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Three Part Question

In [neonates who require diagnositic lumbar puncture] do [topical anesthetics] [reduce the amount of pain experienced].

Clinical Scenario

A three week old infant presents to the emergency department with a fever. As part of the septic workup a lumbar puncture will be preformed. You wonder whether a topical anaesthetic will reduce the baby’s pain.

Search Strategy

Ovid MEDLINE(R) 1950 to September Week 4 2008: [(exp spinal puncture or spinal puncture.mp or lumbar adj puncture.mp.) AND (exp anesthetics/local or exp anesthetics/combined or topical anesthe$.mp. or topical anaesthe$.mp. or exp prilocaine or exp lidocaine or emla.mp)]. Limit to humans AND English AND "newborn infant (birth to 1 month)"
EMBASE 1980 to 2008 Week 39: (lumbar puncture.mp. or exp Lumbar Puncture/ or spinal puncture.mp.) AND (exp Topical Anesthesia/ or topical anaesthe$.mp. or topical anesthe$.mp. or emla.mp. or exp EMLA/ or exp PRILOCAINE/ or exp LIDOCAINE/) LIMIT to (human and english language, Routes of Drug Administration, Topical and (infant or child ))
The Cochrane Library Issue 3 2008: (neonates):ti,ab,kw AND (lumbar puncture):ti,ab,kw 5 records 0 relevant

Search Outcome

Altogether 23 papers were found of which 22 were irrelevant to the question or of insufficient quality for inclusion. The remaining paper is shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kaur G, et al November 2003 India	60 newborns admitted to the neonatal intensive care unit who were less than 4 weeks old, born after 34 weeks gestation, and who were undergoing diagnostic lumbar puncture for rule out sepsis. EMLA vs placebo	PRCT	Mean heart rate at needle insertion	159.3 vs 175.2 (P<0.001)	Not all children had similar gestational ages. Only one person performed the behavioural scoring (it was blinded).
			Total behavioural score at needle insertion	4 vs 5 (P<0.001)

Comment(s)

The only relevant study found was preformed in the neonatal intensive care unit. The study design was well thought out and did show a decrease in the physiologic markers of pain with use of EMLA cream. However both EMLA and placebo group showed significant increases in heart rate and behavioural scores during the procedure. Both groups also had a significant decrease in oximetry during the procedure. It was unfortunate that only one study could be found that dealt exclusively with neonates. Two additional PRCT were identified, but these dealt with children with cancer who were undergoing diagnostic lumbar puncture. Both compared EMLA to placebo, and both showed a favourable effect of EMLA on pain scores. Although the study was performed in the neonatal intensive care unit it should be applicable to the target group (neonates presenting to the ER for septic workup).

Clinical Bottom Line

Topical anaesthetics in one study have been showed to blunt the physiologic markers of pain, but not provide a pain free procedure. Topical anaesthetic is preferable to no anaesthetic during diagnostic lumbar puncture.

References

1. Kaur G, Gupta P, Kumar A A Randomized Trial of Eutectic Mixture of Local Anesthetics During Lumbar Puncture in Newborns Arch Pediatr Adolesc Med 2003;157:1065-1070