Is lidocaine (local anesthetic) gel safe for use in infants?

Safety of Lidocaine Gel in Infants

Lidocaine gel can be safely used in infants when appropriate dosing guidelines are followed, with a maximum recommended dose of 3.0-4.5 mg/kg when used with epinephrine and 1.5-2.0 mg/kg without epinephrine. 1

Dosing and Safety Parameters

Lidocaine gel safety in infants depends on several key factors:

• Maximum safe dosage:

  • With epinephrine: 3.0-4.5 mg/kg 1
  • Without epinephrine: 1.5-2.0 mg/kg 1
  • For neonates and infants under 6 months: Doses should be decreased by 30% 2

• Application considerations:

  • Application time should be shorter in infants than in older children due to their thinner skin barrier 3
  • Recommended application time: approximately 30 minutes 3
  • Avoid multiple applications within the same day to prevent cumulative toxicity 1

Specific Uses in Infants

Lidocaine gel has been demonstrated to be safe and effective for several procedures in infants:

• Laceration repair: Topical lidocaine preparations provide excellent wound anesthesia in 20-30 minutes 2
• Venipuncture and IV insertion: Topical anesthetics are safe in newborn infants and even preterm infants, with appropriate dosing and short administration times 2
• Oral cavity pain: A 2% lidocaine gel has been shown to be safe and effective for painful conditions in the oral cavity in children as young as 6 months 4

Monitoring and Precautions

When using lidocaine gel in infants, important precautions include:

• Monitor for signs of toxicity:

  • Early signs: circumoral numbness, facial tingling, slurred speech 1
  • Advanced signs: seizures, cardiovascular depression 5

• Risk factors for toxicity:

  • Neonates have decreased metabolism and elimination of local anesthetics 6
  • Lower concentrations of alpha-1-acid glycoprotein in neonates lead to increased concentrations of unbound lidocaine 6
  • Highly vascular areas may increase absorption and risk of toxicity 1

• Application technique:

  • Use the smallest effective amount 2
  • Avoid application to large areas or broken skin 1
  • For open wounds, follow dosing guidelines based on weight (0.175 mL/kg in children <17 kg) 2

Special Considerations for Different Age Groups

• Neonates and former preterm infants:

  • Require specific management due to immature hepatic and renal function 2
  • May have prolonged effects due to delayed metabolism 6
  • Skin acts more like mucosa, allowing faster absorption of local anesthetics 3

• Infants 6 months to 4 years:

  • Have demonstrated good tolerability with 2% lidocaine gel for oral cavity pain 4
  • Local tolerability was assessed as very good in over 97% of cases 4

Alternatives and Adjuncts

For pain management in infants, consider these additional approaches:

• Non-pharmacological methods:

  • Sucrose solution (2 mL of 25% solution) can be used as an adjunct for limiting pain associated with procedures 2
  • Pacifier use, alone or with sucrose, has analgesic effects 2
  • Skin-to-skin contact and breastfeeding during procedures decrease pain behaviors 2

• Alternative topical anesthetics:

  • EMLA cream (lidocaine-prilocaine) can be used but requires monitoring for methemoglobinemia, especially with repeated use 3
  • Amethocaine cream may be considered as an alternative 3

Pitfalls to Avoid

• Dosage calculation errors: Always calculate the maximum allowable dose based on the infant's weight before administration 2
• Cumulative dosing: Be aware of the total amount of lidocaine administered when using multiple applications or combining with other local anesthetics 1
• Application to large areas: Limit the surface area of application to reduce systemic absorption 1
• Prolonged application: Avoid extended application times in infants due to their thinner skin barrier 3
• Repeated applications: Limit to once daily use in neonates unless safety for multiple applications has been established 3

By following these guidelines, lidocaine gel can be safely used in infants to provide effective pain relief for various procedures while minimizing the risk of adverse effects.