Topical 4% amethocaine gel reduces the pain of subcutaneous measles-mumps-rubella vaccination

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS)

PROBLEM

Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use.

ELIGIBILITY CRITERIA

Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included.

SAMPLE

Twenty-eight studies (8 psychometric and 20 RCTs) were included.

RESULTS

Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS.

CONCLUSIONS

It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children.

IMPLICATIONS

Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

Evaluation of the anesthetic effect of nasal mucosa with tetracaine 0.5% on hemodynamic changes and postoperative pain of septoplasty: A randomized controlled trial

The nasal septum repair surgery is the dangerous operations that any stimulation of this area causes a large change in the rhythm of the heartbeat and blood pressure. This study aimed to determine the effects of tetracaine 0.5% on changes in heartbeat and heart rhythm, hemodynamic changes during surgery, intraoperative bleeding, and pain after septoplasty surgery. The irregular double-blind clinical trial registry of clinical trials Iran with the code number (IRCT: 20150526625N8) in the first half of 2013 on 86 patients in Kashani hospital of Shahrekord. Having selected and matched the patients were divided into two groups. Case group was dropped tetracaine 0.5% in each of the nasal cavity 15 min before the beginning of the operation. The control group was dropped distilled water 15 min preoperation in each of the nasal cavity. The surgery lasted about 30-60 min. Clinical symptoms were evaluated after anesthetic induction as well as pain using the visual analog scale after the operation, in the recovery room. The collected data were analyzed using SPSS version software 17 through independent t-test, Chi-square, and repeated measures variance analysis. Postoperative pain intensity in the experimental group compared to the control group was significantly lower than the control group (P < 0.05); however, blood pressure and heart rate during anesthesia, there was no difference between groups (P > 0.05). Based on the findings, intake of tetracaine drop 0.5% has no impact on some hemodynamic changes during septoplasty operation. However, compared with the control group, pain was significantly reduced.

Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-Analysis

BACKGROUND

This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan.

DESIGN/METHODS

Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI).

RESULTS

Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD -1.78 (CI, -2.35, -1.22) and (2) before vaccination (n=100): SMD -1.43 (CI, -2.14, -0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD -0.91 (CI, -1.36, -0.47) and self-reported pain in adults (n=60): SMD -0.85 (CI, -1.38, -0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD -0.76 (CI, -1.19, -0.34) or glucose (n=818): SMD -0.69 (CI, -1.03, -0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD -0.78 (CI, -1.08, -0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone.

CONCLUSIONS

Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

The Effects of Instrumental Touching on Infant Pain Perception and the Effects of Eutectic Mixture of Local Anesthetics (EMLA) on the Reduction of Pain

Background:

Premature infants, who have to spend the first week of their lives in neonatal intensive care units (NICUs), experience pain and stress in numerous cases, and they are exposed to many invasive interventions. The studies have shown that uncontrolled pain experienced during early life has negative and long-term side effects, such as distress, and such experiences negatively affect the development of the central nervous system

Objectives:

The purpose of the study was to examine the effects of touching on infant pain perception and the effects of eutectic mixture of local anesthetic (EMLA) on the reduction of pain.

Patients and Methods:

Data for the study were collected between March and August 2012 from the neonatal clinic of a university hospital located in eastern Turkey. The population of the study consisted of premature infants who were undergoing treatment, completed the first month and who were approved for Hepatitis B vaccine. The study consisted of two experimental groups and one control group. Information forms, intervention follow-up forms, and Premature Infant Pain Profile (PIPP) were used to collect the data. EMLA cream was applied on the vastus lateralis muscles of the first experimental group before the vaccination. The second experimental group was vaccinated by imitation (placebo), without a needle tip or medicine. Vaccination was carried out using instrumental touch in this group. A routine vaccination was applied in the control group.

Results:

Mean pain scores of the group to which EMLA was applied were lower in a statistically significant way (P < 0.05) compared to the pain scores of the other groups. Moreover, it was determined that even though invasive intervention was not applied to the newborns, the touching caused them to feel pain just as in the placebo group (P < 0.005).

Conclusions:

The results demonstrated that EMLA was an effective method for reducing pain in premature newborns, and the use of instrumental touch for invasive intervention stimulated the pain perception in the newborns.

Cortical activity evoked by inoculation needle prick in infants up to one-year old

Inoculation is one of the first and most common experiences of procedural pain in infancy. However, little is known about how needle puncture pain is processed by the central nervous system in children. In this study, we describe for the first time the event-related activity in the infant brain during routine inoculation using electroencephalography. Fifteen healthy term-born infants aged 1 to 2 months (n = 12) or 12 months (n = 5) were studied in an outpatient clinic. Pain behavior was scored using the Modified Behavioral Pain Scale. A distinct inoculation event-related vertex potential, consisting of 2 late negative-positive complexes, was observable in single trials after needle contact with the skin. The amplitude of both negative-positive components was significantly greater in the 12-month group. Both inoculation event-related potential amplitude and behavioral pain scores increased with age but the 2 measures were not correlated with each other. These components are the first recordings of brain activity in response to real-life needle pain in infants up to a year old. They provide new evidence of postnatal nociceptive processing and, combined with more traditional behavioral pain scores, offer a potentially more sensitive measure for testing the efficacy of analgesic protocols in this age group.

Distress regulation in infancy: attachment and temperament in the context of acute pain

OBJECTIVE

The relationship between attachment, temperamental fear, and pain-related distress was examined in a sample of 130 caregiver-infant dyads to explore the differential susceptibility hypothesis.

METHOD

Infant distress was measured during routine immunization at 12 months, and attachment and temperamental fear were measured at 12 to 18 months (meanage = 13.74, SD = 1.35) using the Strange Situation Procedure and parent-rated Infant Behavior Questionnaire-Revised, respectively.

RESULTS

Immediately before immunization, avoidant infants exhibited significantly less distress than secure infants. Temperamental fear moderated the relationship between attachment and regulation; under conditions of high temperamental fear, avoidant infants regulated distress more slowly than secure infants, whereas under conditions of low temperamental fear, secure infants regulated distress more slowly than avoidant and disorganized infants.

CONCLUSION

The findings suggest that attachment interacts with extremes in temperamental fear to produce differences in the regulation of distress. The results partially support the differential susceptibility hypothesis.

Effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients

The aim of this study was to investigate the effect of external cold and vibration stimulation via Buzzy on the pain and anxiety level of children during peripheral intravenous (IV) cannulation. This study was a prospective, randomized controlled trial. The sample consisted of 176 children ages 7 to 12 years who were randomly assigned to two groups: a control group that received no peripheral IV cannulation intervention and an experimental group that received external cold and vibration via Buzzy. The same nurse conducted the peripheral IV cannulation in all the children, and the same researcher applied the external cold and vibration to all the children. The external cold and the vibration were applied 1 minute before the peripheral IV cannulation procedure and continued until the end of the procedure. Preprocedural anxiety was assessed using the Children's Fear Scale, along with reports by the children, their parents, and an observer. Procedural anxiety was assessed with the Children's Fear Scale and the parents' and the observer's reports. Procedural pain was assessed using the Wong Baker Faces Scale and the visual analog scale self-reports of the children. Preprocedural anxiety did not differ significantly. Comparison of the two groups showed significantly lower pain and anxiety levels in the experimental group than in the control group during the peripheral IV cannulation. Buzzy can be considered to provide an effective combination of coldness and vibration. This method can be used during pediatric peripheral IV cannulation by pediatric nurses.

Vaccination Related Pain: Comparison of Two Injection Techniques

OBJECTIVE

To compare the acute pain response during immunization in infants using a slow "standard" injection technique vs. "pragmatic" technique.

METHODS

In this randomised controlled trial, source of data were 200 healthy infants of age group 6 wk to one and half years, receiving routine intramuscular vaccination. They were divided randomly using computer generated random numbers into 'Standard group' receiving immunization using standard slow technique with aspiration and 'Pragmatic group' receiving immunization using "pragmatic" technique without aspiration. The entire vaccination procedure was videotaped. Videos were scored for pain using modified behavioral pain scale (MBPS) by 2 clinical psychologists and the mean score was considered for analysis. Pain was scored within 15 s of the immunization, were measured and described the child's maximal pain response to the injection. Cry time was measured by a different person from the start of cry till it ends. Entire data was entered in a preformed proforma. The Z test for two sample population means was used for statistical analysis.

RESULTS

Standard technique of vaccination needs longer time to administer (5-10 s) when compared to pragmatic technique (1-2 s). Mean post vaccination MBPS in standard group was 8.4 (SD - 0.75) and in pragmatic group was 7.8 (SD - 1.17) which was statistically significant (p - 0.00). Mean crying duration in pragmatic group was less (32.1 s) than standard group (37.37 s).

CONCLUSIONS

The "standard" slow technique was significantly more painful and took longer to administer than the "pragmatic" rapid technique. Cry duration is lesser in pragmaticgroup than standard group, but it is statistically not significant.

Toy-mediated distraction: clarifying the role of agent of distraction and preneedle distress in toddlers

BACKGROUND

Distraction has recently gained attention as a technique that may help reduce acute pain in infants and toddlers; however, results remain equivocal. It appears that these mixed results stem from a variety of methodological differences with regard to how distraction is implemented.

OBJECTIVES

To offer more definitive conclusions regarding the efficacy and mechanisms of distraction for pain management during infancy. Specifically, the goal was to examine whether the agent of distraction (i.e., the specific person conducting the distraction) and preneedle distress behaviours impact the efficacy of distraction when toddlers were held by parents.

METHODS

A total of 99 toddlers were randomly assigned to one of three conditions (typical care, research assistant-directed distraction or parent-directed distraction). Toddler distress behaviours were assessed pre- and postneedle. Toddlers were further grouped according to distress behaviours preneedle (low⁄no distress versus high distress). Parental soothing behaviours were also assessed as a manipulation check.

RESULTS

Toddler postneedle pain did not significantly differ among groups. However, toddlers who were distressed preneedle displayed significantly more pain postneedle, regardless of the treatment group. There were no significant interactions between treatment group and preneedle distress behaviours.

CONCLUSIONS

These results suggest that, when being held by a parent, distraction using a toy does not result in lower pain scores in the context of immunization, regardless of who offers the distraction. Furthermore, these findings raise the notion that if clinicians ensured toddlers were regulated before attempting an immunization, postneedle pain may be significantly reduced.

Infant pain regulation as an early indicator of childhood temperament

BACKGROUND

There is considerable variability in infants' responses to painful stimuli, including facial and vocal expressions. This variability in pain-related distress response may be an indicator of temperament styles in childhood.

OBJECTIVE

To examine the relationships among immunization pain outcomes (pain reactivity, pain regulation and parent ratings of infant pain) over the first year of life and parent report of early temperament.

METHODS

A subset of parent-infant dyads in an ongoing Canadian longitudinal cohort was studied. Infant pain behaviours were coded using the Modified Behavior Pain Scale. Parental judgments of infant pain were recorded using the Numeric Rating Scale. Infant temperament was measured using the Infant Behaviour Questionnaire-Revised. Correlational analyses and multiple regressions were conducted.

RESULTS

Multiple regressions revealed that the 12-month regulatory pain scores predicted parent ratings of the Negative Affectivity temperament dimension at 14 months of age. Parent ratings of infant pain at 12 months of age predicted parent ratings of the Orienting⁄Affiliation temperament dimension, with sex differences observed in this substrate.

CONCLUSION

Pain-related distress regulation at one year of age appears to be a novel indicator of parent report of temperament ratings. Pain outcomes in the first six months of life were not related to parent temperament ratings.

Evaluation of methods to relieve parental perceptions of vaccine-associated pain and anxiety in children: a pilot study

INTRODUCTION

The pain and anxiety associated with vaccination is a significant reason why parents are reluctant to have their children vaccinated. Distraction methods and vapocoolant sprays may be use to modify the parent's perceptions of their child's pain and anxiety, thus encouraging parents to return for the child's next vaccination.

METHODS

A convenience sample of 68 parents with children ranging in age from 2 to 12 years was selected. The parents and the child were randomly assigned to three groups: a control group, a DVD distraction group, or a vapocoolant spray group. After the child was vaccinated, parents evaluated the child's pain and anxiety.

RESULTS

No significant difference in the parents' perception of their child's pain or anxiety was found between the two treatment groups compared with the control group. Some parents expressed the desire to be able to choose the type of distraction method their child received rather than having them randomly assigned to a group.

DISCUSSION

Although quantitative results were not statistically significant in this pilot study, parents commented that the DVD distraction method seemed helpful before and/or after vaccination, but not during vaccination, and parents appreciated the distraction. Parents, however, would prefer to choose the intervention rather than being randomly assigned to a group. The effectiveness of interventions with regard to parental perceptions of pain or anxiety warrants further study.

The PIT: SToPP Trial-A Feasibility Randomised Controlled Trial of Home-Based Physiotherapy for People with Parkinson's Disease Using Video-Based Measures to Preserve Assessor Blinding

Purpose. To trial four-week's physiotherapy targeting chair transfers for people with Parkinson's disease (PwPD) and explore the feasibility of reliance on remote outcome measurement to preserve blinding. Scope. We recruited 47 PwPD and randomised 24 to a focused home physiotherapy programme (exercise, movement strategies, and cueing) and 23 to a control group. We evaluated transfers (plus mobility, balance, posture, and quality of life) before and after treatment and at followup (weeks 0, 4, 8, and 12) from video produced by, and questionnaires distributed by, treating physiotherapists. Participants fed back via end-of-study questionnaires. Thirty-five participants (74%) completed the trial. Excluding dropouts, 20% of questionnaire data and 9% of video data were missing or unusable; we had to evaluate balance in situ. We noted trends to improvement in transfers, mobility, and balance in the physiotherapy group not noted in the control group. Participant feedback was largely positive and assessor blinding was maintained in every case. Conclusions. Intense, focused physiotherapy at home appears acceptable and likely to bring positive change in those who can participate. Remote outcome measurement was successful; questionnaire followup and further training in video production would reduce missing data. We advocate a fully powered trial, designed to minimise dropouts and preserve assessor blinding, to evaluate this intervention.

A systematic review of measures for reducing injection pain during adult immunization

OBJECTIVE

To evaluate the effectiveness of different pain-relieving interventions to reduce pain from immunization in adults.

DATA SOURCES

MEDLINE (1950 to October Week 3 2008) PsycINFO (1967 to December Week 1 2008), CINAHL (1982 to October Week 4 2008), EMBASE (1980 to 2008 Week 43) and the Cochrane Central Register of Controlled Trials (3rd Quarter 2008).

REVIEW METHODS

Databases were searched for trials of pharmacological, behavioural, physical or operator-dependant techniques to reduce pain from immunization in adults. The primary outcome was pain as assessed by visual analogue scale or other numeric rating scale.

RESULTS

Six studies representing 853 participants were identified. One study evaluating pharmacological interventions (lidocaine-prilocaine) found them to be effective in reducing pain from immunization. Similarly, two studies evaluating physical pain relieving techniques, either skin cooling interventions (Fluori-Methane) or tactile stimulation (manual pressure at the site of injection) found them to reduce pain. One study of jet injectors found them to be more painful than conventional needle and syringe. Neither freezing needles nor warming vaccines was found to be effective in reducing pain. No studies investigated psychological interventions or oral analgesics (acetaminophen and ibuprofen).

CONCLUSION

There was limited evidence to support the use of lidocaine-prilocaine, Fluori-Methane and manual pressure for reducing immunization pain in adults. There was limited evidence of more pain with jet injectors compared to needle and syringe. Due to limited data, we recommend further investigation of methods to reduce immunization pain in adults, primarily psychological and physical techniques.

Tetracaine (ametop) compared to placebo for reducing pain associated with intramuscular injection of palivizumab (synagis)

Infants receive many painful immunizations before they are 2 years old. The purpose of this study was to evaluate if topical tetracaine reduces the pain of intramuscular palivizumab compared to placebo. There were two study injections, one with tetracaine and one with placebo. Pain was scored by their parents and a pediatric nurse. Topical tetracaine was not associated with a significant reduction in pain score, although it did lead to faster recovery times. Additional pain-reduction strategies are required.

Procedural pain guidelines for the newborn in the United Kingdom

OBJECTIVE

To assess the use of analgesia guidelines for newborn infants in the United Kingdom.

STUDY DESIGN

Postal questionnaire to every neonatal unit in the United Kingdom.

RESULT

A total of 192 of 244 units replied (78.7% response). Most units had a guideline for elective intubation (70%), sedation for ventilation (78%) post-operative pain (when appropriate) (74%). Less prevalent were guidelines for painful minor procedures (35%). Only 33% of units gave a sweet-tasting solution for analgesia before routine painful procedures and 12% used a topical anesthetic cream.

CONCLUSION

Since the last survey in 2000 there has been a modest increased uptake in measures to prevent pain neonatal pain in the United Kingdom, but no pain guideline was present in almost 25% of units and no guideline for routine painful procedures in the majority.

Vaccine-related pain: randomised controlled trial of two injection techniques

OBJECTIVE

To compare acute pain response during immunisation in infants using a slow standard of care injection technique versus a rapid pragmatic technique.

DESIGN

Randomised controlled trial.

SETTING

Single-centre, urban paediatric primary care practice.

SUBJECTS

Healthy infants 4-6 months of age receiving their routine DPTaP-Hib immunisation.

INTERVENTIONS

Standard of care group: slow aspiration prior to injection, slow injection and slow withdrawal. Pragmatic group: no aspiration, rapid injection and rapid withdrawal.

MAIN OUTCOME MEASURES

Immediate infant pain measured by the Modified Behavior Pain Scale (MBPS), crying and parent/paediatrician visual analogue scale (VAS).

RESULTS

113 infants participated; there were no observed differences in age, birth order or prior analgesic use. Mean MBPS scores (95% confidence interval (CI)) were higher (p<0.001) for the standard group compared to the pragmatic group, 5.6 (5 to 6.3) vs 3.3 (2.6 to 3.9). The standard group was more likely to cry, 47/57 (82%) vs 24/56 (43%), to cry longer, median (interquartile range (IQR)) 14.7 s (8.7-35.6) vs 0 s (0-11.30), and to take longer to have the vaccine injected, median (IQR) 8.8 s (7.9-10.3) vs 0.9 s (0.8-1.1), p<0.001 for all comparisons. The median (IQR) VAS scores by parents and paediatricians were higher for the standard group: VAS parent, 3.5 (1.6-5.5) vs 1.9 (0.1-3.1) and VAS paediatrician, 2.8 (2.0-5.1) vs 1.4 (0.2-2.4). There were no adverse events.

CONCLUSION

Immunisation using a pragmatic rapid injection technique is less painful than a slow standard of care technique and should be recommended for routine intramuscular immunisations.

Routine immunization practices: use of topical anesthetics and oral analgesics

BACKGROUND

Immunization pain is a global public health issue. Despite an abundance of data that demonstrate the efficacy of local anesthetics for decreasing immunization pain, their adoption in practice has not been determined. Our objective was to evaluate analgesic use during childhood immunization.

PATIENTS AND METHODS

We used a cluster-sampling survey of pediatricians in the greater Toronto area (who administer immunizations) and multiparous women. By using a self-administered survey, pediatricians reported frequency of analgesic use in their practice for 2 phases of immunization: injection (needle puncture and vaccine administration) and postinjection (hours to days postvaccination). By using an interviewer-administered face-to-face survey, mothers reported analgesic practices for their children.

RESULTS

Of 195 eligible pediatricians, 140 (72%) responded. During the injection phase, 58% rarely or never used analgesics compared with 11% for the postinjection phase. During injection, the local anesthetics lidocaine-prilocaine and tetracaine were used at least sometimes in 12% and 2% of the practices, respectively, whereas acetaminophen and ibuprofen were used in 81% and 46%, respectively. Postinjection, acetaminophen and ibuprofen were used in 89% and 56% of practices. Of 257 eligible mothers, 200 (78%) participated. During injection, analgesics were used in 25% of immunizations (acetaminophen [87%], ibuprofen [7%], and lidocaine-prilocaine [6%]). Postinjection, analgesics were used in 33% of immunizations (acetaminophen [86%] and ibuprofen [14%]).

CONCLUSIONS

A minority of pediatricians and mothers use topical local anesthetics during childhood immunization despite evidence to support their use. Oral analgesics are used more commonly, but this practice is not consistent with scientific evidence. Knowledge-translation strategies are needed to increase the use of local anesthesia.

Delays in immunization have potentially serious health consequences

When children are not administered vaccinations according to the recommended schedule, they not only fail to receive timely protection from preventable diseases at a time when they are most vulnerable, but also increase their risk of never fully completing the vaccination course. Both outcomes compromise a successful childhood immunization program. Although current data suggest that vaccination rates are near 95% for school-aged children in the US, the rate of timely vaccination is much lower. A number of large studies have found that the majority of children are not currently vaccinated on schedule. Moreover, immunization levels for 2- to 3-year-old children have reached a plateau. It is essential to recognize that low overall rates of the targeted diseases mask the persistent threat they pose if adherence to vaccination schedules declines. A delay in one vaccine will produce a domino effect if catch-up adjustments in scheduled visits are not implemented aggressively. Published reports have demonstrated that failure to adhere to scheduled booster immunizations, not just the initial inoculation, results in resurgence of disease. Children fall off the vaccination schedule for a variety of reasons. Although many studies suggest that inadequate availability to healthcare is not a major determinant of delayed immunization, it still factors into parental decisions. Parents should be reminded of available healthcare options. From the clinician's end, computerization of healthcare records should allow for the generation of reminders. It is vital for clinicians to be aware that there are few contraindications to vaccination. They should also be prepared to address parental concerns regarding the safety of vaccines and should not hesitate to use topical analgesics or distraction techniques to facilitate inoculation. With the anticipation of several novel vaccines being added to the childhood and adolescent immunization schedule in the future, pediatricians face new challenges to not only provide every vaccination, but to do so in a timely manner. A lack of willingness on the part of the parent, or, occasionally, on the part of the clinician, to have multiple vaccines administered to the child during a single visit has been shown to be a significant cause of delayed vaccination. Since combination vaccines reduce the number of shots that need to be administered, the use of combination vaccines may provide the best opportunity to simplify the immunization schedule, increasing adherence in the process. Improved adherence to established schedules may present a major opportunity to further protect children from disease.

Pain reduction during pediatric immunizations: evidence-based review and recommendations

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

How effective is tetracaine 4% gel, before a venipuncture, in reducing procedural pain in infants: a randomized double-blind placebo controlled trial

BACKGROUND

Procedural pain relief is sub-optimal in neonates. Topical tetracaine provides pain relief in children. Evidence of its efficacy and safety in neonates is limited. The objective of this study was to assess the efficacy and safety of topical tetracaine on the pain response of neonates during a venipuncture.

METHODS

Medically stable infants greater than or equal to 24 weeks gestation, requiring a venipuncture, were included. Following randomization and double blinding, 1.1 g of tetracaine or placebo was applied to the skin for 30 minutes. Participants received oral sucrose if they met local eligibility criteria. The venipuncture was performed according to a standard protocol. A medium effect size in the pain score (corresponding to about 2 point difference in the PIPP score) was considered clinically significant, leading to a sample size of 142 infants, with 80% statistical power. Local skin reactions and immediate adverse cardiorespiratory events were noted. The primary outcome, PIPP score at 1 minute, was analysed using an independent Student's t-test.

RESULTS

One hundred and forty two infants were included, 33 +/- 4 weeks gestation, 2100 +/- 900 grams and 6 +/- 3 days of age. There was almost no difference in PIPP scores at 1 minute between groups (mean difference -0.09; 95% confidence interval [CI]: -1.68 to 1.50; P = . 91). Similarly, there were no differences in PIPP scores during the 2nd, 3rd and 4th minute. Duration of cry did not differ between the groups (median difference, 0; 95% CI, -3 to 0; P = . 84). The majority of infants in both groups received sucrose 24%. Sucrose had a significant effect on the PIPP score, as assessed by an ANOVA model (p = 0.0026). Local skin erythema was observed transiently in 11 infants (7 in the tetracaine and 4 in the placebo group). No serious side effect was observed.

CONCLUSION

Tetracaine did not significantly decrease procedural pain in infants undergoing a venipuncture, when used in combination with routine sucrose administration.

Skin surgery in children: local anaesthesia and sedation techniques

In the past, procedural pain control in young children was undertreated as it was incorrectly alleged that their neuronal pain pathways were undeveloped. However, it is now recognised that even neonates are able to experience pain. Moreover, intensely painful physical experiences in childhood can have persisting physiological and psychological consequences. Therefore, the management of acute pain is essential. In this paper, the authors provide an in-depth discussion regarding the anaesthetic options for paediatric patients undergoing dermatological surgery.

Common medical pains

Pain in infancy and childhood is extremely common. Sources of pain include illness, injury, and medical and dental procedures. Over the past two decades, tremendous progress has been made in the assessment, prevention and treatment of pain. It is important for the paediatric health care provider to be aware of the implications and consequences of pain in childhood. A multitude of interventions are available to reduce or alleviate pain in children of all ages, including neonates. These include behavioural and psychological methods, as well as a host of pharmacological preparations, which are safe and effective when used as indicated. Many complementary and alternative treatments appear to be promising in treating and relieving pain, although further research is required. The present article reviews the most common sources of pain in childhood and infancy, as well as current treatment strategies and options.

Prevalence of IgG antibody against measles, mumps and rubella in bangladeshi children: a pilot study to evaluate the need for integrated vaccination strategy

The present study was carried out to determine the seroprevalence of IgG antibodies in Bangladeshi children against measles (irrespective of vaccination status), mumps and rubella (MMR) to assess strategic need of combined vaccination for these diseases. A total of 456 children of 1 month to 15 years, were studied. Serum IgG antibodies against MMR were measured by enzyme-linked immunosorbent assay (ELISA). By 3 months, protective IgG antibody level (>40 AU for measles and mumps and >15 IU/ml for rubella) for the diseases found to be between 50% and 80% among the studied children. Protective measles antibody (IgG) was not detected in all the children of 3-9 months and significant number of children between 9 months and 5 years were unprotected (87-65%; P < 0.001). Moreover, children of 3-15 months had no protective antibody level against mumps and significant number of children between 15 months and 5 years were unprotected (92-71%; P < 0.001). Between 5 and 15 years of age, significant number of children became protective (63-85%, P < 0.001). Although, a majority of children between 3 months and 5 years had shown to have no protective antibody against rubella (89-71%; P < 0.01-0.001) between >10 and 15 years 71% children had protective level of antibodies (P < 0.001). No significant difference was observed in antibody prevalence regarding socioeconomic classes, nutritional status and parental education. The data showed that: (i) a significant number of children remain unprotected against MMR in childhood and (ii) an extensive nationwide survey is required to suggest an integrated vaccination strategy in order to implement appropriate control measures of the three infectious diseases.

Methods of blinding in reports of randomized controlled trials assessing pharmacologic treatments: a systematic review

BACKGROUND

Blinding is a cornerstone of therapeutic evaluation because lack of blinding can bias treatment effect estimates. An inventory of the blinding methods would help trialists conduct high-quality clinical trials and readers appraise the quality of results of published trials. We aimed to systematically classify and describe methods to establish and maintain blinding of patients and health care providers and methods to obtain blinding of outcome assessors in randomized controlled trials of pharmacologic treatments.

METHODS AND FINDINGS

We undertook a systematic review of all reports of randomized controlled trials assessing pharmacologic treatments with blinding published in 2004 in high impact-factor journals from Medline and the Cochrane Methodology Register. We used a standardized data collection form to extract data. The blinding methods were classified according to whether they primarily (1) established blinding of patients or health care providers, (2) maintained the blinding of patients or health care providers, and (3) obtained blinding of assessors of the main outcomes. We identified 819 articles, with 472 (58%) describing the method of blinding. Methods to establish blinding of patients and/or health care providers concerned mainly treatments provided in identical form, specific methods to mask some characteristics of the treatments (e.g., added flavor or opaque coverage), or use of double dummy procedures or simulation of an injection. Methods to avoid unblinding of patients and/or health care providers involved use of active placebo, centralized assessment of side effects, patients informed only in part about the potential side effects of each treatment, centralized adapted dosage, or provision of sham results of complementary investigations. The methods reported for blinding outcome assessors mainly relied on a centralized assessment of complementary investigations, clinical examination (i.e., use of video, audiotape, or photography), or adjudication of clinical events.

CONCLUSIONS

This review classifies blinding methods and provides a detailed description of methods that could help trialists overcome some barriers to blinding in clinical trials and readers interpret the quality of pharmacologic trials.

How effective is tetracaine 4% gel, before a peripherally inserted central catheter, in reducing procedural pain in infants: a randomized double-blind placebo controlled trial [ISRCTN75884221]

BACKGROUND

Procedural pain relief is sub-optimal in infants, especially small and vulnerable ones. Tetracaine gel 4% (Ametop, Smith-Nephew) provides pain relief in children and larger infants, but its efficacy in smaller infants and for peripherally inserted central catheters (PICC) remains uncertain. The objective of this trial was to assess the safety and efficacy of tetracaine gel on the pain response of very low birth weight (VLBW) infants during insertion of a PICC.

METHODS

Medically stable infants greater than or equal to 24 weeks gestation, requiring a non-urgent PICC, were included. Following randomization and double blinding, 1.1 g of tetracaine or placebo was applied to the skin for 30 minutes. The PICC was inserted according to a standard protocol. Pain was assessed using the Premature Infant Pain Profile (PIPP). A 3-point change in the pain score was considered clinically significant, leading to a sample size of 54 infants, with 90% statistical power. Local skin reactions and immediate adverse cardiorespiratory events were noted. The primary outcome, PIPP score at 1 minute, was analysed using an independent Student's t-test.

RESULTS

Fifty-four infants were included, 27 +/- 2 weeks gestation, 916 +/- 292 grams and 6.5 +/- 3.2 days of age. Baseline characteristics were similar between groups. The mean PIPP score in the first minute was 10.88 in the treatment group as compared to 11.74 in the placebo group (difference 0.86, 95% CI -1.86, 3.58). Median duration of crying in non-intubated infants was 181 seconds in the tetracaine group compared to 68 seconds in the placebo group (difference -78, 95% CI -539, 117). Local skin erythema was observed transiently in 4 infants (3 in the treatment and 1 in the placebo group). No serious harms were observed.

CONCLUSION

Tetracaine 4% when applied for 30 minutes was not beneficial in decreasing procedural pain associated with a PICC in very small infants.

Pregnancy and Dermatologic Surgery

The physiologic changes of pregnancy and risks to the fetus require attention during dermatologic surgery. Elective surgery should be performed in the second trimester or the postpartum period. Cosmetic work should occur after delivery to avoid hypertrophic or hyperpigmented scars. Skin preparatory agents and anesthetics may have fetal implications and should be chosen with care. Antibiotic selection for any infections must take into account possible maternal and fetal risks. Attention to detail and awareness of the changes in pregnancy should lead to safe surgery in the pregnant patient.

A critical review of the topical local anesthetic amethocaine (Ametop) for pediatric pain

A topical formulation of the ester-type local anesthetic amethocaine (tetracaine) [Ametop ] is currently available for reducing pain from cutaneous procedures such as venipuncture. The Ametop mark preparation contains 40 mg of amethocaine base (4% w/w) and produces anesthesia within 30-45 minutes of application; duration of action ranges from 4 to 6 hours. Clinical studies have demonstrated the superiority of the 4% amethocaine preparation over placebo in pediatric populations for indications such as intravenous cannulation, vaccination, and venipuncture. Amethocaine has been shown to produce anesthesia comparable to that of 5% lidocaine-prilocaine for procedures such as venipuncture and accessing centrally placed devices; in general, anesthesia was achieved more rapidly with amethocaine than lidocaine-prilocaine. In the neonatal population amethocaine was found to be ineffective at reducing the pain of heel prick and peripherally inserted central catheters. Depending on the type of procedure, amethocaine application times between 30 and 60 minutes have produced clinically acceptable anesthesia; application times <30 minutes have not been associated with reliable anesthesia. The 4% amethocaine preparation is well tolerated; the most commonly reported local skin reaction is transient local erythema while local edema and itching have been reported more rarely. There have been no accounts of systemic toxicity with topical use of the preparation. Several cases of sensitization have been described in adults upon repeated exposure to topical amethocaine. In summary, the novel preparation of 4% amethocaine gel has been shown to be clinically effective for managing pain associated with minor cutaneous procedures while maintaining a good tolerability profile. Amethocaine has also demonstrated similar efficacy to lidocaine-prilocaine when appropriate application times are used; the more rapid onset of action and extended duration of action of amethocaine may make it more useful than lidocaine-prilocaine in busy clinical settings.