The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letters to the Editor

Editor, – Further to the article 'Managing painful paediatric procedures' (Aust Prescr 2006;29:94-6), a recent Cochrane review1 affirms what many breastfeeding mothers know instinctively: '† that neonates undergoing a single painful procedure should be provided either breastfeeding or supplemental breast milk for analgesia when available compared to positioning/pacifier/holding and swaddling. If it is not available/feasible to give breastfeeding or supplemental breast milk alternatives such as glucose or sucrose should be considered.'

Tricia Taylor
Pharmacist, Counsellor Mother Safe
Royal Hospital for Women
Randwick, NSW

Editor, – The methods and techniques outlined in the article 'Managing painful paediatric procedures' (Aust Prescr 2006;29:94-6) were excellent and relevant and are used on an almost daily basis in mixed and paediatric emergency departments. However, I feel that the minimisation of pain arising from the procedure of intravenous cannulation was inadequately covered. Intravenous cannulation of ill and injured children and adolescents is common and is often required as an emergency procedure within minutes of the patient presenting.

The use of subcutaneous local anaesthetic has been shown to significantly decrease the pain of intravenous cannulation2-4 while not decreasing the success rate of intravenous cannulation attempts.5 In children less than 24 months of age, the success rate with subcutaneous local anaesthetic was 73% versus 77% without subcutaneous local anaesthetic (p = 0.5).6

After skin preparation, the skin overlying the target vessel is pulled laterally and a small volume (approximately 0.2 mL) of 1% lignocaine is injected into the subcutaneous tissue using an insulin syringe. After allowing the skin to return to its former position, the cannula is inserted.

I would urge clinicians to investigate the use of subcutaneous local anaesthetic for intravenous cannulation in both adult and paediatric patients and to incorporate the technique into their practice.

Robert Douglas
Emergency Registrar
Rockingham-Kwinana District Hospital and Fremantle Hospital

Author's comments

Adjunct Professor John Murtagh, author of the article, comments:

I do agree with the use of subcutaneous local anaesthetic to minimise the pain of intravenous cannulation. However, space precluded me from devoting more time to the issue. The use of this method also applies to the common emergency procedure of an intravenous cutdown. A combination of topical anaesthesia and subcutaneous injection is optimal, but not always practical.


  1. Shah PS, Aliwalas LL, Shah V. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database of Systematic Reviews 2006, Issue 3: Art. No.: CD004950. DOI: 10.1002/14651858. CD004950.pub2.
  2. Nuttall GA, Barnett MR, Smith RL, Blue TK, Clark KR, Payton BW. Establishing intravenous access: a study of local anesthetic efficacy. Anesth Analg 1993;77:950-3.
  3. Harris T, Cameron PA, Ugoni A. The use of pre-cannulation local anaesthetic and factors affecting pain perception in the emergency department setting. Emerg Med J 2001;18:175-7.
  4. Langham BT, Harrison DA. Local anaesthetic: does it really reduce the pain of insertion of all sizes of venous cannula? Anaesthesia 1992;47:890-1.
  5. Holdgate A, Wong G. Does local anaesthetic affect the success rate of intravenous cannulation? Anaesth Intensive Care 1999;27:257-9.
  6. Sacchetti AD, Carraccio C. Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age. Acad Emerg Med 1996;3:1016-9.