Pain perception and effectiveness of the eutectic mixture of local anesthetics in children undergoing venipuncture.

The emulsion of lidocaine and prilocaine (EMLA) is effective in preventing the pain of venipuncture in children. It is therefore important to identify children who could benefit the most from EMLA. We studied the safety and feasibility of two methods of application of EMLA (patch and cream) in a randomized, open-label trial of EMLA patch versus EMLA cream in 160 children with chronic diseases undergoing venipuncture. EMLA patch or cream was applied 60 to 120 min before puncture. Pain was assessed by the children using a visual analogue score. Children also scored the pain of their last puncture and the pain of removing the tape. EMLA patch and cream had similar efficacy (visual analogue scores for the venipuncture were 8.5 +/- 16 and 9.5 +/- 17 out of 100, respectively). Side effects occurred in similar frequencies in the two groups. Adhesiveness of the patch was less effective than that of the cream with Tegaderm. Age was a major determinant of pain perception; younger children recalled more severe pain in their previous puncture. Children recently diagnosed had higher visual analogue scores than those with a long history of chronic disease. We concluded that EMLA patch and cream have a similar efficacy in children undergoing venipuncture. Young children recently diagnosed with chronic disease are most likely to benefit from EMLA.     

A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns

OBJECTIVE: To determine the efficacy of a topical anesthetic cream, eutectic mixture of local anesthetics (EMLA), in alleviating pain associated with lumbar puncture in newborns. DESIGN: Randomized double-blind placebo-controlled trial. SETTING: Neonatal intensive care unit of a university teaching hospital.Patients Sixty consecutive newborns (gestational age, >or=34 weeks) undergoing diagnostic lumbar puncture.Intervention Topical application of 1 g of EMLA or placebo 60 to 90 minutes before lumbar puncture. MAIN OUTCOME MEASURES: Heart rate, transcutaneous oxygen saturation level, and total behavioral score recorded on a video camera and graded according to the Neonatal Facial Coding System. RESULTS: Compared with baseline, all newborns experienced pain as evidenced by increased heart rate, decreased oxygen saturation level, and total behavioral score (all within-groups differences were significant using repeated-measures analysis of variance; P<.001) during the procedure. Compared with placebo, EMLA significantly attenuated the pain response as shown by a lower mean +/- SE heart rate (per minute), particularly at needle insertion (EMLA: 159.3 +/- 2.3; placebo: 175.2 +/- 2.7; P<.001) and needle withdrawal (EMLA: 153.8 +/- 2.6; placebo: 167.3 +/- 2.5; P<.001), and a lower mean +/- SE total behavioral score, again at insertion (EMLA: 4.0 +/- 0.3; placebo: 5.0 +/- 0.0; P =.004) and withdrawal (EMLA: 1.8 +/- 0.3; placebo: 3.9 +/- 0.3; P<.001). There was no statistically significant difference between groups with regard to oxygen saturation level. CONCLUSIONS: Lumbar puncture in newborns produces pain responses. Eutectic mixture of local anesthetics is an efficacious agent for reducing the pain associated with needle insertion and withdrawal during lumbar puncture in newborns.     

Practical use of local anesthetics in children]

Simple techniques of local analgesia applicable in children either in the medical office or in the emergency room by non-specialist practitioners are described: infiltration of the skin, topical anaesthesia of the skin, whether intact or damaged, topical anaesthesia of the mucosae.... In addition safety rules, early signs and treatment of local anaesthetics intoxication are underlined.     

Methemoglobinemia in an infant receiving nitric oxide after the use of eutectic mixture of local anesthetic

High levels of methemoglobinemia can cause tissue hypoxia and cyanosis. We report the case of a 7-month-old girl with pulmonary dysplasia receiving inhaled nitric oxide who had cyanosis caused by methemoglobinemia after prolonged use of a eutectic mixture of local anesthetics cream.     

Randomised controlled trial of eutectic mixture of local anaesthetics cream for venepuncture in healthy preterm infants

AIM—To assess the safety and efficacy of EMLA cream (eutectic mixture of local anaesthetics) used to induce surface anaesthesia for venepuncture in healthy preterm infants.METHODS—Nineteen infants, median gestational age 31 weeks (range 26-33 weeks) were assessed in a randomised, double blind, placebo controlled, cross-over trial. Changes in physiological variables (heart rate, blood pressure, oxygen saturation) and behavioural responses (neonatal facial coding system score, crying time) before and after venepuncture with EMLA cream were compared with those obtained with a placebo cream to assess efficacy. Toxicity was assessed by comparing methaemoglobin concentrations at 1 hour and 8 hours after application.RESULTS—There was no significant difference in efficacy between EMLA and placebo creams in physiological and behavioural responses. There was no significant difference in methaemoglobin concentrations one hour after the cream had been applied. At eight hours, however, concentrations were significantly higher after EMLA than placebo (p=0.016). There was no evidence of clinical toxicity.CONCLUSION—This study does not support the routine use of EMLA for venepuncture in healthy preterm infants.     

Effect of the specific infant formula mixture of oligosaccharides on local immunity and development of allergic and infectious disease in young children: randomized study

Aim

The aim of our open prospective randomized nutritional intervention study was to evaluate the effect of feeding with a standard infant formula enriched with the specific mixture of oligosaccharides on local digestive immunity system and further development of allergic and infectious diseases in young children.

Material and methods

Depending on the type of feeding the infants were divided into 3 groups (with random allocation to one of the formula feeding groups): 80 infants who were breastfed, 80 infants consuming the formula supplemented with oligosaccharides, 80 infants fed with a standard formula.

Results

Breastfed infants had the highest content of Bifidobacteria and Lactobacilli in feces (9.047 ± 1.075 and 7.26 ± 0.65 CFU/g accordingly). In infants fed with formula supplemented with scGOS/lcFOS fecal concentrations of Bifidobacteria and Lactobacilli were similar to those in breastfed infants (8.92 ± 1.011 and 7.22 ± 0.74 CFU/g accordingly). It was found that infants fed with breast milk and supplemented formula had significantly less allergic reactions to food products compared to the babies from the third group (3.92% and 4.84% vs. 16.98% accordingly; p < 0,05).

Conclusions

The mixture of prebiotic oligosaccharides (scGOS/lcFOS – 9:1; 8 g/L) has a similar to breast milk positive impact on the factors of local digestive immunity system in formula-fed infants. This effect may reduce the risk of allergic and infectious diseases in children aged up to 18 months of life, compared with babies fed with the standard formula without oligosaccharides.     

Loss of anatomical landmarks with eutectic mixture of local anesthetic cream for neonatal male circumcision

We report two cases of newborns who developed marked local edema after application of a eutectic mixture of local anesthetic (EMLA) topical anesthetic cream for neonatal male circumcision (NMC). Although local edema and erythema are known potential side effects of EMLA cream, a common anesthetic used for NMC, the loss of landmarks precluding safe NMC has not previously been reported, and is described here. Although we cannot recommend an alternate local anesthetic for neonates with this reaction to EMLA, based on a review of the published data we think that serious systemic adverse events related to EMLA are extremely rare.     

Safety of lidocaine-prilocaine cream application four times a day in premature neonates: a pilot study

Although safety is established for lidocaine-prilocaine cream application to the heel once a day in neonates, it is often necessary to repeat heel lances several times a day in the clinical situation. A pilot safety study applying 0.5 g lidocaine-prilocaine cream to the heel covering an area of 5 cm² with an occlusive dressing during 30 min four times a day was carried out. Twelve neonates (5 male, 7 female) with a gestational age of 30.1–36.3 weeks (mean 31.6 weeks) and a birth weight of 1100–2910 g (mean 1665 g) were enclosed. To establish safety, methaemoglobin levels and plasma concentrations of lidocaine, prilocaine and o-toluidine were measured until 24 h after the final application. Methaemoglobin levels were no different from baseline measurements, ranging from 0.2–1.1% and 0.1–0.7% respectively. Plasma concentrations of lidocaine and prilocaine were very low, maxima at 0.230 and 0.223 mg/l respectively. Plasma o-toluidine concentrations remained below the detection limit (0.025 mg/l). Conclusion Application of 0.5 g lidocaine-prilocaine cream to the heel under occlusion four times a day during 30 min is safe in preterm neonates. Establishing safety by measuring the methaemoglobin level by daily application is recommended. Received: 14 April 1998 / Accepted in revised form: 29 October 1998     

Remifentanil in neonatal intensive care and anaesthesia practice

Remifentanil is a relatively new ultrashort action synthetic opioid. Studies on the use of remifentanil in neonatology have emerged demonstrating its effectiveness and safety in neonates. The present study describes the use of remifentanil in both full‐term and premature newborns, highlighting the theoretical benefits for this population in terms of both neonatal intensive care and anaesthesia. A Medline search was undertaken of all reviews and reports about the use of remifentanil in neonates published between 1996 and 2009 using MeSH search terms ‘remifentanil’, ‘analgesia’, ‘anaesthesia’, ‘newborn’ and ‘neonate’. The review points that remifentanil has been used with advantages in newborns including preterm neonates and even for foetal anaesthesia. It proved to be a good option to attenuate the hemodynamic/endocrine markers of stress related to surgery. Owing to its unique pharmacokinetic profile, shorter extubation times can be achieved what makes the drug also a good option for short duration invasive procedures in NICUs (InSurE). A concern on its use is that the hemodynamic response (hypotension) may become significant when the drug is associated to other drugs like sevoflurane. Conclusion: Remifentanil seems to be an effective and safely used opioid for neonatal intensive care and anaesthesia practice.     

非营养性吸吮联合音乐治疗对新生儿疼痛的缓解作用

目的观察非营养性吸吮（NNS）、音乐治疗（MT）及非营养性吸吮联合音乐治疗(NNS+MT)在缓解新生儿疼痛中的作用。方法收集2008年1～6月在南京医科大学附属南京儿童医院新生儿医学中心普通新生儿病房收治的新生儿作为研究对象，对符合纳入和排除标准的新生儿按照住院号从小到大顺序分为干预组（NNS亚组、MT亚组、NNS+MT亚组）和空白对照组，干预措施在新生儿足后跟采血前2 min开始持续至研究结束，共15 min，空白对照组不予干预措施。通过观察新生儿的心率、经皮氧饱和度（SpO2）及新生儿疼痛行为（NIPS）评分，采集采血针刺前1 min、针刺时和针刺后13 min过程中的每一分种数据，比较各种干预措施缓解新生儿疼痛的临床效果。采用SPSS 11.0软件进行多变量方差分析，ANOVA方差检验，同时应用Post Hoc进行组间比较。结果纳入住院新生儿80例，男54例，女26例；各亚组和空白对照组各20例。疼痛刺激后各组的心率均显著加快，于刺激后0～2 min达峰值，之后逐渐减慢；NNS亚组与空白对照组心率差异无统计学意义，MT、NNS+MT亚组与空白对照组心率差异均有统计学意义，MT亚组和NNS+MT亚组心率差异无统计学意义。疼痛刺激后各亚组SpO2均显著降低，于刺激后2～4 min降至最低值，之后逐渐升高；NNS亚组与对照组SpO2差异无统计学意义，MT、NNS+MT亚组与空白对照组SpO2差异均有统计学意义，MT亚组和NNS+MT亚组SpO2差异无统计学意义。疼痛刺激后各组NIPS评分均显著提高,于0~1 min达峰值,之后逐渐降低，各亚组NIPS评分差异均无统计学意义。与空白对照组比较，MT、NNS+MT干预措施均可缓解疼痛刺激引起的心率、SpO2和NIPS评分变化。结论新生儿临床医护人员可通过使用MT和NNS+MT可缓解新生儿疼痛。     

A practical approach to hemophilia care in children

Hemophilia A and B are the most common of the severe bleeding disorders. The present article focuses on the practical aspects of the management of neonates and children diagnosed with hemophilia, and is based on questions frequently posed to paediatric hematologists. It highlights the importance of early diagnosis, the principle of early intervention and the role of comprehensive care hemophilia treatment centres.     

Effect of gender and hand laterality on pain processing in human neonates

Background

Previous studies in adults have reported that handedness and gender can affect pain perception. However, it is currently unclear when these differences emerge in human development. Therefore, we examined prefrontal responses to pain stimulation among newborns during their first acute pain experience after birth.

Methods

Forty newborns at 4-6 days postnatal age were observed during clinically required blood sampling while prefrontal activation was measured with near infrared spectroscopy. Blood sampling in this study was the first experience of a procedure involving skin breaking for these infants. We divided subjects into a right-hand stimulation group (n = 21) and a left-hand stimulation group (n = 19), depending on whether blood was sampled from the right or the left hand. A three-way analysis of variance (ANOVA) was conducted to examine the effects of several variables on the magnitude of the oxy-Hb value in response to pain stimulus, including stimulus side (right hand or left hand), gender (male or female), recording side (right prefrontal area or left prefrontal area) and interactions between these variables.

Results

The data revealed a significant effect of stimulus side (F (1, 72) = 9.892, P = 0.002), showing that the right-hand stimulation induced a greater prefrontal activation than the left-hand stimulation. No significant gender difference or interactions were found.

Conclusion

Our findings suggest that hand laterality affects pain perception even in neonates. However, gender differences in pain perception did not appear to occur during the neonatal period. Further investigations using brain-imaging techniques are required to identify laterality- or gender-related differences in pain processing in humans.     

Percutaneous catheterization in newborn infants and older children

Summary Between 1966 and 1977 we performed percutaneous venous or arterial catheter insertions in 174 newborn infants and other children. Insertion was successfully completed in all but three. Catheterization, using the same vessels, was repeated in 13 patients between four days and three months later. Peripheral arterial pulses remained palpable in all patients, but in one instance a broken catheter tip embolized into the posterior tibial artery. Vascular complications and unsuccessful insertion of the catheter were avoided in a high percentage of cases by careful attention to detail.     

Recurrent pain symptoms in children and parents

Recurrent pain in five different areas (stomach, arms & legs, head, back and neck & shoulders) in a population of 348 school children and their parents has been investigated. The study presented here is restricted to 229 mother-father-child trios. Forty-four percent of the children reported pain in at least one area compared to 60% of the mothers and 51% of the fathers. Headache and pains in arms and legs were most common in boys. The most frequent pain sites for girls were head and back. Overall, girls complained more than boys. No significant associations between complaints in parents and their children were demonstrated, analysed by logistic regression analysis. Furthermore, there was no significant association between the reported pain in the mother and father. Conclusion: Children's pain did not associate with parental pain in this study.The results do not support previous hypotheses that recurrent pain clusters in families.