Published online May 26, 2009
PEDIATRICS Vol. 123 No. 6 June 2009, pp. 1548-1555 (doi:10.1542/peds.2008-1897)
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ARTICLE

Does Nebulized Lidocaine Reduce the Pain and Distress of Nasogastric Tube Insertion in Young Children? A Randomized, Double-Blind, Placebo-Controlled Trial

Franz E. Babl, MD, MPH, FRACP, FAAPa,b,c, Christopher Goldfinch, BScc, Christine Mandrawa, BScc, Dianne Crellin, MNa,b,c, Ronan O'Sullivan, MB, FRCSI, FCEM, MBAa and Susan Donath, PhDb,c

a Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
b Murdoch Children's Research Institute, Parkville, Victoria, Australia
c Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia

OBJECTIVES. Nasogastric tube insertion is a common procedure in children that is very painful and distressing. Although nebulized lidocaine has been shown to be effective in reducing the pain and discomfort of nasogastric tube insertion in adults, there have been no similar studies in children. We set out to investigate the role of nebulized lidocaine in reducing pain and distress of nasogastric tube insertion in young children.

METHODS. We conducted a randomized, double-blind, placebo-controlled trial of nebulized 2% lidocaine at 4 mg/kg versus saline placebo during nasogastric tube insertion at a tertiary urban pediatric emergency department. Patients were eligible if they were aged from 1 to 5 years with no comorbid disease and a clinical indication for a nasogastric tube. Nebulization occurred for 5 minutes, 5 minutes before nasogastric tube insertion. Video recordings before, during, and after the procedure were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) pain and distress assessment tool (primary outcome measure) and pain and distress visual analog scale scores (secondary outcome measures). Difficulty of insertion and adverse events were also assessed.

RESULTS. Eighteen participants were nebulized with 2% lidocaine and 18 participants with normal saline. Nebulization was found to be highly distressing. FLACC scores during nasogastric tube insertion were very high in both groups. There was a trend in the post–nasogastric tube insertion period toward lower FLACC scores in the lidocaine group. Visual analog scale scores for this postinsertion period were significantly lower in the lidocaine arm for pain and distress. There were no significant differences between groups in terms of difficulty of insertion and the number of minor adverse events. The study was terminated early because of the distress and treatment delay associated with nebulization.

CONCLUSIONS. Nasogastric tube insertion results in very high FLACC scores irrespective of lidocaine use. Nebulized lidocaine cannot be recommended as pain relief for nasogastric tube insertion in children. The delay and distress of nebulization likely outweigh a possible benefit in the postinsertion period.

Key Words: nasogastric intubation • lidocaine • child • distress • pain • FLACC

Abbreviations: NGT—nasogastric tube • ED—emergency department • VAS—visual analog scale • RCT—randomized, controlled trial • FLACC—Face, Legs, Activity, Cry and Consolability • IQR—interquartile range

Accepted Sep 25, 2008.


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