Neonatal Analgesia

SuperbabyIn general, I try to do things that make my life easier.  Selfish or Brilliant? I’ll let you decide.  But on occasion, choices that we think should make things easier actually can be counterproductive.  A great example of this is whether we use lidocaine (or any analgesia) for our neonatal lumbar punctures.

We have already discussed that the Bloody Tap is an often encountered issue (~30% of the time).  The traumatic LP results can make interpretation difficult and it would be best to avoid the situation all together.  Making your first attempt your best attempt can help do this.

First Attempt Best Attempt

  1. Appropriate positioning (Don’t Flex the Neck)
    1. Teach your holder how best to hold.
    2. Place the neonate on a firm surface
      1. The mattress of the examination table (even infant warmer) can make alignment difficult.
      2. The board that you place under a patient during chest compressions is very helpful in helping to position the neonate.
    3. Check the positioning once, twice, then thrice…. and then thrice more.
  2. Provide ANALGESIA for the neonate (or any aged person)!

 

“But using lidocaine makes my job harder.”

Applying the previously noted selfish directive, I may convince myself (and others) to not use any analgesia during the neonatal lumbar puncture. When I inject the lidocaine, it will distort the rather small landmarks. It also requires an additional poke with a needle, which, if I am awesome, is one poke more than needed (hmmm… except I’m not always that awesome). Additionally, it is an additional step and makes the procedure take longer.  Plus, these neonates won’t care if I cause some discomfort now… they won’t remember it.

Many think this way!

  • Studies show that children do not often receive analgesia for Lumbar Punctures.
    • One study showed only 6.5% of 0-2 month olds got analgesia.
    • Still only 14.3% of 3-18 month olds received analgesia.
    • Interestingly, kids treated in the ED were given analgesia 12.6% of the time, while in the Nursery only 0.9% of the time! Neither group should be proud of that.

Neonates DO Feel Pain… and It Matters.

  • Neonates due not mount the same vigorous behavioral responses to pain like older kids and adults… leading to under-appreciation of pain in the neonate.
  • Unfortunately, neonates often undergo many painful procedures and are often under treated or untreated.
  • There is evidence that suggests that neonates are more sensitive to pain than older kids and adults.
  • Additionally, the immature neonate brain is more susceptible to long-term effects of painful stimulation.
  • Just because the neonate can’t yell at you that it hurts doesn’t mean doesn’t.
  • If a procedure would hurt an adult, it should be treated as if it would hurt a neonate (or anyone really).
  • Don’t be cruel out of convenience.

 

Lidocaine Does NOT Make Your Job Harder!

  • Injected lidocaine has been shown to decreased struggling and wiggling of the patient.
  • Injected lidocaine has been shown to be safe (if there are cardiac events, it is likely from your improper positioning – don’t flex the neck – that leads to suboptimal airway alignment!
  • Injected lidocaine does not decrease success rate of the procedure.

 

Oral Sucrose… good, but not enough

  • Oral Sucrose effectively reduces the acute behavioral response to painful procedures,
  • But does not reduce spinal reflex response or cortical activity.

 

Why Use a Needle When You Don’t Need To?

  • Topical Lidocaine
    • Eutectic Mixture of Local Anesthesia (EMLA) cream or 4% Liposomal Lidocaine (LMX) have been shown to be safe and effective.
    • Pro is that no needle is needed.
    • Con is that they take time to be effective.
      • Personally, I apply the LMX when I walk in the room to get the history and perform the exam.
      • By the time I have discussed the plan, gotten the consent form signed, and ordered all of my labs and antibiotics, 20 minutes has elapsed and my LMX is working.
  • Needle-Free Injection of 1% Lidocaine (J-Tip)
    • Found to be effective and convenient.
    • Can be administered at the time of the Lumbar Puncture.

 

Moral of the Morsel

  • Neonates (and kids of all ages) feel pain and may actually have more adverse outcomes because of pain.  Don’t be cruel out of convenience.
  • Use techniques that make sense for your work-flow, but don’t under-estimate the pain you may be inflicting — FIRST DO NO HARM.
  • A struggling and squirming child is harder to get a clean CSF sample on than a quiet and still one.  Make your first attempt your best attempt!

 

References

Walker SM. Neonatal pain. Paediatr Anaesth. 2014 Jan;24(1):39-48. PMID: 24330444. [PubMed] [Read by QxMD]

Ferayorni A, Yniguez R, Bryson M, Bulloch B. Needle-free jet injection of lidocaine for local anesthesia during lumbar puncture: a randomized controlled trial. Pediatr Emerg Care. 2012 Jul;28(7):687-90. PMID: 22743744. [PubMed] [Read by QxMD]

Fein D, Avner JR, Khine H. Pattern of pain management during lumbar puncture in children. Pediatr Emerg Care. 2010 May;26(5):357-60. PMID: 20404782. [PubMed] [Read by QxMD]

Bouza H. The impact of pain in the immature brain. J Matern Fetal Neonatal Med. 2009 Sep;22(9):722-32. PMID: 19526425. [PubMed] [Read by QxMD]

Anand KJ; International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001 Feb;155(2):173-80. PMID: 11177093. [PubMed] [Read by QxMD]

Pinheiro JM, Furdon S, Ochoa LF. Role of local anesthesia during lumbar puncture in neonates. Pediatrics. 1993 Feb;91(2):379-82. PMID: 8424014. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. August 10, 2014

    […] Read More:  Neonatal Analgesia […]

  2. November 24, 2014

    […] EM Morsels reminds us that just because babies are small, doesn’t mean they don’t feel pain. Neonatal analgesia. […]

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