Trial of a topically administered local anesthetic (EMLA cream) for pain relief during central venous port accesses in children with cancer

Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline

BACKGROUND

Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress.

METHODS

Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents.

RESULTS

The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.

CONCLUSION

In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.

Reducing pain in children with cancer: Methodology for the development of a clinical practice guideline

Although pain is one of the most prevalent and bothersome symptoms children with cancer experience, evidence-based guidance regarding assessment and management is lacking. With 44 international, multidisciplinary healthcare professionals and nine patient representatives, we aimed to develop a clinical practice guideline (following GRADE methodology), addressing assessment and pharmacological, psychological, and physical management of tumor-, treatment-, and procedure-related pain in children with cancer. In this paper, we present our thorough methodology for this development, including the challenges we faced and how we approached these. This lays the foundation for our clinical practice guideline, for which there is a high clinical demand.

Effects of Distraction on Pain, Fear, and Distress During Venous Port Access and Venipuncture in Children and Adolescents With Cancer

This study evaluates the effect of self-selected distracters (ie, bubbles, I Spy: Super Challenger book, music table, virtual reality glasses, or handheld video games) on pain, fear, and distress in 50 children and adolescents with cancer, ages 5 to 18, with port access or venipuncture. Using an intervention-comparison group design, participants were randomized to the comparison group (n = 28) to receive standard care or intervention group (n = 22) to receive distraction plus standard care. All participants rated their pain and fear, parents rated participant fear, and the nurse rated participant fear and distress at 3 points in time: before, during, and after port access or venipuncture. Results show that self-reported pain and fear were significantly correlated (P = .01) within treatment groups but not significantly different between groups. Intervention participants demonstrated significantly less fear (P <.001) and distress (P = .03) as rated by the nurse and approached significantly less fear (P = .07) as rated by the parent. All intervention parents said the needlestick was better because of the distracter. The authors conclude that distraction has the potential to reduce fear and distress during port access and venipuncture.

Pain reduction in children during port-à-cath catheter puncture using local anaesthesia with EMLA™

INTRODUCTION

Alleviating pain is of high importance for children undergoing chemotherapy. Eutectic mixture of lidocain-prilocain cream (EMLA) is assumed to require 60 min application time.

MATERIALS AND METHODS

We prospectively compared the pain during port-à-cath punctures after 40 min compared to 60 min of application time. A prospective, unblinded, cross-over study was performed. The children received two punctures during their chemotherapy protocol. Patients in group 1 had the first puncture after 40 min EMLA application time. Their second puncture (approximately a week later) was done after 60 min. Patients in group 2 started after 40 min. Pain was scored using the visual analogue scale (VAS) and the Bieri scale. Patients, parents and a nurse scaled the pain after the intervention. Eighty-seven children between 2 and 18 years with different malignant diseases were included.

RESULTS AND DISCUSSION

On the VAS pain scale, the mean pain was 2.3 (minimum 0, maximum 9.2) after 40 min and 1.9 (minimum 0, maximum 9.4) after 60 min according to the observations of the nurse and very similarly according to the parents' observations. The children expressed more pain after 40 min of EMLA application time (mean pain, 3.5) and a significant pain reduction after 60 min application time (mean pain 1.7).

CONCLUSION

In this study children experienced less pain after 60 min application time, but pain reduction was already seen after 40 min. The child's perception of pain differed from observers' point of view and should therefore always be included in pain management.

Pain, distress, and adult-child interaction during venipuncture in pediatric oncology: an examination of three types of venous access

This study examined pain and distress from needles in children undergoing blood sampling as a function of adult-child interaction and type of venous access (i.e., central external venous lines, internalized ports, or peripheral access via venipuncture). Participants were 55 pediatric oncology patients, aged 3-18 years, who were undergoing routine blood work. Pain ratings were obtained using the Faces Pain Scale-Revised (FPS-R) and conversation during the procedure was audio taped for coding using the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R). Children's ratings of pain using the FPS-R were similar in the port (M=2.57/10, standard deviation [SD]=3.46) and peripheral (M=2.56/10, SD=3.24) groups, despite the fact that most children with internal ports were given a topical anesthetic. Similarly, there were no differences between port and peripheral groups in rates of child coping or distress, or parent and nurse observations of child pain. As would be expected, external line access was not associated with pain or distress, even among very young children, suggesting that they appropriately understood the pain rating scale. Results of the transcribed CAMPIS-R data indicate that the influences in adult-child interaction are bidirectional. Support was found for the well-established positive relationship between child distress and adult reassurance and empathy. Implications for intervention and selection of central venous access devices are discussed.

Cancer pain management in children

Unrelieved pain may have a major impact on the care of children with cancer. The type and severity of pain experienced by children with cancer varies from acute, procedure-related pain to progressive chronic pain associated with the progression of the disease or sequelae of treatment. Drugs are the mainstay of treatment. Regular pain assessments combined with appropriate analgesic administration at regular dosing intervals, adjunctive drug therapy for control of adverse effects and associated symptoms, and nonpharmacological interventions are recommended. Although standard dosing of opioids adequately treats most cancer pain in children, more complex treatment is required by a significant group. Strategies to improve analgesia include the use of epidural or intrathecal infusions of a combination of opioids and other adjuvants, or other regional anaesthesia techniques. Procedure- and treatment-related pain is an even greater problem than cancer pain. Recommendations have been published with regard to the monitoring and personnel required when children are sedated which aim to set the standard of care and minimize both physical discomfort or pain and negative psychological responses, by providing analgesia; and to maximize the potential for amnesia; and to control behaviour.

The management of pain in the oncology patient

The treatment of cancer pain is improving, but pain remains a significant problem. Although better analgesics with greater efficacy and fewer side effects are needed, the most significant problem regarding the appropriate management of cancer pain remains a lack of knowledge among physicians treating cancer patients. Cancer management should be undertaken within a palliative care model, in which autonomy and respect for individuals and their families guides all aspects of care.

Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines

The growing abundance of highly immunogenic vaccines has arrived with a burden of pain, distress, and common adverse reactions that in turn may interfere with parental compliance and aggravate anti-vaccine sentiment. In a study of 150 children in each of 2 age-groups, we found that approximately 20% of the subjects suffered serious distress or worse. During the procedural phase, approximately 90% of the 15-to-18 month old children and 45% of the 4-to-6 year old children showed serious distress or worse. To address non-adherence with pediatric vaccine schedules, we must consider all of the possible issues that might prevent a parent from taking a child to a health care provider for vaccination. In that same study we identified useful predictors for both preparatory and procedural distress - predictors that might be used in identifying children who might benefit from preventive interventions. Vaccine providers might consider a variety of interventions. Attitude, empathy, instruction, and practice have all been shown to have a salutatory effect upon pain and anxiety with medical procedures in general and specifically with vaccinations. Distraction has also been found to be an effective method for distress and pain prevention in children. More formal methods of clinical hypnosis which combine a deep state of relaxation with focused imagery and suggestion have also been found to be effective in helping children and adolescents prepare for, cope with, and tolerate the pain and anxiety associated with medical procedures. So-called 'sugar nipples' delivering small amounts of sucrose orally at the time of a painful procedure in an infant has been not been shown to decrease vaccination pain and studies on refrigerant topical anesthetics are mixed. Studies have found a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) effective in providing adequate local anesthesia in children, but it suffers from problems in practical application. Studies with various injection techniques have not identified ready solutions, and although jet injection appears to provoke less anxiety and cause less immediate pain, studies also indicate a somewhat greater incidence of delayed local reactogenicity including soreness and edema. Other measures to prevent or rapidly treat other common adverse events have been shown effective and should be considered as well.

Pharmacologic pain management in children: a review of intervention research

In the past decade, an explosion of interest in pediatric pain has resulted in the proliferation of research studies. This review examines 41 studies that focus on pharmacologic interventions in children during the last decade. Criteria for inclusion in this paper were studies that (1) tested a pharmacological intervention prospectively, (2) were conducted with children only, (3) had a sample size over 30, (4) randomly assigned participants to two or more groups, and (5) provided sufficient methodological and statistical detail for critique. Studies focused on postoperative and procedural pain, were conducted most frequently with pre-school-aged children or older, and demonstrated the efficacy of pharmacologic interventions.

Topical application of lidocaine-prilocaine (EMLA) cream reduces the pain of intramuscular infiltration of saline solution

OBJECTIVE

Intramuscular injections may be painful. Some of this pain may be caused by the infiltration of medication into the muscle, separate from the pain of skin puncture. We hypothesized that topical application of lidocaine/prilocaine (EMLA) cream would reduce the pain of intramuscular infiltration.

METHODS

A double-blinded, placebo-controlled study was performed in 40 adult volunteers to compare the pain of needle puncture and of infiltration of saline into the deltoid muscle after application of EMLA cream or placebo. Each subject served as his or her own control. Pain scores were obtained by using a 100 mm visual analog scale (VAS).

RESULTS

Pain associated with needle puncture was significantly reduced by EMLA cream as compared with placebo (median VAS score, 7.5 vs 19.5; p = 0.0043), as was pain associated with intramuscular infiltration (median VAS score, 2.5 vs 11; p < 0.00005).

CONCLUSIONS

Our results suggest that further clinical studies of EMLA cream for modifying perceived pain from intramuscular injection in children are warranted.

The silent ones: a review of sampling issues and biases pertinent to the area of pediatric oncology procedural pain

Pain related to procedures for pediatric oncology patients is a salient topic. Although these procedures can cause much distress, this area has been neglected in research. Previous research has suffered from serious sampling problems, such as using small, nonrepresentative, biased samples. In addition, little is known about the influence of sociocultural factors on the phenomena of pain in children. This article presents the results of a review of the past 10 years of pertinent literature, argues that sociocultural influences on pain need to be studied, and offers suggestions for improving sampling designs.