Comparison of topical anaesthesia methods for venous cannulation in adults. Milk-induced hypoalgesia in human newborns. Topical anesthetics for intravenous insertion in children: a randomized equivalency study. Topical 4% Amethocaine Gel Reduces the Pain of Subcutaneous Measles-Mumps-Rubella Vaccination The use of a topical refrigerant anesthetic to reduce injection pain in children. Oral glucose as an analgesic to reduce infant distress following immunization at the age of 3, 5 and 12 months. Comparison of lignocaine‐prilocaine cream and amethocaine gel for local analgesia before venepuncture in children The use of breast-feeding for pain relief during neonatal immunization injections. Mitigation of pain during intravenous catheter placement using a topical skin coolant in the emergency department Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream. Effective pain reduction for multiple immunization injections in young infants. Comparison of the vasoactivity of amide and ester local anaesthetics. An intradermal study. Children's expectations and memories of acute distress: short- and long-term efficacy of pain management interventions. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial Analgesic Properties of Oral Sucrose During Routine Immunizations at 2 and 4 Months of Age Ethyl chloride and venepuncture pain: a comparison with intradermal lidocaine Analgesia for venous cannulation: a comparison of EMLA (5 minutes application), lignocaine, ethyl chloride, and nothing. Intra-Oral Administration of Sweet-Tasting Substances and Infants’ Crying Response to Immunization: A Randomized, Placebo-Controlled Trial Ethyl Vinyl Chloride Vapocoolant Spray Fails to Decrease Pain Associated with Intravenous Cannulation in Children Sucrose as an analgesic agent for infants during immunization injections. A revised measure of acute pain in infants. Determinants of success and failure of EMLA Sucrose decreases infant biobehavioral pain response to immunizations: a randomized controlled trial. Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures A Randomized Controlled Trial of Vapocoolant for Pediatric Immunization Distress Relief Effects of a skin refrigerant/anesthetic and age on the pain responses of infants receiving immunizations. Topical vapocoolant quickly and effectively reduces vaccine-associated pain: results of a randomized, single-blinded, placebo-controlled study. EMLA® cream and oral glucose for immunization pain in 3-month-old infants “Sucrose Analgesia” and Diphtheria‐Tetanus-Pertussis Immunizations at 2 and 4 Months The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. Evaluation of an amethocaine gel preparation for percutaneous analgesia before venous cannulation in children.
A prospect i ve , r and omized clinical trial was performed in order to assess the efficacy and side-effects of commonly used topical anaesthesia methods in adults receiving peripheral venous cannulation . The study was double-blinded to the degree that the method ologies allowed . One hundred and fifty healthy adults undergoing elective surgery were allocated at r and om to five groups : EMLA cream , ethyl chloride spray , intracutaneous infiltration with 2 % lidocaine , placebo cream and no treatment . Venipuncture was performed with a 18 G cannula on the dorsal side of the h and . Puncture pain and pain caused by the topical treatment itself were measured using a visual analogue scale ( VAS , range : 0 - 100 mm ) . Haemodynamic response , difficulties in performing the puncture and side-effects were recorded . All analgesic techniques were well tolerated . Haemodynamic response and degree of puncture difficulty showed no differences among the groups . Puncture pain ( median mrnVAS ) following infiltration ( 1.0 ) and EMLA ( 10.0 ) was significantly lower than no treatment ( 30.0 ) or placebo ( 30.0 ) . The benefit of local infiltration was altered by injection pain ( 11.5 ) . Spray did not significantly lower puncture pain ( 26.5 ) and , in addition , was associated with discomfort ( 10.5 ) . In adults , EMLA cream significantly reduces puncture pain and represents an acceptable alternate method for topical anaesthesia in venous cannulation . Local lidocaine infiltration is impaired by applicational pain , whereas spraying the puncture site with ethyl chloride has no analgesic benefit OBJECTIVE To determine whether milk and its components reduce  crying  in newborns during and after blood collection for phenylketonuria evaluation . METHODOLOGY Seventy-two normal newborns ingested 2 mL of milk ( Similac ) , Ross Special Formula , fat , protein , lactose , sucrose , or water for the 2 minutes preceding blood collection via heel lance . Crying duration during and for the 3 minutes after the procedure was determined by scorers who were blind to the ingestive substance . RESULTS Sucrose and Similac each reduced crying during the blood collection procedure . Sucrose , fat , protein , and Ross Special Formula were effective during the 3-minute recovery period . Neither water nor lactose were effective during or after blood collection . CONCLUSION Milk and some of its components are antinociceptive in human newborns . Based on previous studies , reduced crying during and after painful stimulation may be mediated through endogenous opioids . These findings are of potential clinical significance : natural protective mechanisms , normally engaged during suckling , may safely and noninvasively be activated to reduce  newborn crying to painful stimulation OBJECTIVES Children view needle sticks as the worst source of pain and fear in the hospital setting . In an effort to minimize the pain of needle sticks , the use of eutectic mixture of lidocaine and prilocaine ( EMLA ) has become st and ard practice in many children 's hospitals . Unfortunately , EMLA requires at least 60 minutes to be fully effective and reportedly may cause vasoconstriction , leading to difficult vein cannulation . A newly available local anesthetic ( ELA-Max ) may require less time and cause less vasoconstriction . The purpose of this r and omized crossover study was to investigate the anesthetic equivalence of EMLA and ELA-Max . METHODS Thirty well children ( 14 girls and 16 boys ) who were between the ages of 7 and 13 years volunteered to have EMLA  applied to the dorsal aspect of 1 h and for 60 minutes and ELA-Max applied to the other h and for 30 minutes . Right and left h and s were r and omized to treatment type and order of intravenous ( IV ) insertion . Clinical Research Center nurses , blind to the anesthetic r and omization , attempted to insert a 22-gauge Teflon IV catheter into a vein in each h and . The children rated pain during IV insertion on the Oucher scale , and the nurse rated the difficulty of the insertion . RESULTS There was no significant difference in pain ratings for h and s that were treated with EMLA ( mean : 20.5 ) or with ELA-Max ( mean : 24 ) , and there was no difference for the difficulty of vein cannulation .  Children 's preprocedure state anxiety was positively associated with pain ratings . CONCLUSIONS ELA-Max , applied for 30 minutes before IV cannulation , has an anesthetic effectiveness similar to EMLA applied for 60 minutes . Some children rated IV insertion pain fairly high for both h and s ( eg , 60 on a 0- to 100-point scale ) despite anesthetic treatment . Preprocedural anxiety may affect the perception and /or rating of pain . There were no differences between h and s that were treated with EMLA or with ELA-Max for success of IV insertion Objectives . Ametop gel ( 4 % amethocaine ) is a relatively new topical anesthetic that produces anesthesia within 30 to 45 minutes and therefore may be appropriate for use in busy outpatient setting s. The objective of this study was to assess the efficacy and safety of 4 % amethocaine in reducing the pain of subcutaneous measles-mumps-rubella vaccination in 1-year-old infants . Methods .A double-blind , r and omized , placebo-controlled trial was conducted in pediatric outpatient clinics . Results .A total of 120 infants participated in the study ; 60 were followed up for assessment of antibody titers after 1 month . Either 1 g of amethocaine or placebo was applied for 30 minutes before vaccination . The Modified Behavioral Pain Scale was used to assess pain ; the mean ( st and ard deviation ) pain scores for the amethocaine group ( n = 61 ) was 1.5 ( 1.6 ) versus 2.3 ( 2.2 ) for the placebo group ( n = 59 ) . The rate of vaccination success ( 88 % and 87 % ) was not different between treatment groups . Conclusions .4 % Amethocaine significantly reduces the pain of measles-mumps-rubella vaccination in infants when compared with placebo and does not seem to interfere with subsequent development of protective antibody levels . Because of its relatively short application time ( 30 minutes ) , 4 % amethocaine may be suitable for busy clinics and emergency departments Early childhood experiences with painful injections may lead to anxiety and fear . These reactions need not develop if steps are taken to reduce the pain associated with injections . The purpose of this study was to assess the efficacy of a refrigerant topical anesthetic in reducing injection pain in preschool children experiencing routine diphtheria-pertussis-tetanus ( DPT ) immunizations . This double-blind placebo-controlled study was conducted in community health clinics in conjunction with ongoing immunization programs . Ninety subjects , aged 4 - 5.5 years , were r and omly assigned to one of three groups : ( a ) refrigerant topical anesthetic ; ( b ) placebo topical spray ; and ( c ) no-spray control .  Pain was measured subjectively using a four-point visual analogue scale . Both the refrigerant topical anesthetic spray and the placebo spray significantly reduced injection pain . Age was found to be an important factor influencing pain response in this study . Parental anxiety was not a significant factor influencing pain response . In addition , parents were not good at predicting their child 's pain . The results of the study support the use of an intervention , such as refrigerant topical anesthetic , as a practical , simple , and effective treatment strategy for reduction of short-term painful procedures like injections AIM To evaluate oral glucose as an analgesic to reduce  infant distress after immunization during the first year of life and to investigate if these effects change during this period . METHODS A prospect i ve controlled trial of the effectiveness of glucose on crying response to immunizations at 3 , 5 and 12 months of age . A total of 110 infants were r and omized to receive 2 mL of 30 % glucose or water . The same solution was given at 3 , 5 and 12 months . Crying was registered from onset of the injection up to 120 seconds . Infanrix Polio Hib was administered intra-muscular in the thigh . Observation nurse and parents were blind to the nature of the solution . RESULTS Administration of glucose reduced the mean crying time by 22 % at 3 months , 62 % at 5 months and 52 % at 12 months . The difference was significant at 5 and at 12 months . In the water group , there was a significant correlation between the children who cried at 3 months and who subsequently cried at 5 and 12 months . No correlations were found in the glucose group . CONCLUSION Sweet solution can be used as a simple and safe method to reduce the distress following immunization in infants up to 12 months The efficacy of lignocaine‐prilocaine cream ( EMLA ™ ) and amethocaine gel ( Ametop ™ ) in reducing the pain and distress of venepuncture  was compared in a single‐blind r and omized study of 34 children aged 1—14 y. The influences of age , anxiety and past experience were also investigated . Pain was assessed by the research er using the Observation Scale of Behavioural Distress , and by the parent , doctor and child ( if old enough ) using a 10‐cm , 100‐point Visual Analogue Scale ( VAS ) . Doctors also completed a simple rating scale for difficulty of venepuncture . Compared to older children , infants had significantly more anxious parents and were more distressed when being held still . Anticipatory anxiety correlated with higher pain ratings . No differences in the analgesic effect of the two preparations were found . We conclude that whilst EMLA and Ametop are equally effective at reducing the pain of needle puncture , under some circumstances the use of Ametop may be more advantageous . □ Children , local anaesthetic ,  needle pain , The objective of this study was to examine the pain-relieving effect of breast-feeding during immunization injections in healthy neonates . Sixty-six healthy infants returning to a clinic for their second- , third- , or fourth-month immunization with intramuscular diphtheria , tetanus , and pertussis  were r and omized to be breast-fed before , during , and after the injection or to be given the injection according to routine clinic procedure ( no breast-feeding ) . To assess the pain responses of the neonates during and after immunization , we noted their heart rates , oxygen saturation levels , and length of crying . The crying time was shorter in the experimental ( breast-feeding ) group ( M + /- SD duration , 35.85 + /- 40.11 seconds ) than in the control group ( M + /- SD duration , 76.24 + /- 49.61 seconds ; p = .001 ) . The heart rate and oxygen saturation levels were almost the same in both groups . We concluded that breast-feeding , maternal holding , and skin-to-skin contact significantly reduced crying in infants receiving an immunization injection for diphtheria , tetanus , and pertussis Objective : Although intravenous ( IV ) line placement is a common procedure in the emergency department ( ED ) , it is an uncomfortable experience for many patients . Topical analgesic agents are rarely used because they have long onsets of action and thereby cause unacceptable treatment delays . Cryoanaesthesia , the use of cooling agents to reduce pain , has been recognised for many years as a potential pain management strategy . The purpose of this study was to determine whether an instantaneous topical skin coolant spray reduces patient ’s pain during IV cannulation and represents a feasible alternative for cutaneous analgesia in the ED setting . Methods : We conducted an unblinded , r and omised , controlled study , in a convenience sample of ED patients . Utilising a r and om number generator to assign patients to the control or study group , patients over the age of 18 years who required IV cannulation as part of their evaluation were enrolled at two tertiary care hospitals . In both groups , IV lines were placed in accordance with accepted clinical st and ards of practice , with the single addition of the coolant spray delivered to the IV site before needle insertion in the study group . All study participants answered question naires before and after IV placement and rated pain during procedure on a 100 mm visual analogue scale . Results : Of the 92 patients enrolled in the study , 47 ( 51.1 % ) were r and omised to the study group and received the anaesthetic spray , and 45 ( 48.9 % ) were r and omised to the control group and had their IV placed in a st and ard method . 66 patients were female ( 71.8 % ) and 26 ( 28.2 % ) were males . The mean pain score in the study group was 27 mm ( 95 % confidence interval ( CI ) 19.9 to 34.1 mm ) and 28 mm ( 95 % CI 20.4 to 35.6 m ) in the control group ( p = 0.934 ) . Subgroup analysis of female and male patients did not show significance . Conclusions : Our study failed to detect a difference in pain perception result ing from the pre-procedural application of a skin coolant associated with IV placement in the ED setting We have determined the depth and duration of analgesia to needle insertion after topical application of EMLA cream ( Eutectic Mixture of Local Analgesics ) . EMLA was applied for 30 , 60 , 90 and 120 min and the sensory and pain threshold depths were determined before analgesia ( 1.0 and 1.9 mm , respectively ) and up to 4 h after the cream was removed from the skin . The maximal depth of analgesia ( approx . 5 mm ) was observed 30 min after a 90-min application and during the 60-min period after a 120-min application of EMLA cream , for both sensory and pain thresholds . For application times shorter than 120 min , the depth of analgesia increased during the period after removal of the cream . This suggests new guidelines for the use of this topical analgesic BACKGROUND Infants experience undue pain with multiple immunization injections . OBJECTIVE To assess the effectiveness , feasibility , and parental acceptance of a simple combination pain reduction intervention for infants receiving multiple immunization injections . DESIGN R and omized , controlled , clinical trial . SETTING Academic hospital-based primary care center . PARTICIPANTS Infants receiving their 2-month immunizations , consisting of 4 injections  ( diphtheria and tetanus toxoids and acellular pertussis vaccine , inactivated poliovirus vaccine , Haemophilus influenzae b conjugate and hepatitis B vaccine [ Comvax ] , and heptavalent pneumococcal conjugate vaccine [ Prevnar ] ) . INTERVENTIONS Subjects were r and omly assigned to the intervention or control group for administration of 4 injections . The intervention group received sucrose and oral tactile stimulation ( with a pacifier or a bottle ) and were held by their parents during immunization . The control group did not receive these interventions ( st and ard practice ) . MAIN OUTCOME MEASURES Blinded assessment of audiotaped crying , heart rate , parent preference for future use of the injection technique , and nurse-rated ease of vaccine administration . RESULTS One hundred sixteen infants ( mean + /- SD age , 9.5 + /- 2.0 weeks ) participated . The median ( 25th-75th percentile range ) first cry duration was 19.0 ( 5.8 - 62.8 ) seconds for the intervention group compared with 57.5 ( 31.0 - 81.5 ) seconds for the control group ( P = .002 ) . Parents of the intervention group reported a stronger preference for future use of the injection procedure . For intervention vs control , the median ( 25th-75th percentile ) parent preference visual analog scale score was 97.0 ( 82.0 - 100.0 ) vs 44.0 ( 5.0 - 77.2 ) ( P<.001 ) ( 100 indicates definitely prefer ) . Nurse-rated ease of vaccine administration was equivalent for both treatment groups . CONCLUSIONS Combining sucrose , oral tactile stimulation , and parental holding was associated with significantly reduced crying in infants receiving multiple immunization injections . Parents stated a strong preference for future use of this method , and nurses found the intervention injection technique easy to apply The vascular effects and duration of action of two ester-linked local anaesthetics , procaine and amethocaine , and four amide-linked local anaesthetics , cinchocaine , lignocaine , mepivacaine and prilocaine , were investigated in 10 volunteers by intradermal injection using a double-blind technique . Procaine and amethocaine produced marked vasodilatation ; weal formation was observed at 80 % of the amethocaine injection sites . Mepivacaine had a marked vasoconstrictor effect ; the other three agents produced more variable vasoactivity . Duration of action was concentration-dependent for all six drugs , the slopes of the log dose-- duration plots reflecting the observed vasoactivity OBJECTIVE To examine the effect of psychologic and pharmacologic interventions on children 's expectations and 6-month re collection s of painful procedures . METHODS A repeated measures design allowed examination of 22 fourth grade rs ' expectations , experiences , and memories of distress across three conditions ( typical care , distraction , topical anesthetic ) for a three-injection vaccination series .  All participants were African American and from urban , low-income families . RESULTS Across conditions , children 's expectations of distress were significantly higher than their experience of distress . Distress ratings did not differ among conditions prior to or immediately following the injections ; however , children later recalled that the treatment conditions were superior to control for distress relief . Analyses of recall accuracy suggest that the interventions buffered the children from forming negative re collection s that occurred with typical care . CONCLUSIONS Children have negative expectations prior to a procedure despite knowing that a distress management intervention will be employed . However , interventions may thwart the development of negative memories of distress Background : Established noninvasive pharmacologic means of alleviating pain and anxiety in children undergoing intravenous cannulation are time-consuming , and thus impractical for routine use in the emergency department . Vapocoolant sprays provide transient skin anesthesia within seconds of application . We compared the effect of a new vapocoolant spray to placebo on  pain due to intravenous cannulation in children . Methods : In this double-blind r and omized controlled trial , which we conducted between June 1 and Sept. 12 , 2006 , 80 children aged 6–12 years received either vapocoolant spray or placebo before cannulation . Children rated their pain using a 100-mm colour visual analogue scale . Secondary outcomes included success rate on first attempt at cannulation and pain ratings by the children 's parents , nurses and child life specialists . Results : We found a modest but significant reduction in pain with the use of vapocoolant spray ( mean difference 19 mm , 95 % confidence interval [ CI ] 6–32 mm ; p < 0.01 ) . Cannulation on first attempt was more often successful with the use of vapocoolant spray ( 85.0 % ) than with placebo ( 62.5 % ) ( mean difference 22.5 % , 95 % CI 3.2%–39.9 % ; p = 0.03 ) . The number needed to treat to prevent 1 cannulation failure was 5 ( 95 % CI 3–32 ) . Parents ( p = 0.04 ) , nurses ( p = 0.01 ) and child life specialists ( p < 0.01 ) considered the children 's pain to be reduced with the use of vapocoolant spray . Interpretation : The vapocoolant spray in our study quickly and effectively reduced pain due to intravenous cannulation in children and improved the success rate of cannulation . It is an important option to reduce childhood procedural pain in emergency situations , especially when time precludes traditional interventions . ( http:// Clinical Trials.gov trial register no. NCT00130650 . OBJECTIVE . The purpose of this work was to evaluate the analgesic properties of oral sucrose during routine immunizations in infants at 2 and 4 months of age . PATIENTS AND METHODS . A prospect i ve , r and omized , placebo-controlled clinical trial was conducted at a pediatric ambulatory care clinic . One-hundred healthy term infants scheduled to receive routine immunizations were recruited , r and omly stratified into 2- or 4-month study groups , and further r and omly assigned to receive 24 % oral sucrose and pacifier or the sterile water control solution . The study preparations were administered 2 minutes before the combined diphtheria-tetanus-acellular pertussis , inactivated polio vaccine , and hepatitis B vaccine . Haemophilus influenzae type b vaccine was administered 3 minutes after the combined injection , followed by the pneumococcal conjugate vaccine , 2 minutes after the H influenzae type b injection . The University of Wisconsin Children 's Hospital Pain Scale measured serial acute pain responses for the treatment and control groups at baseline and 2 , 5 , 7 , and 9 minutes after solution administration . Repeated- measures analysis of variance examined between-group differences and within-subject variability of treatment effect on overall pain scores . RESULTS . Two- and 4-month-old infants receiving oral sucrose ( n = 38 ) displayed reductions in pain scores 2 minutes after solution administration compared with 2- and 4-month-old infants in the placebo group ( n = 45 ) . Between-group comparisons for the oral sucrose and placebo groups showed lower pain responses at 5 , 7 , and 9 minutes after solution administration . The oral sucrose and placebo groups demonstrated their highest mean pain score at 7 minutes , with a mean pain score of 3.8 and 4.8 , respectively . At 9 minutes , the placebo group had a mean pain score of 2.91 whereas the mean pain score for the oral sucrose group returned to near baseline , reflecting a 78.5 % difference in mean pain score ( oral sucrose − placebo ) relative to the placebo mean . CONCLUSIONS . Oral sucrose is an effective , easy-to-administer , short-acting analgesic for use during routine immunizations One hundred and twenty unpremedicated patients undergoing gynaecological surgery were r and omly allocated to one of three equal treatment groups to assess the effectiveness of ethyl chloride in producing instant skin anaesthesia to prevent the pain of venepuncture from a 20 G cannula . They received either no anaesthetic , 0.2 ml one per cent lidocaine plain intradermally or a ten-second spray of ethyl chloride at the cannulation site . Ethyl chloride produced skin anaesthesia that significantly reduced the pain of venepuncture . However , it was not as effective as intradermal lidocaine . It had no effect on vein visualisation or ease of cannulation .  Ethyl chloride can be recommended as a method of producing instant skin anaesthesia . RésuméAfin d’évaluer l’anesthésie cutanée produite par le chlorure d’éthyl , nous avons r and omisé en trois groupes , 120 c and i date s à une chirurgie gynécologique n’ayant pas reçu de prémédication . Avant l’insertion percutanée d’une canule de calibre 20 , nous n’utilisions soil aucun agent , soil une injection intradermique de 0,2 ml de lidocaïne une pour cent , soil une vaporisation de chlorure d’éthyl de dix secondes au site d’insertion . Le chlorure d’éthyl produit alors une anesthésie cutanée capable de diminuer la douleur lors de l’insertion d’une canule veineuse ( mais pas de façon aussi marquée que la lidocaïne ) sans en compliquer la technique ni entraver la visualisation de la veine . Il s’agit done là d’une technique acceptable d’anesthésie cutanée presque instantanée Three commonly available local anaesthetics were compared , in a controlled trial , for use before venous cannulation . The pain of application of the local anaesthetic , the pain of cannulation , and the rate of successful cannulations were compared . The value of EMLA cream applied for 5 min was question ed . Venous cannulation with a 20 G venflon was found to be significantly more painful than the application of any of the local anaesthetics ( P < 0.01 ) . Lignocaine 1 % , injected subcutaneously , and ethyl chloride spray significantly reduced the pain of venous cannulation ( P < 0.01 ) . The use of lignocaine did not result in significantly more failed cannulations than the control group . It was concluded that local anaesthesia should be used before venous cannulation , even for 20 G cannulae The analgesic effects of four solutions administered intra-orally ( 25 and 50 % sucrose solutions , hydrogenated glucose , and a sterile water placebo ) were tested in groups of babies receiving routine DTP ( diphtheria , tetanus , and pertussis ) and HIB ( Haemophilus influenzae type B ) injections at the first , second , or third immunization . The duration of the baby ’s cry during 3 min following DTP and HIB injections was measured as main outcome . For all three immunization groups , the babies receiving the placebo generally spent most time crying . For both the DTP and HIB injections , the difference between 50 % sucrose and placebo was most evident in the group receiving the 3rd immunization . Intra-oral administration of the 50 % sucrose solution , compared to placebo , appeared to reduce the cry response to painful experiences in babies beyond the neonatal period The purpose of the study was to determine the effect of ethyl vinyl chloride vapocoolant spray on pain reported by children undergoing intravenous cannulation . A r and omized , double-blinded , placebo-controlled trial was conducted on eligible children between the ages of 9 and 18 years seen in a pediatric emergency department and requiring intravenous cannulation . Informed consent was obtained , and children were r and omized to receive ethyl vinyl chloride spray , isopropyl alcohol spray , or no spray ( control group ) . Patient demographics and information pertaining to each intravenous cannulation were recorded . Children indicated the degree of pain associated with intravenous cannulation on a 100-mm visual analog scale ( VAS ) compared to a baseline pain score of “ zero . ” Statistical analysis was performed by using Stata version 7 . One hundred twenty-seven subjects were enrolled : 37 received ethyl vinyl chloride vapocoolant spray , 48 received isopropyl alcohol spray ( placebo ) , and 42 received no pretreatment .  Mean VAS scores for pain experienced during cannulation were 34 , 33 , and 31 mL for each group , respectively . Ethyl vinyl chloride vapocoolant spray failed to measurably reduce pain associated with intravenous cannulation when compared to those pretreated with isopropyl alcohol spray or receiving no intervention OBJECTIVE To assess the effectiveness of sucrose as an analgesic agent during routine immunization injections for infants ( age range , 2 weeks to 18 months ) . STUDY DESIGN Double-blind , r and omized control trial . SETTING Ambulatory care clinic of a large tertiary care center . PARTICIPANTS A consecutive sample of 285 infants were r and omly assigned to one of three treatment groups . INTERVENTION Subjects received either no intervention or drank 2 mL of sterile water or 2 mL or a 12 % sucrose solution 2 minutes before administration of the immunization . MAIN OUTCOME MEASURE Infants were videotaped during immunization for later interval recording of pain-induced vocalizations . RESULTS Results were analyzed by using two-way repeated measure analyses of variance . Two-week-old infants who received either the sterile water or sucrose solution  cried significantly less than infants who received no intervention ( F=5.92,P<.005 ) . For older infants , those who received water or sucrose cried significantly less only if they were administered one injection rather than two injections ( F=3.36,P<.05 ) . CONCLUSIONS We found that when infants drank sucrose or sterile water , significantly fewer pain vocalizations were produced , but only for 2-week-old infants . For older infants , differences were found only when the number of injections was included in the analysis . We exp and on previous findings by demonstrating that both the age of the child and the number of painful exposures can attenuate calming effects . In addition , the results suggest that in the absence of nonnutritive sucking , the actual analgesic effects of sucrose may be nonspecific . Further study is needed of the possible analgesic effects of sucrose Acute  pain in infants is not assessed or managed optimally . The objectives of the study were ( a ) to adapt a behavioral pain assessment measure ( Children 's Hospital of Eastern Ontario Pain Scale , CHEOPS ) for use with infants , and ( b ) to establish the reliability and validity of the measure in a study of infants undergoing immunization . Ninety-six healthy 4- to 6-month-old infants were r and omized to receive either the local anesthetic cream Eutectic Mixture of Local Anesthetics ( EMLA ) ( N = 49 ) , or a placebo ( N = 47 ) prior to immunization . The infant 's behavioral response was videotaped immediately before and following the immunization . Postprocedural pain scores were assessed from the videotape and were significantly lower in infants who received EMLA ( P = 0.01 ) . Pain scores were also significantly correlated with visual analogue scale ( VAS ) scores assessed during vaccination . Five independent raters also independently rated ten infants to determine interrater reliability . Agreement between raters ' scores was high ( intraclass correlation coefficient , 0.95 ) . Results from this study suggest that this measure has beginning construct and concurrent validity and interrater reliability when used in a research study . Further testing of the measure in the clinical setting is required & NA ; Although EMLA is known to be an effective topical anesthetic , its rate of success is unknown . Indeed , research ers have suggested that EMLA may fail with young and apprehensive children . Therefore , the objectives of this study were to assess EMLA 's rate of success as well as factors which predict success . A double‐blind , placebo‐controlled design was utilized . The sample included 258 children and adolescents aged 5–18 years who were having venipuncture or intravenous ( i.v . ) cannulation . After having their anxiety assessed , subjects were r and omly assigned to have EMLA or placebo applied over the procedure site for 90 min . The visual analogue scale was used to assess pain caused by removal of the semi‐permeable dressing and by the procedure . Other information that was collected included : duration of drug application , interval between drug removal and procedure , skin changes at b and age and drug sites and rated difficulty of the procedure .  EMLA was successful 84 % of the time for venipuncture and 51 % of the time for i.v . cannulation . Factors which predicted success of EMLA  included type of procedure , duration of drug application and anxiety .  EMLA was less successful for i.v . cannulation compared to venipuncture even with duration of drug application controlled . Those who had a poor outcome were more anxious than those with a good outcome . Age of child was not a factor . Strategies for improving efficient use of EMLA were recommended PURPOSE To evaluate the effectiveness and age-related changes in analgesia of oral sucrose as a preprocedural intervention during routine immunizations in infants at 2 and 4 months of age . DESIGN A double-blind , r and omized , placebo-controlled clinical trial of 40 healthy term infants scheduled to receive routine immunizations from a pediatric ambulatory care clinic during May 2005 to July 2005 . METHODS Infants received 24 % oral sucrose solution or the control solution of sterile water 2 minutes before routine immunizations at both their 2- and 4-month , well-child visits . The University of Wisconsin Children 's Hospital pain scale was used to measure serial acute behavioral pain responses at baseline , 2 , and 5 minutes after administration of the solution . Repeated measures ANOVA was used to examine between-group differences and within-subject variability of the effects of treatment on overall behavioral pain scores . FINDINGS Infants receiving oral sucrose ( n=20 ) showed a significant reduction in behavioral pain response 5 minutes after administration compared to those in the placebo group ( n=20 ) . At 2 minutes following solution administration , both sucrose and sterile water showed the highest mean pain score ( 4.54 and 4.39 respectively ) indicating a severe amount of pain . At 5 minutes , the sucrose group returned to near normal at 0.27 while the placebo group remained at 3.02 indicating a percentage difference in mean pain scores relative to sterile water pain scores of 90.9 . No statistically significant age-related change in behavioral pain response was noted between 2- and 4-month-old infants at 2 minutes and 5 minutes following treatment administration . CONCLUSION Sucrose is an effective preprocedural intervention for decreasing behavioral pain response in infants after immunizations . CLINICAL RELEVANCE Efforts to decrease the pain associated with immunizations can promote parental adherence to recommended immunizations schedules , prevent a resurgence of vaccine-preventable diseases and mitigate adverse neurologic outcomes in infants Background : Sucrose is widely used to manage procedural pain in term newborns despite a lack of evidence of its effectiveness for different procedures and infant population s. Our objectives were to evaluate the effectiveness and safety of sucrose in newborns undergoing various medical procedures within 2 days of birth . Methods : We performed a double-blind , r and omized controlled trial . We included newborns ( ≥ 36 weeks gestation ) of diabetic mothers and nondiabetic mothers . Each newborn received 2 mL of a 24%-sucrose or placebo solution before all procedures . We used the Premature Infant Pain Profile to assess pain during intramuscular injection of vitamin K , venipuncture for the newborn screening test and the first 3 heel lances for glucose monitoring ( newborns of diabetic mothers only ) . Scores ranged from from 0 ( no pain ) to 18 ( maximum pain ) . Results : We included 240 newborns ( 120 from diabetic mothers , 120 from nondiabetic mothers ) .  The overall mean pain score was lower among newborns who received sucrose than among those who received a placebo ( mean difference –1.3 , 95 % confidence interval [ CI ] –2.0 to –0.6 ) . We found that pain scores during intramuscular injection did not differ significantly between the sucrose and placebo groups for newborns of diabetic or nondiabetic mothers ( newborns of nondiabetic mothers : mean difference –1.1 , 95 % CI –2.4 to 0.2 ; newborns of diabetic mothers : mean difference –1.0 , 95 % CI –2.4 to 0.4 ) . During venipuncture , newborns who received sucrose  had lower pain scores compared with those who received a placebo ( newborns of nondiabetic mothers : mean difference –3.2 , 95 % CI –4.6 to –1.8 ; newborns of diabetic mothers : mean difference –2.4 , 95 % CI –3.8 to –1.0 ) . Among newborns of diabetic mothers , there was no difference in pain during the first 3 heel lances or mean glucose levels between the sucrose and placebo groups ( p = 0.94 and p = 0.29 respectively ) . Interpretation : We found a modest reduction of pain in newborns of both diabetic and nondiabetic mothers when sucrose was used for all medical procedures performed in the first 2 days after birth . However , when each procedure was analyzed separately , we found that the effectiveness of sucrose was limited to venipuncture for the newborn screening test . ( http:// Clinical trials.gov trial register no. NCT00213213 . Objectives The purpose of this study was to evaluate the effectiveness of vapocoolant for preschoolers ' immunization injection pain relief  . Methods Fifty-seven 4 to 6-year-old children were  r and omized  into vapocoolant alone or typical care conditions .  Pain was measured at the baseline and at injection via self-report , caregiver report , nurse report , and by an observational scale . Results Self-report of pain suggested that children in the vapocoolant alone condition demonstrated stronger increases in pain from baseline to injection than children in the typical care condition . All other measures showed significant increases in pain from baseline to injection , but no other measures indicated treatment effects . Discussion This study revealed that vapocoolant is not an effective pain management intervention for children 's intramuscular injections Although pain management is an important nursing responsibility , few interventions for minimizing distress of infants during painful procedures have been studied . Sixty infants , 2 through 6 months of age , were studied during a routine DPT immunization in order to examine ( a ) the effectiveness of cooling the skin in reducing distress behaviors and ( b ) the relationship between age and distress behavior . Infants were r and omly assigned to experimental or control groups . Prior to the injection , the sites were sprayed for 2 to 3 s with either a skin refrigerant/anesthetic or compressed air . Behaviors were video- and audio-taped during and 60 s post injection , and coded for ( a ) facial expression , ( b ) cry , and ( c ) body movements . MANOVA revealed fewer distress behaviors following refrigerant spray and more complex , varied behavioral responses for older infants . The findings provide further evidence that infants perceive pain and that nursing interventions for pain reduction should be tested and extended to the very young BACKGROUND Comprehensive international travel preparation often requires several vaccines . Up to 90 % of adults have some fear of injections , mostly due to injection-related pain . Pediatric studies with routine vaccines have shown topical anesthetic EMLA cream ( lidocaine and prilocaine , Astra Pharmaceuticals , Inc. ) and the topical vapocoolant Fluori-Methane ( dichlorodifluoromethane and trichlorodifluoromethane , Gebauer Co. ) to be equally effective in reducing pain from vaccinations . EMLA cream is expensive and requires a 60-min application , while Fluori-Methane ( FM ) is immediate in onset of action and inexpensive . Skin anesthesia begins at 10 degrees C. Fluori-Methane can briefly cool the skin to 0 degrees C. METHODS We studied the effectiveness of topical vapocoolant on adult clients at our international travel clinic in a r and omized , controlled trial of topical FM vs. cold ( 4 degrees C ) saline placebo . Using a preset r and omization table , participants served as their own controls , receiving placebo/control or active agent ( participant blinded ) in one arm ( left or right ) , and a similar number of vaccines in the untreated arm . Vaccines were administered according to a set protocol per arm to minimize the risk of bias . Pain was measured using a modified McGill present pain intensity ( PPI ) pain index . Subjects rated their pain immediately and at 5 min on a six-level scale , noting treated and untreated arms separately . A question naire was completed on intervention preferences . Sample size was predetermined to achieve 90 % statistical power estimating 25 % efficacy ( minimum n=172 ) . RESULTS One hundred and eighty-five participants were enrolled ; 93 FM and 92 cold saline placebo .  FM-treated arms had a significant reduction in immediate pain compared to untreated arms ( pain scale mean 2.2 vs. 3.1 ; p<.0001 ) , and compared to placebo ( mean 2.2 vs. 2.8 ; p<.01 ) . Delayed pain at 5 min was not affected by FM or control ( mean 1.9 vs. 2.0 ) compared to no intervention ( pain scale 1.9 ) . The intervention preference question naire indicated that participants did not find FM therapy uncomfortable . They would choose FM therapy in the future , over a cream , especially if a wait was involved . CONCLUSION The topical vapocoolant Fluori-Methane is an effective , quick , preferred , inexpensive agent for reducing vaccine-associated injection pain for international travel clients & NA ; The objective of this study is to determine whether use of lidocaine – prilocaine 5 % cream ( EMLA ® ) and oral glucose decreases pain associated with diphteria – pertussis – tetanus ( DPT ) immunization in 3‐month‐old infants . Design : r and omized , double‐blind , controlled trial in outpatient paediatric practice in northern Sweden .  EMLA or placebo was applied to the infant 's lateral region of the right thigh and covered with an occlusive dressing 1 h before the immunization . In addition , 1 ml of glucose ( 300 mg/ml ) or placebo ( water ) was instilled on the baby 's tongue within 2 min before the DPT‐injection . Forty‐five infants received EMLA and glucose  and 45 infants placebo cream and water . ECG was recorded and stored in a computer and the procedure was videotaped . The parents and the nurse assessed the infants ' pain on a visual analogue scale ( VAS ) after the immunization . Heart rate and heart rate variability pre‐ and post‐injection were calculated . From the videotapes , the modified behavioural pain scale ( MBPS ) was used to assess pain scores during baseline and after immunization . The latency of the first cry and total crying time were measured . The parents and the nurse scored the infants ' pain on the VAS significantly lower in the treatment group than in the placebo group . The infants ' responses to the immunization measured as the difference in MBPS scores pre‐ and post‐injection were significantly lower in the EMLA – glucose group compared with the placebo group . More infants cried after the immunization in the placebo group compared with the EMLA – glucose group and the latency of the first cry after the injection was shorter in the placebo group . A biphasic transient heart rate response with a marked deceleration followed by a subsequent acceleration was seen more frequently in the placebo group compared to the EMLA – glucose group . EMLA and glucose  alleviate immunization pain in 3‐month‐old infants In human newborns , small amounts of sucrose reduce crying with procedural pain by about 50 % . To determine whether “ sucrose analgesia ” could be extended to painful procedures beyond the newborn period , 57 infants were r and omly assigned to receive three 250-$mUl doses of 50 % sucrose solution ( g/100 mL ) or water before their diphtheria-tetanus-pertussis immunizations at 2 and 4 months of age . Crying during and after injection was measured separately to determine whether sucrose modified crying during the noxious stimulus , recovery from the stimulus , or both . Sucrose was effective in reducing crying only from 83 to 69 % , and the reduction was limited to the postinjection period . We conclude that , although sucrose continues to have some effect beyond the newborn period , the effect is limited to recovery from the noxious stimulus , is clinical ly modest , and is probably smaller than in the newborn period Eighteen , healthy male newborns , 2–5 days old , were subjects in this study of the effects of a pacifier on the newborn 's behavioral and adrenocortical responses to circumcision . Half of the subjects were r and omly assigned to a condition in which they were encouraged to suck on a pacifier during circumcision , while half served in a no pacifier , control condition .  Behavioral observations were made for 1/2 hour before , during , and after circumcision ; while blood sample s for serum cortisol determination were obtained immediately before circumcision and 30 min later . The results showed that stimulating the newborn with the pacifier  reduced crying by about 40 % . Reducing crying , however , had no significant effect on the adrenocortical response . Elevations of serum cortisol predicted average behavioral state following circumcision , whereas crying during circumcision did not . Furthermore , there was evidence that the neonatal adrenocortical system was sensitive to variations in surgical procedures . The results indicate the importance of obtaining data on both behavioral and hormonal systems in studies of stress and coping in human newborns We have evaluated the efficacy and safety of a preparation of 4 % amethocaine gel in alleviating the  pain of venous cannulation in children . In an initial open study of 148 children , clinical ly acceptable anaesthesia was achieved in 92 % of cases . The preparation was then compared with 5 % EMLA cream in a single-blind study in 94 patients using an application time of 40 min . We found clinical ly acceptable conditions in 85 % of patients receiving amethocaine gel compared with 66 % in the EMLA group . There were no significant adverse effects noted in each group , although 37 % of those children treated with amethocaine gel showed localized erythema at the application site . The results suggest that amethocaine gel has greater efficacy and a faster onset time than EMLA cream when used for this purpose in children
BACKGROUND Immunization is the most common cause of iatrogenic pain in childhood .
Despite the availability of various analgesics to manage vaccine injection pain , they have not been incorporated into clinical practice .
To date , no systematic review has been published on the effectiveness of pharmacologic and combined interventions for reducing injection pain .
OBJECTIVES The objectives of this article were to assess the effectiveness and tolerability of various pharmacologic and combined interventions for reducing the pain experienced by children during immunization .