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Children with cancer have many needles, lumbar punctures and bone marrow tests. An international guideline says every needle procedure should use numbing cream and distraction, and every child having a lumbar puncture should be offered deep sedation or a general anaesthetic. Sedation is given by a trained team with monitoring, after the child and family are prepared for what will happen.
The international clinical practice guideline on needle procedures in children with cancer (Loeffen et al., Eur J Cancer 2020; GRADE, 48 randomised trials, 2,271 participants, evidence very low to moderate) makes strong recommendations for topical anaesthetics in all needle procedures, for offering deep sedation or general anaesthesia to all children undergoing lumbar puncture, for deep sedation or general anaesthesia in major procedures in children of all ages, and for hypnosis and active distraction in all needle procedures. NICE CG112 (sedation in under 19s) sets the safety frame: trained pre-sedation assessment and documented consent, psychological preparation suited to the child's development, parents offered the chance to be present, a team with life support skills (advanced life support for deep sedation), an anaesthetist available for propofol, sevoflurane or opioids with ketamine, continuous monitoring including capnography for deep sedation, and discharge criteria. Fasting is not needed for minimal sedation, nitrous oxide or moderate sedation with verbal contact; for deeper sedation professional fasting guidance applies, with the 2018 move to 1 hour for clear fluids. For painful procedures NICE suggests considering a local anaesthetic as well as a sedative.
Why: Children with cancer have many needles during treatment; numbing the skin reduces pain each time and the fear that builds up.
“Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.”
International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 · Strong recommendation
Why: Psychological methods reduce pain and distress at little cost and work alongside numbing cream.
International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 · Strong recommendation
Why: Lumbar punctures are repeated many times in leukaemia treatment; deep sedation lets the child keep still and avoids the procedure becoming traumatic.
International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 · Strong recommendation
Why: The assessment picks out children who need a specialist or an anaesthetist, such as those with airway problems or ASA grade 3 or above.
“Ensure that trained healthcare professionals (see section 1.4) carry out pre‑sedation assessments and document the results in the healthcare record.”
Why: Families decide better, and children cope better, when they know what will happen.
“Obtain and document informed consent for sedation.”
Why: Preparation lowers distress, and checking understanding shows whether the explanation worked.
“Ensure that the information is appropriate for the developmental stage of the child or young person and check that the child or young person has understood the information.”
Why: Many children are calmer with a parent there, and parents cope better when they know what to do.
“Offer parents and carers the opportunity to be present during sedation if appropriate. If a parent or carer decides to be present, offer them advice about their role during the procedure.”
Why: Fasting protects the airway under deep sedation but is not needed for lighter sedation; long fasts are distressing for small children.
“Before starting sedation, confirm and record the time of last food and fluid intake in the healthcare record.”
Why: Deep sedation can stop a child breathing; the person giving it must be able to rescue the airway.
“Ensure that all members of the sedation team have basic life support skills for minimal, moderate and deep sedation. At least 1 team member should have intermediate life support skills for moderate sedation and advanced life support skills for deep sedation.”
Why: A lumbar puncture enters a sterile space; gloves alone may not prevent contamination.
“For some tasks on clean sites (lumbar puncture, surgical procedures, tracheal suctioning, etc.), the use of gloves is standard procedure. In this case, hand hygiene is required before donning gloves because gloves alone may not entirely prevent contamination”
Why: Monitoring catches slowed breathing or low oxygen early; the person giving sedation does nothing else.
“The healthcare professional administering sedation should be involved only in continuously monitoring, interpreting and responding to all of the above.”
Why: Some sedatives last longer than the procedure; going home too early risks a drowsy child with no one watching.
“the child or young person is awake (or returned to baseline level of consciousness) and there is no risk of further reduced level of consciousness”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Follow the international paediatric oncology needle-procedure guideline (Loeffen 2020): topical anaesthetic, active distraction and hypnosis for every needle procedure, and deep sedation or general anaesthesia offered for every lumbar puncture and major procedure, all strong recommendations. Deliver the sedation within NICE CG112's safety frame of assessment, consent, preparation, a skilled team, continuous monitoring and discharge criteria. NICE CG112 is general rather than oncology-specific, and for painful procedures it suggests lighter options first (nitrous oxide or oral or intranasal midazolam for minimal or moderate sedation, then ketamine or intravenous midazolam with or without fentanyl, then propofol) where the oncology guideline offers deep sedation for every lumbar puncture.
International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 · NICE 2010
Where it differs: For painful procedures at minimal or moderate target depth, considers nitrous oxide and/or oral or intranasal midazolam first, then intravenous or intramuscular ketamine or intravenous midazolam with or without fentanyl, then a specialist technique such as propofol, with a local anaesthetic in all cases.
Evidence: NICE does not grade recommendations; the guideline is for all procedures in under 19s, not oncology, and its examples are suturing and fracture manipulation.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Topical anaesthetics in all needle procedures | Strong recommendation | International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 |
| Offer deep sedation or general anaesthesia to all children undergoing lumbar puncture | Strong recommendation | International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 |
| Hypnosis and active distraction in all needle procedures | Strong recommendation | International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 |
| Quality of evidence across the recommendations “Quality of evidence supporting the recommendations ranged from very low to moderate.” | very low to moderate (GRADE) | International inter-disciplinary guideline panel (Loeffen et al.), European Journal of Cancer 2020 |
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