Infraorbital nerve block for postoperative pain following cleft lip repair in children
Postoperative pain is a barrier to the quality of paediatric care, the proper management of which is a challenge. Acute postoperative pain often leads to adverse functional and organic consequences that may compromise surgical outcome. Cleft lip is one of the most common craniofacial birth defects and requires surgical correction early in life. As expected after a surgical intervention in such a sensitive and delicate area, the immediate postoperative period of cleft lip repair may be associated with moderate to severe pain. Infraorbital nerve block associated with general anaesthesia has been used to reduce postoperative pain after cleft lip repair.
To assess the effects of infraorbital nerve block for postoperative pain following cleft lip repair in children.
We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, Issue 6, 2015), MEDLINE, EMBASE, and Literatura Latino‐Americana e do Caribe em Ciências da Saúde (LILACS) from inception to 17 June 2015. There were no language restrictions. We searched for ongoing trials in the following platforms: the metaRegister of Controlled Trials; ClinicalTrials.gov (the US National Institutes of Health Ongoing Trials Register), and the World Health Organization International Clinical Trials Registry Platform (on 17 June 2015). We checked reference lists of the included studies to identify any additional studies. We contacted specialists in the field and authors of the included trials for unpublished data.
We included randomised controlled clinical trials that tested perioperative infraorbital nerve block for cleft lip repair in children, compared with other types of analgesia procedure, no intervention, or placebo (sham nerve block). We considered the type of drug, dosage, and route of administration used in each study. For the purposes of this review, the term 'perioperative' refers to the three phases of surgery, that is preoperative, intraoperative, and postoperative, and commonly includes ward admission, anaesthesia, surgery, and recovery.
Data collection and analysis
Two review authors (GF and EH) independently identified, screened, and selected the studies, assessed trial quality, and performed data extraction using the Cochrane Pain, Palliative and Supportive Care Review Group criteria. In case of disagreements, a third review author (EMKS) was consulted. We assessed the evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE).
We included eight studies involving 353 children in the review. These studies reported different types of interventions (lignocaine or bupivacaine), observation times, and forms of measuring and describing the outcomes, making it difficult to conduct meta‐analyses. In the comparison of infraorbital nerve block versus placebo, there was a large effect in mean postoperative pain scores (our first primary outcome) favouring the intervention group (standardised mean difference (SMD) ‐3.54, 95% confidence interval (CI) ‐6.13 to ‐0.95; very low‐quality evidence; 3 studies; 120 children). Only one study reported the duration of analgesia (in hours) (second primary outcome) with a difference favouring the intervention group (mean difference (MD) 8.26 hours, 95% CI 5.41 to 11.11; very low‐quality evidence) and less supplemental analgesic requirements in the intervention group (risk ratio (RR) 0.05, 95% CI 0.01 to 0.18; low‐quality evidence). In the comparison of infraorbital nerve block versus intravenous analgesia, there was a difference favouring the intervention group in mean postoperative pain scores (SMD ‐1.50, 95% CI ‐2.40 to ‐0.60; very low‐quality evidence; 2 studies; 107 children) and in the time to feeding (MD ‐9.45 minutes, 95% CI ‐17.37 to ‐1.53; moderate‐quality evidence; 2 studies; 128 children). No significant adverse events (third primary outcome) were associated with the intervention, although three studies did not report this outcome. Five out of eight studies found no unwanted side effects after the nerve blocks. Overall, the included studies were at low or unclear risk of bias. The reasons for downgrading the quality of the evidence using GRADE related to the lack of information about randomisation methods and allocation concealment in the studies, very small sample sizes, and heterogeneity of outcome reporting.
There is low‐ to very low‐quality evidence that infraorbital nerve block with lignocaine or bupivacaine may reduce postoperative pain more than placebo and intravenous analgesia in children undergoing cleft lip repair. Further studies with larger samples are needed. Future studies should standardise the observation time and the instruments used to measure outcomes, and stratify children by age group.
Gustavo Feriani, Eric Hatanaka, Maria Regina Torloni, Edina MK da Silva
Plain language summary
Infraorbital nerve block for pain after cleft lip surgery in children
Cleft lip is one of the most common birth defects. The surgery to correct this defect can cause moderate to severe pain. Many of the drugs to reduce pain (analgesics) used in adults can have unwanted side effects in children. The treatment of the pain associated with the surgical correction of cleft lip can therefore be a challenge. One technique that can provide pain relief for these children is known as infraorbital nerve block which involves the injection of an anaesthetic around the nerve that is responsible for the sensation of touch and pain of the upper lip.
We reviewed the effectiveness of infraorbital nerve block compared with placebo ('sham' block) or other interventions for the control of pain in children having cleft lip surgery.
We included eight studies with a total of 353 boys and girls, who ranged in age from 1 month to 13 years. These studies had been published up to June 2015. Three studies compared nerve block with sham block. Three studies compared nerve block with injected analgesics, and two studies compared nerve block with local anaesthesia.
The children who received the infraorbital nerve block (with lignocaine or bupivacaine) had less pain and more time between finishing surgery and needing more analgesics. These children also had less need for analgesics than those who received the sham block. The children who received the infraorbital nerve block also had less pain and were able to eat sooner than those who received injected (intravenous) analgesics. The nerve block did not appear to alter heart rate, breath rate, and blood pressure. Five out of eight studies found no unwanted side effects after the nerve blocks; the other three studies did not mention side effects.
Quality of the evidence
The overall quality of the evidence was low or very low due to the small number of children included in the studies and differences between the studies (heterogeneity) regarding the types of intervention, the observation time, and the forms of measuring and describing the outcomes. Further studies with larger numbers of children are needed.
Gustavo Feriani, Eric Hatanaka, Maria Regina Torloni, Edina MK da Silva
Implications for practice
For children with postoperative pain following cleft lip repair surgery
Infraorbital nerve block with lignocaine or bupivacaine may reduce postoperative pain compared with placebo (sham block) and intravenous analgesia. This finding is uncertain due to the very small samples sizes and differences in the interventions and outcomes in the included trials (very low‐quality evidence). There is a lack of information about adverse events in many studies and the absence of evidence for some outcomes of interest.
For clinicians and policymakers
There is low‐ to very low‐quality evidence that infraorbital nerve block may be an effective intervention to be routinely adopted in surgery for cleft lip repair in children.
Implications for research
Further studies, probably multicentre to obtain a larger sample, are needed to consolidate this evidence, and the most appropriate anaesthetic agent as well as the optimal dosage should also be evaluated.
Double‐blind randomised clinical trials with high methodology quality (that is adequate report of randomisation, allocation concealment, blinding, etc.) are needed. Future studies should standardise the observation time and the instruments used to measure outcomes, and stratify children by age group.
The main outcome should be pain measured by validated instruments proper for each age group. The measurements must be made long enough to measure analgesia time and predefined as an hourly basis. The parameters to provide rescue analgesia should be described and standardised across studies. Studies should also report the time to feeding, parental satisfaction, and duration of hospitalisation.