Topical anesthetic may not reduce distress from nasogastric-tube insertion in young kids

Last Updated: 2019-05-07

By Scott Baltic

NEW YORK (Reuters Health) - A nasal spray containing lidocaine and phenylephrine appears to be no better than placebo in relieving procedure-related distress in infants and young children undergoing nasogastric-tube insertion, Australian researchers have found.

"Having a nasogastric tube placed is really uncomfortable. There have been many studies in adults which suggest that we can make it hurt less by using a numbing medication, either with a spray, or gel, or as an inhaled mist," Dr. Simon Craig of Monash Medical Centre, in Melbourne, told Reuters Health by email.

"It is almost impossible in a young child to work out whether they are upset during a procedure because it hurts, or because it is scary, or because it's yucky having something placed in your nose and down your throat," he explained.

"In young children, usual practice in most places is just to hold them still while the procedure is done, without much pain relief. Unfortunately, the procedure is quite distressing, and we were hoping to demonstrate that the use of medication in children might help," Dr. Craig added.

He and his colleagues conducted a double-blind, randomized, placebo-controlled superiority trial in 100 children ages 6 months to 5 years who were assigned to receive either a commercially available nasal spray with 5% lidocaine hydrochloride and 0.5% phenylephrine hydrochloride or placebo (0.9% sodium chloride)

The study, online April 15 in The Lancet Child and Adolescent Health, is the first adequately powered trial to evaluate the effectiveness of topical local anesthetic and vasoconstrictor use before nasogastric tube insertion in children in that age range, the researchers say.

It was based on a convenience sample of patients who were slated to have a nasogastric tube inserted as part of treatment in the emergency department of a tertiary referral center from 2014 to 2017. The most common reason for tube insertion was dehydration arising from gastroenteritis.

One spray of active medication delivered 5 mg lidocaine and 0.5 mg phenylephrine. Children weighing 6-12 kg received one spray to each nostril, and children over 12 kg received two sprays to each nostril.

The primary outcome was procedure-related distress as measured with the Face, Legs, Activity, Cry and Consolability (FLACC) scale.

There was no between the treatment and placebo groups in the median FLACC score between active treatment (9) and placebo (9) during insertion.

Dr. Craig advised clinicians to "remember how uncomfortable nasogastric tubes are. We should only use them when necessary, and do our best to manage distress relating to their insertion with whatever means we have," including local anesthetic spray, sedation, or both.

In a linked editorial, Dr. Rebeccah Slater of the department of pediatrics at the University of Oxford John Radcliffe Hospital, in the U.K., highlights the fact that "in more than 30% of the children in each group nasogastric tube insertion evoked the maximum FLACC score, limiting the discriminative ability of the outcome measure for this procedure."

Noting the difficulties of distinguishing between pain and distress in young children, she concludes that "we must be cautious, as the authors are, not to fall into the trap of saying that analgesics do not provide pain relief in children until we are confident that the outcome measures we are using adequately measure analgesic efficacy."

Dr. Rita Agarwal, president of the Society for Pediatric Pain Medicine, expressed similar concerns. She added that the two most uncomfortable areas with tube placement are at the top of the nasopharynx and getting the tube past the back of the mouth, because of the gag reflex.

Unless lidocaine can get to those areas, which are deep and hard to reach, "it is unlikely that there would be a significant decrease in pain/distress," Dr. Agarwal, who was not involved in the study, told Reuters Health by email.

Another issue is dosing, according to Dr. Agarwal. "It is unclear how much lidocaine spray would need to be administered to have any effect and how much would be too much. Without that information, they are guessing, somewhat blindly."

"(G)enerous lidocaine jelly should be more effective, if it could be administered slowly enough and the children tolerated having it in their noses," she advised.

The study did not have commercial funding, and the authors disclosed no conflicts of interest.

SOURCE: https://bit.ly/2IwlrYc and https://bit.ly/2vuCH7E

Lancet Child Adolesc Health 2019.