STEAMBOAT SPRINGS, COLO. – Make lidocaine, epinephrine, and tetracaine gel your choice for pain control when repairing lacerations in children, Dr. Steven M. Selbst said.

Adoption of LET gel for routine use in wound repair may be the single most important change in practice that physicians can make in terms of analgesia for children, said Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

"Even if you don’t suture wounds in your office, I think it’s key to try to make sure that the emergency department near your office uses LET in wound repair for children. It’s an incredible agent. I’ve been using it for 20 years, and I know it has been around for longer than that. I’ve seen so many anxious kids who are scared to death of having a wound repair with suturing that have had a completely painless repair with LET without any injection whatsoever. To me it’s amazing that some hospitals still don’t use LET," said Dr. Selbst, who is chair of the executive committee of the American Academy of Pediatrics Section on Pediatric Emergency Medicine.

The advantages of pharmacist-compounded LET gel over commercially available anesthetic creams, such as eutectic mixture of local anesthetics (EMLA) and lidocaine 4% (LMX-4), include much lower cost and a good anesthetic response within 20-30 minutes after LET is applied. In contrast, EMLA requires 60 minutes of contact, making it less practical for laceration repair. LET is as effective as tetracaine, adrenaline, and cocaine (TAC) solution, but it costs less and has less morbidity, he said at the meeting.

Once the treated site shows blanching due to LET’s vasoconstrictive activity, the physician can proceed with pain-free suturing, even on the face and scalp.

The gel formulation of LET contains 10 mL of injectable lidocaine 20%, 5 mL of racemic epinephrine, 12.5 mL of tetracaine hydrochloride 2%, 31.5 mg of sodium metabisulfite, and methylcellulose gel 5% added in sufficient quantity to bring the total volume to 50 mL. The ingredients are stirred or shaken until completely mixed, which takes about 2-3 minutes.

The LET gel remains stable for 4 weeks at room temperature or for 6 months if refrigerated.

"You can apply the gel directly to the wound or put it on cotton gauze and tape it to the wound. Use a generous amount," Dr. Selbst said.

Numerous studies have documented that inadequate pain control is far more common in children with painful conditions than in adults. Children with lower-extremity fractures, serious burns, or sickle cell crises were less than half as likely to get analgesics in the emergency department, compared with adults with the same conditions, according to an earlier study done by Dr. Selbst and a colleague. They also found that kids younger than 2 years got analgesics less frequently than older children (Ann. Emerg. Med. 1990;19:1010-3).

Recent studies indicate this gap has narrowed somewhat, although inadequate dosing of analgesics in children continues to be a problem. Possible explanations include the inability of infants and young children to verbalize, the disproved myth that babies don’t feel or remember pain, and fear of causing respiratory depression or addiction, although there is no evidence that giving a single dose of a narcotic for an acute painful condition is associated with an increased risk of addiction, Dr. Selbst emphasized.

He reported having no financial conflicts.