Published: November 1999

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EMLA Cream Safe and Effective (But Caution in the First Three Months of Life)

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Prescriber Update 19: 18-20
November 1999

Dr John Goldsmith FRACP, Paediatrician, Good Health Wanganui, Wanganui, New Zealand

• EMLA™ cream is an effective and well-tolerated topical anaesthetic agent for needle insertion and minor dermatological procedures including laser therapy of birthmarks*.
• The manufacturer’s dosage recommendations should be followed carefully to avoid toxicity.
• EMLA cream should be used with caution in infants up to 3 months of age as adverse effects, particularly methaemoglobinaemia, are more likely in this age group. There is little evidence that EMLA works in infants up to 3 months except for reducing the pain of circumcision.

EMLA cream (2.5% lignocaine, 2.5% prilocaine) at recommended dosages¹ is a safe and effective topical anaesthetic agent in adults and children over three months of age for procedures involving needle insertion² (including blood testing, cannulation and lumbar puncture) as well as dermatological procedures such as wart removal, skin biopsy and laser therapy*.³

EMLA may be of little or no use in reducing the pain of heel pricks or venepuncture in newborn infants up to 3 months.^2,4 EMLA should be used with caution in infants because of reports of methaemoglobinaemia.^2,5,6,7 Those at greatest risk include:

• infants up to 12 months of age co-prescribed sulphonamides or other methaemoglobin-inducing drugs
• preterm infants with a gestational age less than 37 weeks
• children and adults with pre-existing methaemoglobinaemia (where EMLA is contraindicated).

Several studies have shown it to be effective for reducing the pain of infant circumcision, but other anaesthetics (e.g. ring block with 1% lignocaine) may be better.^7,8

Local blanching and redness are common. Other local reactions are rare and rarely, if ever, serious.⁹

The effectiveness of EMLA is dependent primarily on the dose, application time and area of application. EMLA cream must be applied at least 60 minutes before procedures involving intact skin, and covered with an occlusive dressing (details are on the package insert). Maximal anaesthesia may take up to 2 hours.² However, for safety reasons the maximum application time for infants under 3 months is 1 hour.¹ EMLA cream remains effective for up to 1 hour after removal.²

The occlusive dressing should be well secured so that children cannot rub the cream in their eyes or ingest it.¹⁰ It may be advisable to cover the dressing with a secondary protective dressing (e.g. a crepe bandage).

Dosages for children¹:

Age	Dose	Maximum Coverage
under 3 months	up to 1g (1 patch or 1/5th of a 5g tube of cream)	10cm²
3 months to 11 months	up to 2g	20cm²
1 to 5 years	up to 10g (2x5g tubes of cream)	100cm²
6 to 12 years	up to 20g	200cm²

The maximum area of application tends to be more relevant to use in adults. Systemic absorption is more likely if the cream is spread too thinly.

*Treatment of birthmarks by laser therapy is not an approved indication for EMLA

Correspondence to Dr John Goldsmith, Paediatrician, Good Health Wanganui, Private Bag 3003, Wanganui, New Zealand. Phone 06 348 1234, fax 06 348 1257, e-mail johng@ghw.co.nz

References

1. EMLA cream data sheet
2. Russell SC, Doyle E. A risk-benefit assessment of topical percutaneous local anaesthetics in children. Drug Saf 1997;16(4): 279-87.
3. McCafferty DF, Woolfson AD, Handley J, et al. Effect of percutaneous local anaesthetics on pain reduction during pulse dye treatment of portwine stains. Br J Anaesthesia 1997;78:286-9.
4. Acharya AB, Bustani PC, Phillips JD, et al. Randomised controlled trial of eutectic mixture of local anaesthetics cream for venepuncture in healthy preterm infants. Arch Dis Child Fetal Neonatal Ed 1998;78:F138-F142.
5. Frayling IM, Addison GM, Chattergee K, et al. Methaemoglobinaemia in children treated with prilocaine-lignocaine cream. BMJ 1990;301:153-4.
6. Kumar AR, Dunn N, Naqvi M. Methemoglobinaemia associated with a prilocaine-lidocaine cream. Clin Pediatr 1997;36:239-40.
7. Russell CT, Chaseling J. Topical anaesthesia in neonatal circumcision: a study of 208 consecutive cases. Aust Fam Physician 1996;Suppl 1:S30-4.
8. Lander J, Brady-Fryer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anaesthesia for neonatal circumcision: a randomised controlled trial. JAMA 1997;278:2157-62.
9. Calobrisi SD, Drolet BA, Esterly NB. Petechial eruption after the application of EMLA cream. Pediatrics 1998;101:471-3.
10. Norman J, Jones PL. Complications of the use of EMLA (letter). Br J Anaesthesia 1990;64:403.