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Eutectic mixture of local anesthetics and amethocaine as topical anesthetics in pediatrics: a meta-analysis

Pediatric Research (2024)Cite this article

Abstract

Background

Pediatric patients often receive topical anesthesia before skin procedures in the Emergency Department, with EMLA cream and amethocaine gel being common choices. The most effective option remains a subject of debate.

Objective

Our goal was to compare EMLA cream with amethocaine gel in pediatric patients undergoing topical anesthesia, focusing on outcomes: first-attempt cannulation success, child-reported visual analogue scale (VAS) score, parent-reported VAS score, observed pain score, child-reported absence of pain, and child-reported acceptable anesthesia.

Methods

A database search for studies comparing EMLA cream and amethocaine gel in pediatric topical anesthesia was conducted. Two reviewers extracted and cross-verified data, with a third ensuring accuracy. Using R software, a pairwise meta-analysis was performed via the Mantel-Haenszel method. Outcomes were pooled as risk ratios or standard mean differences with 95% confidence intervals using the random-effects model.

Results

Amethocaine gel surpasses EMLA cream in child-reported pain absence and first cannulation success. No significant differences were found in child-reported acceptable anesthesia or observed pain scores. Similarly, child- and parent-reported VAS scores showed no variations between EMLA and amethocaine.

Conclusion

This analysis favors amethocaine gel for pediatric topical anesthesia. Further large randomized trials comparing EMLA cream and amethocaine gel in pediatric patients are warranted.

Impact

Procedural pain is a major concern for pediatric patients, their families, and physicians. Topical anesthesia is routinely given prior to children undergoing skin-related procedures in the Emergency Department. In pediatric patients, topical anesthetics such as eutectic mixture of local anesthetics cream and amethocaine gel have proved to be pioneering in pain reduction, but the most effective method is often disputed. Presently, this is the most comprehensive pooled analysis of trials comparing EMLA cream and amethocaine gel in pediatric patients undergoing topical anesthesia. Amethocaine performed better with regards to child-reported absence of pain and first attempt cannulation success.

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Fig. 1: Forest plot comparing Eutectic mixture of local anesthetics (EMLA) cream with amethocaine gel for first attempt cannulation success rate.
Fig. 2: Forest plot comparing Eutectic mixture of local anesthetics (EMLA) cream with amethocaine gel for child-reported absence of pain.
Fig. 3: Forest plot comparing Eutectic mixture of local anesthetics (EMLA) cream with amethocaine gel for child-reported visual analogue scale (VAS) score.
Fig. 4: Forest plot comparing Eutectic mixture of local anesthetics (EMLA) cream with amethocaine gel for parent-reported visual analogue scale (VAS) score.
Fig. 5: Forest plot comparing Eutectic mixture of local anesthetics (EMLA) cream with amethocaine gel for observed pain score.
Fig. 6: Forest plot comparing Eutectic mixture of local anesthetics (EMLA) cream with amethocaine gel for child-reported acceptable anesthesia.

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Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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Author notes

  1. These authors contributed equally: Kathryn S. Varghese, Adham Ahmed.

Authors and Affiliations

  1. CUNY School of Medicine, New York, NY, USA

    Kathryn S. Varghese, Adham Ahmed, Dave M. Mathew & Peter J. Fusco

  2. The Feinstein Institutes for Medical Research, New Hyde Park, NY, USA

    Mabel N. Abraham

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Contributions

Two authors (K.V. & A.A.) reviewed 1438 titles and abstracts after eliminating duplicate citations. Two investigators (A.A. & D.M.) reviewed the full texts of the remaining articles for eligibility, with disagreements being resolved by a third investigator (P.F.). After reviewing the articles, two authors (K.V. and A.A.) independently extracted data from the studies that were included. If there were any disagreements, a third author (M.A.) reviewed them. To ensure accuracy and fairness, two separate authors (A.A. & D.M.) evaluated the quality of each study using the Newcastle Ottawa Scale for observational studies, which rates observational studies quality via asterisk score in three domains: up to four asterisks for patient selection, up to two for comparability of study arms, and up to three asterisks for sufficient outcome follow-up duration/assessment. In cases where there were discrepancies, a third author (P.F.) was consulted and a group discussion was held to reach a consensus. One author (M.A.) oversaw the editing and development of the manuscript.

Corresponding author

Correspondence to Kathryn S. Varghese.

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Varghese, K.S., Ahmed, A., Mathew, D.M. et al. Eutectic mixture of local anesthetics and amethocaine as topical anesthetics in pediatrics: a meta-analysis. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03113-7

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