Procedure Pain Management
Painful procedures can be very distressing for both children and parents, with lasting negative effects.
Pain can impede the child’s co-operation, destroy trust, grow their fear of medical experiences, and increase risk of post-traumatic stress.
However, procedure pain can be effectively managed with medications or psychological support. A combination of both works best for children, addressing both physical and emotional distress.
Anaesthetic and Sedation
Young children are often sedated for painful procedures such as bone marrow aspirate and lumbar puncture. Many are also anaesthetised when they must lie very still for painless procedures such as MRI or radiotherapy.
Three types of anaesthetic are used for children.
- Local anaesthetic numbs skin and tissues below.
- Sedation relaxes the awake child.
- General anaesthetic is a controlled sleep.
EMLA (Eutectic Mixture of Local Anesthetics) cream contains lidocaine, and must be applied 1-2 hours before the procedure. EMLA is only available on prescription in most countries.
Ametop gel contains amethocaine, takes effect in 30-45 minutes and numbs the skin for 4-6 hours. Ametop is available over the counter in many countries.
Place a blob of EMLA or Ametop on the skin and cover it with a bandage or clear cling film / saran wrap to keep it in place.
Numby Stuff cream is used with a mild electrical current to rapidly numb the skin. A medication patch is placed over the area to be numbed, and a second grounding patch is placed on the skin close by. A hand-held unit connected to both patches delivers a tiny electrical current. The child feels a light tingling sensation until the cream takes effect in about 5-10 minutes. Numby stuff penetrates up to 10 mm, compared to 3-5 mm with EMLA and Ametop.
Freezy spray uses ethyl chloride to numb the skin immediately before the procedure, and is usually only available on prescription.
Sedation and General Anaesthetic
Sedative and general anesthetic medications are given intravenously or through a mask by an anaesthetist. Ask if you can accompany your child during anaesthetic induction – many hospitals allow this, recognizing that children benefit greatly from parental presence.
Sedative and Anaesthetic Drugs
Common sedatives and general anaesthetics for children are Valium or Versed (in combination with pain medication), Propofol, and Ketamine. With all these medications, your child’s heart rate and breathing will be closely monitored during the procedure and recovery. Emergency equipment will be on stand by just in case your child’s breathing becomes difficult.
Valium / Versed are sedatives. They relax the body during an awake procedure. Morphine or fentanyl is also given to control pain.
Propofol is a short acting general anaesthetic. This is the general anaesthetic of choice for EUA and other procedures as it has a rapid effect and quick recovery.
Ketamine is the most widely available general anaesthetic in the developing world, but recovery time is much longer than with propofol. Many children also experience confusion irritability and even hallucinations which can be very scary.
Some sedatives and pain relievers become ineffective with regular use, so your child’s drugs and dosage may be adjusted. Always ask the anaesthetist or doctor to explain changes and reasons for them. Similarly, if you find the drugs are not working for your child, ask for an alternative.
Child Life Support
Child Life Specialists can work with you and your child to create a “pain management plan” for routine painful procedures, including a variety of supportive approaches that can complement or replace pain medications.