Pain management strategies for thoracocentesis and thoracostomy in neonates: A systematic review and meta-analysis.

Objectives: Thoracostomy and thoracocentesis are painful invasive procedures. Several professional organizations have recommended the combined use of non-pharmacological and pharmacological interventions to alleviate pain from these procedures in neonates. However, none of these recommendations are based on a systematic review of the literature. The primary objective of this systematic review and meta-analysis was to synthesize the literature on pain management strategies for thoracotomy and thoracocentesis. Methods: Databases were searched for randomized trials evaluating pharmacological and non-pharmacological interventions for pain mitigation for thoracocentesis and thoracostomy in any age group from inception to March 2025. The literature search was updated in June 2025 and no additional eligible articles were identified for inclusion. Title and abstract screening, full-text screening, and data extraction were performed in duplicate. Risk of bias was assessed using Cochrane's risk of bias (RoB) tool version 2.0. The critically important outcome was pain measured using validated tools including unidimensional behaviours (comprising facial actions, body movements, and cry) tools and multidimensional (comprising combinations of contextual, behavioural, and/or physiological components) tools. Secondary outcomes included procedure success, procedure duration, ease of procedure, and adverse events. Pooled effect estimates were standardized mean difference and relative risk with 95% confidence intervals using random effects model. A GRADE assessment of the overall certainty of the evidence for each outcome was completed. Results: One study with 36 adult participants assessing pain from thoracocentesis was included. The interventions compared were topical vs subcutaneous administration of local anaesthetics. There was no difference in the overall procedural pain, patient satisfaction, and the number of attempts between the two groups. There was very low evidence of certainty for the critical outcome of pain. Conclusions: No recommendation for pain management for these procedures can be made from the single included study. Currently, professional guidelines recommend the use of subcutaneous lidocaine and intravenous opioids for thoracostomy. Future studies are recommended to evaluate the effectiveness of various pharmacological and non-pharmacological interventions (head-to-head comparison).