1 +/- 9 min) (P = 0.011) but there was no significant difference when comparing the other groups. However, this difference was not clinically significant. POD was significantly worse at sedating children compared with POM and INM on all four scores (ie, doctor, nurse, parent, and investigator), but INM and POM were equivalent. Total time in the department was no different between POM and INM or POM and POD, but was significantly different for POD (53.9 +/- 16 min) and INM (48 +/- 12 min); however, this difference was minimal. More patients were said to be drowsy at home in the POM group (51%) than the POD group (32%). CONCLUSIONS: The oral route of delivery of POM and POD was better tolerated than INM. POM and INM were more effective at sedation than POD, but there was no clinical difference between any groups for time to sedation or time to discharge. More patients in the POM group had side effects after leaving the department. POD may be an alternative to POM, but a higher dose may be required, possibly with longer recovery times.     

Parent visual analogue scale ratings of children's pain do not reliably reflect pain reported by child

OBJECTIVES: To determine whether parent and child visual analogue scale (VAS) scores for the pain associated with acute conditions in the child agree sufficiently for these methods of measurement to be considered interchangeable in pain and analgesia research. DESIGN: This was a prospective, two-group, repeated measures, blinded study in an urban pediatric emergency department. Children aged 8 to 15 years seeking treatment for painful conditions and the parents of these children were asked to rate the child's pain independently using a VAS on as many as four occasions at 20-minute intervals. Both participants were blinded to their previous rating and the rating of the other participant. The main outcome measure was the correlation of child and parent VAS pain scores by Pearson correlation and bias plot (Bland-Altman) analysis of agreement between tests. RESULTS: Seventy-eight child-parent sets participated, yielding 289 VAS pain score comparison pairs for evaluation. The correlation between child and parent VAS pain scores was 0.63 (95% CI, 0.56-0.70). Bias plot analysis revealed a bias of 5% and 95% limits of agreement from -38 to +47 mm. The degree of difference between child and parent scores was variable, but there was an increasing tendency for parents to underestimate the child's pain when the child recorded VAS pain scores at the higher end of the scale. CONCLUSIONS: Parents' VAS score ratings of their children's pain correlate only moderately with the children's VAS pain scores and show poor levels of agreement. The difference between the measures is variable and appears to be more marked when the child reports a higher VAS score. This research raises doubt about whether parental rating of a child's pain is an appropriate surrogate marker in pediatric pain and analgesia research.     

Comparing two methods of topical anesthesia used before intravenous cannulation in pediatric patients.

INTRODUCTION: The purpose of this study was to compare the efficacy of two methods of topical anesthesia before venipuncture or intravenous cannulation of pediatric patients to assess which type of topical anesthetic would better alleviate pain in the least amount of time with the greatest success rate of cannulation. METHODS: This study was a randomly controlled trial of 100 preoperative pediatric patients aged 5 to 21 years. The following methods of topical anesthesia were compared: (a) iontophoresis of a topical solution of 2% lidocaine with epinephrine 1:100,000 using a Phoresor Dose Controller (PDC) with Numby Stuff electrodes and a eutectic mixture of local anesthetic and (b) 2.5% lidocaine and 2.5% prilocaine (eutectic mixture of local anesthetics [EMLA] cream). RESULTS: Children reported less pain with iontophoresis (M = 0.08) compared with EMLA cream (M = 1.88, P < .001). Time to accomplish topical anesthesia was shorter with iontophoresis (13 minutes) compared with EMLA cream (60 minutes, P < .001). Failure to accomplish venipuncture occurred 5 times with the iontophoresis method and 8 times with the EMLA method (not significant). No dermal burns resulted from use of iontophoresis. DISCUSSION: We conclude that use of iontophoresis in pediatric patients is safe, rapid, and significantly more effective than is EMLA cream in reducing pain associated with venipuncture or intravenous cannulation.