What is the best course of treatment for a child with a lip laceration, considering their medical history and potential for infection?

Lip Laceration Repair in Children

For pediatric lip lacerations, immediately apply topical LET (lidocaine-epinephrine-tetracaine) solution at triage for 20-30 minutes before repair, use layered closure with precise vermilion border alignment for through-and-through lacerations, and refer complex cases involving the vermilion border to plastic surgery since even 1mm misalignment causes permanent cosmetic deformity. 1, 2, 3

Immediate Pain Management at Triage

Apply topical anesthetic immediately upon arrival to minimize procedural pain and anxiety:

• Place LET solution (lidocaine-epinephrine-tetracaine) directly on the open wound using a cotton ball soaked with solution, covered with occlusive dressing 4, 2
• Allow 20-30 minutes for wound edges to blanch, indicating adequate anesthesia 4, 2
• Dosing: 3 mL for children >17 kg; 0.175 mL/kg for children <17 kg (maximum 5 mg/kg lidocaine) 4
• Contraindications: allergy to amide anesthetics and grossly contaminated wounds 4
• Administer oral acetaminophen for systemic pain relief 1
• Apply topical 2.5% lidocaine ointment cautiously to wound edges, using sparingly to avoid accidental ingestion and systemic toxicity 1

Critical pitfall: Avoid overuse of topical anesthetics as accidental ingestion can lead to toxicity in young children 1

Wound Preparation

• Clean the wound with warm saline using gauze or an oral sponge 1
• If additional anesthesia is needed after topical application, inject lidocaine using pain-minimizing techniques: buffer with bicarbonate, warm the solution, use a small-gauge needle, and inject slowly 4, 2

Repair Technique Selection

Simple, Low-Tension Lacerations Without Vermilion Border Involvement

• Use octyl cyanoacrylate tissue adhesive for essentially painless closure 4, 2
• Steri-Strips offer similar painless closure and are less expensive than tissue adhesives 4, 2
• Consider absorbable sutures for facial wounds requiring suturing to eliminate pain and anxiety of suture removal 4, 2

Full-Thickness Lacerations or Vermilion Border Involvement

These require layered closure with precise anatomical alignment 3:

• The vermilion border is the most critical landmark—misalignment of even 1mm creates permanent visible deformity 3
• The "white roll" (ridge at vermilion-cutaneous border) must be precisely set 3
• Use vertical incision approach for lesions traversing both vermilion and cutaneous tissues 1
• Use transverse mucosal incision to hide the scar at the junction of vermilion and vestibular mucosa 1
• Layered closure is essential: oral mucosa, orbicularis oris muscle, and skin layers 3

Indications for Plastic Surgery Referral

Refer immediately for 3:

• Complex lacerations involving the vermilion border (even 1mm misalignment causes permanent deformity) 3
• Full-thickness lacerations requiring layered closure with precise alignment of anatomical landmarks 3
• Bulky lesions causing lip lengthening that require wedge excision 1
• Lacerations requiring tissue transfer or reconstruction 3
• Major facial trauma in children ≤5 years should be transferred to pediatric trauma centers with pediatric plastic surgeons 3

Post-Repair Care Protocol

Wound Care

• Apply white soft paraffin ointment to the lips every 2 hours during acute healing phase to prevent drying and cracking 1, 2
• Lubricate lips with lip balm or petroleum-based ointment frequently 1
• Clean the mouth daily with warm saline mouthwashes 1, 2
• Apply benzydamine hydrochloride anti-inflammatory rinse or spray every 2-4 hours, particularly before eating 2
• Maintain oral hygiene with soft toothbrush and mild fluoride toothpaste 1

Critical pitfall: Never use alcohol-containing mouthwashes post-repair, as they cause additional pain and irritation 2

Dietary Modifications

• Avoid irritants including spicy foods, hot foods and drinks, and citrus fruits, as these delay healing 1
• Offer soft, bland foods at room temperature during healing period 1
• Ensure adequate hydration, as painful lip injuries may cause children to resist drinking 1
• For infants, nursing care is important as adjunct therapy 1

Infection Prevention

• Tetanus prophylaxis should be provided if indicated 5
• Good evidence supports that irrigation with potable tap water rather than sterile saline does not increase risk of wound infection 5
• Use of nonsterile gloves during laceration repair does not increase risk of wound infection compared with sterile gloves 5

Timing Considerations

• Depending on wound type, it may be reasonable to close even 18 or more hours after injury—there is no absolute "golden period" 5
• However, earlier repair is preferable for optimal cosmetic outcomes, particularly for facial lacerations 6