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EMLA or amethocaine (tetracaine) for topical analgesia in children

Three Part Question

In [a 5 year old child] is [EMLA or amethocaine gel] better at [reducing the pain of venepunture]?

Clinical Scenario

A 5 year old child is to undergo venepuncture for a diagnostic blood test. You wonder if the application of Ametop (4% amethocaine gel) or EMLA (eutectic mixture of local anaesthetics [2.5% lignocaine (lidocaine)with 2.5% prilocaine]) will be better at reducing the pain of venepuncture.

Search Strategy

Medline 1966-09/04 using the OVID interface and The Cochrane Library, Issue 3, 2004.
Medline: [(exp tetracaine OR OR AND (exp prilocaine OR OR OR exp lidocaine OR AND (exp anesthetics, combined OR exp anesthetics, local)] LIMIT to human AND English language.
Cochrane: emla OR tetracaine

Search Outcome

Altogether 274 papers were found of which 268 were irrelevant or of insufficient quality. The remaining six papers are shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Lawson RA et al,
Convenience sample of 94 children age 3-12 years undergoing pre-op cannulation Amethocaine vs EMLA PRCTSelf reported abscence of pain62% (34/55) vs 32% (18/55) (p<0.05)40 minute application time for EMLA too short
Van Kam HJ et al,
Convenience sample of 68 children age 1-15 years undergoing cannulation or venepuncture Tetracaine vs EMLA PRCTAdequacy of analgesia reported by phlebotomists76% (26/34) vs 97% (31/32) (p=0.02)No standardised method of pain scoring
Choy L,
Convenience sample of 34 children aged over 1 year undergoing outpatient venepuncture Amethocaine vs EMLA PRCTSelf reported pain scoreNo significant difference Very small numbers and no power calculation
Observational behaviour pain scoreNo significant difference
Romsing J et al,
Convenience sample of 60 children age 3-15 years undergoing pre-op cannulation Tetracaine vs EMLA PRCTSelf reported pain scoreSignificantly lower in tetracaine group (p<0.05)Variable time from removal to cannulation in tetracaine group
Bishai R et al,
39 children aged 5-16 undergoing port-a-cath insertionPRCTPain scores from patients, parents and nursesNo significant difference between the two groupsBlinding only successful in >70% children
Arrowsmith J and Campbell C,
Convenience sample of 120 children age 1-15 years undergoing cannulation Amethocaine vs EMLA PRCTObservational behaviour pain score72% (43/60) nil or mild vs 55% (33/60)


The studies listed are of variable quality but the trend seems to favour Ametop as the superior anaesthetic. This product may also have advantages in terms of speed of onset and vasodilation.

Editor Comment

Search updated 09/2004 no new papers found. N.B. A relevant protocol was found in Cochrane (Lander JA, Weltman BJ. Topical anaesthetics (EMLA and AMETOP creams) for reduction of pain during needle insertion in children (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd). The review is expected to be published in Issue 4, 2004.

Clinical Bottom Line

Ametop is superior to EMLA for topical analgesia before venepuncture in children.


  1. Lawson RA, Smart NG, Gudgeon AC et al. Evaluation of an amethocaine gel preparation for percutaneous analgesia before venous cannulation in children. Br J Anaesth 1995;75:282-5.
  2. Van Kam HJ, Egberts AC, Rijnvos WP et al. Tetracaine versus lidocaine-prilocaine for preventing venipuncture-induced pain in children. Am J Health-Syst Pharm 1997;54:388-92.
  3. Choy L, Collier J, Watson AR. Comparison of lignocaine-prilocaine cream and amethocaine gel for local analgesia before venepuncture in children. Acta Paediatr 1999;88:961-4.
  4. Romsing J, Henneberg SW, Walther-Larson S et al. Tetracaine gel vs EMLA cream for percutaneous anaesthesia in children. Br J Anaesth 1999;82(4):637-8.
  5. Bishai R, Taddio A, Bar-Oz B et al. Relative efficacy of amethocaine gel and lidocaine-prilocaine cream for port-a-cath puncture in children. Pediatrics 1999;104(3):e31.
  6. Arrowsmith J, Campbell C. A comparison of local anaesthetics for venepuncture. Arch Dis Child 2000;82:309-10.