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Topical anesthetics in children

Deborah C Hsu, MD, MEd
Section Editor
Anne M Stack, MD
Deputy Editor
James F Wiley, II, MD, MPH


Painful procedures, such as venipuncture, intravenous cannulation, lumbar puncture, and laceration repair, are common in pediatrics and cause distress to children and their parents. The stress response to pain is associated with metabolic and hormonal changes that are attenuated by anesthesia [1,2].

Anesthesia can be provided by injection. However, topical anesthetics can be applied painlessly without needles and reduce the need for physical and chemical restraints [3]. They also avoid the tissue distortion that occurs with infiltrated anesthetics [4].

Nonpharmacologic interventions (eg, behavioral techniques, cognitive techniques) are an essential part of any attempt to attenuate pain in the conscious child and enhance the benefit of local anesthesia. (See "Procedural sedation in children outside of the operating room", section on 'Nonpharmacologic interventions'.)

The use of topical anesthetics is reviewed here. A general approach to the management of pain and sedation in children, and prevention and treatment of neonatal pain are discussed elsewhere. (See "Procedural sedation in children outside of the operating room" and "Prevention and treatment of neonatal pain".)


LET is a combination of lidocaine (4 percent), epinephrine (0.1 percent), and tetracaine (0.5 percent) available as an aqueous solution or methylcellulose based gel. The local anesthetics cause sensory and motor blockade primarily by reversible inhibition of axonal sodium channels, blocking conduction of action potentials [5]. This results in numbness and weakness. Epinephrine causes local vasoconstriction that slows systemic absorption and metabolism of the anesthetics [6]. Lidocaine, in the amide class of anesthetics, is metabolized by the liver; tetracaine, in the ester class, is metabolized in plasma by pseudocholinesterase [5].

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Literature review current through: Nov 2017. | This topic last updated: Sep 22, 2016.
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  1. Cordoni A, Cordoni LE. Eutectic mixture of local anesthetics reduces pain during intravenous catheter insertion in the pediatric patient. Clin J Pain 2001; 17:115.
  2. Goldman RD, Koren G. Biologic markers of pain in the vulnerable infant. Clin Perinatol 2002; 29:415.
  3. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999; 34:356.
  4. Smith GA, Strausbaugh SD, Harbeck-Weber C, et al. Comparison of topical anesthetics without cocaine to tetracaine-adrenaline-cocaine and lidocaine infiltration during repair of lacerations: bupivacaine-norepinephrine is an effective new topical anesthetic agent. Pediatrics 1996; 97:301.
  5. Berde CB. Toxicity of local anesthetics in infants and children. J Pediatr 1993; 122:S14.
  6. Kennedy RM, Luhmann JD. The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am 1999; 46:1215.
  7. Schilling CG, Bank DE, Borchert BA, et al. Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Ann Emerg Med 1995; 25:203.
  8. Ernst AA, Marvez E, Nick TG, et al. Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics 1995; 95:255.
  9. Resch K, Schilling C, Borchert BD, et al. Topical anesthesia for pediatric lacerations: a randomized trial of lidocaine-epinephrine-tetracaine solution versus gel. Ann Emerg Med 1998; 32:693.
  10. Singer AJ, Stark MJ. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: a randomized double-blind trial. Acad Emerg Med 2000; 7:751.
  11. Singer AJ, Stark MJ. LET versus EMLA for pretreating lacerations: a randomized trial. Acad Emerg Med 2001; 8:223.
  12. Tayeb BO, Eidelman A, Eidelman CL, et al. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database Syst Rev 2017; 2:CD005364.
  13. Karim A, Ahmed S, Siddiqui R, Mattana J. Methemoglobinemia complicating topical lidocaine used during endoscopic procedures. Am J Med 2001; 111:150.
  14. Bonadio WA. TAC: a review. Pediatr Emerg Care 1989; 5:128.
  15. Harman S, Zemek R, Duncan MJ, et al. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ 2013; 185:E629.
  16. Brofeldt BT, Cornwell P, Doherty D, et al. Topical lidocaine in the treatment of partial-thickness burns. J Burn Care Rehabil 1989; 10:63.
  17. Fein JA, Zempsky WT, Cravero JP, et al. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2012; 130:e1391.
  18. Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2004; 114:1348.
  19. Leahy S, Kennedy RM, Hesselgrave J, et al. On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics 2008; 122 Suppl 3:S161.
  20. Zempsky WT. Pharmacologic approaches for reducing venous access pain in children. Pediatrics 2008; 122 Suppl 3:S140.
  21. Steward DJ. Eutectic mixture of local anesthetics (EMLA): what is it? What does it do? J Pediatr 1993; 122:S21.
  22. Gajraj NM, Pennant JH, Watcha MF. Eutectic mixture of local anesthetics (EMLA) cream. Anesth Analg 1994; 78:574.
  23. Babich D, Crollick JS. Pediatric dermatologic surgery for the primary care pediatrician. Pediatr Clin North Am 1998; 45:1437.
  24. Zempsky WT, Karasic RB. EMLA versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med 1997; 30:163.
  25. Halperin DL, Koren G, Attias D, et al. Topical skin anesthesia for venous, subcutaneous drug reservoir and lumbar punctures in children. Pediatrics 1989; 84:281.
  26. Lander J, Hodgins M, Nazarali S, et al. Determinants of success and failure of EMLA. Pain 1996; 64:89.
  27. Young SS, Schwartz R, Sheridan MJ. EMLA cream as a topical anesthetic before office phlebotomy in children. South Med J 1996; 89:1184.
  28. Bjerring P, Arendt-Nielsen L. Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream. Br J Anaesth 1990; 64:173.
  29. Juhlin L, Hägglund G, Evers H. Absorption of lidocaine and prilocaine after application of a eutectic mixture of local anesthetics (EMLA) on normal and diseased skin. Acta Derm Venereol 1989; 69:18.
  30. Elsner P, Dummer R. Signs of methaemoglobinaemia after topical application of EMLA cream in an infant with haemangioma. Dermatology 1997; 195:153.
  31. Curtis LA, Dolan TS, Seibert HE. Are one or two dangerous? Lidocaine and topical anesthetic exposures in children. J Emerg Med 2009; 37:32.
  32. Sinisterra S, Miravet E, Alfonso I, et al. Methemoglobinemia in an infant receiving nitric oxide after the use of eutectic mixture of local anesthetic. J Pediatr 2002; 141:285.
  33. Jakobson B, Nilsson A. Methemoglobinemia associated with a prilocaine-lidocaine cream and trimetoprim-sulphamethoxazole. A case report. Acta Anaesthesiol Scand 1985; 29:453.
  34. Hoss DM, Gross EG, Grant-Kels JM. Histopathology of an adverse reaction to a eutectic mixture of the local anesthetics lidocaine and prilocaine. J Cutan Pathol 1999; 26:100.
  35. Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics 2002; 109:1093.
  36. Kleiber C, Sorenson M, Whiteside K, et al. Topical anesthetics for intravenous insertion in children: a randomized equivalency study. Pediatrics 2002; 110:758.
  37. Koh JL, Harrison D, Myers R, et al. A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth 2004; 14:977.
  38. Smith DP, Gjellum M. The efficacy of LMX versus EMLA for pain relief in boys undergoing office meatotomy. J Urol 2004; 172:1760.
  39. Taddio A, Soin HK, Schuh S, et al. Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial. CMAJ 2005; 172:1691.
  40. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg 2012; 38:709.
  41. O'Brien L, Taddio A, Lyszkiewicz DA, Koren G. A critical review of the topical local anesthetic amethocaine (Ametop) for pediatric pain. Paediatr Drugs 2005; 7:41.
  42. Poonai N, Alawi K, Rieder M, et al. A comparison of amethocaine and liposomal lidocaine cream as a pain reliever before venipuncture in children: a randomized control trial. Pediatr Emerg Care 2012; 28:104.
  43. Maulidi H, McNair C, Seller N, et al. Arrhythmia associated with tetracaine in an extremely low birth weight premature infant. Pediatrics 2012; 130:e1704.
  44. Singer AJ, Taira BR, Chisena EN, et al. Warm lidocaine/tetracaine patch versus placebo before pediatric intravenous cannulation: a randomized controlled trial. Ann Emerg Med 2008; 52:41.
  45. Zempsky WT, Robbins B, Richards PT, et al. A novel needle-free powder lidocaine delivery system for rapid local analgesia. J Pediatr 2008; 152:405.
  46. Zempsky WT, Bean-Lijewski J, Kauffman RE, et al. Needle-free powder lidocaine delivery system provides rapid effective analgesia for venipuncture or cannulation pain in children: randomized, double-blind Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial. Pediatrics 2008; 121:979.
  47. Jimenez N, Bradford H, Seidel KD, et al. A comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient. Anesth Analg 2006; 102:411.
  48. Spanos S, Booth R, Koenig H, et al. Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care 2008; 24:511.
  49. Auerbach M, Tunik M, Mojica M. A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department. Acad Emerg Med 2009; 16:388.
  50. Lunoe MM, Drendel AL, Brousseau DC. The use of the needle-free jet injection system with buffered lidocaine device does not change intravenous placement success in children in the emergency department. Acad Emerg Med 2015; 22:447.
  51. Gulur P, Cohen AR, Watt L, et al. Elevated lidocaine serum concentration after subcutaneous lidocaine administration using a needle-free device in pediatric patients. Pediatr Emerg Care 2014; 30:829.
  52. Griffith RJ, Jordan V, Herd D, et al. Vapocoolants (cold spray) for pain treatment during intravenous cannulation. Cochrane Database Syst Rev 2016; 4:CD009484.
  53. Cohen Reis E, Holubkov R. Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children. Pediatrics 1997; 100:E5.
  54. Farion KJ, Splinter KL, Newhook K, et al. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ 2008; 179:31.
  55. Yoon WY, Chung SP, Lee HS, Park YS. Analgesic pretreatment for antibiotic skin test: vapocoolant spray vs ice cube. Am J Emerg Med 2008; 26:59.
  56. Galinkin JL, Rose JB, Harris K, Watcha MF. Lidocaine iontophoresis versus eutectic mixture of local anesthetics (EMLA) for IV placement in children. Anesth Analg 2002; 94:1484.
  57. Kim MK, Kini NM, Troshynski TJ, Hennes HM. A randomized clinical trial of dermal anesthesia by iontophoresis for peripheral intravenous catheter placement in children. Ann Emerg Med 1999; 33:395.
  58. Zempsky WT, Anand KJ, Sullivan KM, et al. Lidocaine iontophoresis for topical anesthesia before intravenous line placement in children. J Pediatr 1998; 132:1061.
  59. Squire SJ, Kirchhoff KT, Hissong K. Comparing two methods of topical anesthesia used before intravenous cannulation in pediatric patients. J Pediatr Health Care 2000; 14:68.
  60. Irsfeld S, Klement W, Lipfert P. Dermal anaesthesia: comparison of EMLA cream with iontophoretic local anaesthesia. Br J Anaesth 1993; 71:375.
  61. Pryor GJ, Kilpatrick WR, Opp DR. Local anesthesia in minor lacerations: topical TAC vs lidocaine infiltration. Ann Emerg Med 1980; 9:568.
  62. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg 2009; 108:837.
  63. Seibert RW, Seibert JJ. Infantile methemoglobinemia induced by a topical anesthetic, Cetacaine. Laryngoscope 1984; 94:816.
  64. Byrne MF, Mitchell RM, Gerke H, et al. The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia. J Clin Gastroenterol 2004; 38:225.
  65. Dahshan A, Donovan GK. Severe methemoglobinemia complicating topical benzocaine use during endoscopy in a toddler: a case report and review of the literature. Pediatrics 2006; 117:e806.
  66. US FDA Public Health Advisory. Benzocaine topica products: Sprays, gels and liquids-risk of methemoglobinemia. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm250264.htm (Accessed on June 02, 2011).
  67. US FDA Public Health Advisory. Benzocaine sprays marketed under different names, including Hurricaine, Topex, and Cetacaine. April 30, 2009. http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/ucm124350.htm (Accessed on October 22, 2009). http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/ucm124350.htm.
  68. Moore TJ, Walsh CS, Cohen MR. Reported adverse event cases of methemoglobinemia associated with benzocaine products. Arch Intern Med 2004; 164:1192.