ArticleLiterature Review

Current concepts in management of pain in children in the emergency department

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Abstract

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects. Copyright © 2015 Elsevier Ltd. All rights reserved.

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... Pain is the most prevalent symptom in an emergency setting and continues to be one of the most difficult challenges for emergency care providers, particularly in children [1]. Pain accounts for up to 80% of pediatrics' emergency department visits, with musculoskeletal injury as the most common complaint, followed by headache, abdominal discomfort, otalgia and sore throat [1]. ...
... Pain is the most prevalent symptom in an emergency setting and continues to be one of the most difficult challenges for emergency care providers, particularly in children [1]. Pain accounts for up to 80% of pediatrics' emergency department visits, with musculoskeletal injury as the most common complaint, followed by headache, abdominal discomfort, otalgia and sore throat [1]. ...
... Inadequate treatment of acute pain may have both short-and long-term repercussions. Indeed, neuroimaging studies have discovered long-lasting modifications in brain structure and connectivity correlating with the amount of acute pain exposure during the perinatal period and with subsequent cognitive and behavioral effects in adult age [1,2]. For this reason, in 2001, the American Academy of Pediatrics and the American Pain Society reiterated the need to eliminate pain in pediatric patients, using a multidisciplinary method [3]. ...
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Pain is the most common complaint reported by children who access the emergency departments, but despite its frequency and the availability of many international guidelines, it often remains underreported and undertreated. Recently, the American Academy of Pediatrics and the American Pain Society have reiterated the importance of a multidisciplinary approach in order to eliminate pain in children. In all pediatric settings, an adequate assessment is the initial stage in a proper clinical approach to pain, especially in the emergency departments; therefore, an increasing number of age-related tools have been validated. A wide range of analgesic agents are currently available for pain management, and they should be tailored according to the patient’s age, the drug’s pharmacokinetics and the intensity of pain. In order to facilitate the choice of the appropriate drug, a treatment algorithm based on a ladder approach can be used. Moreover, non-pharmacological techniques should be considered to alleviate anxiety and distress in pediatric age. This review aims to offer a simple but intuitive description of the best strategies for pain relief in children, starting with the prompt recognition and quantification of pain through adequate assessment scales, and following with the identification of the most appropriate therapeutic choice among the ones available for pediatric age.
... During emergency room stays, invasive procedures are commonly performed for diagnostic and/or therapeutic purposes, which generates an increase in pain and anxiety levels in children [1,2]. Intravenous catheterization, venipuncture or wound sutures are among the most widely used procedures in emergency units globally [3]; at the same time, they are among the most feared by pediatric patients [4] and they increase children's anxiety levels [4][5][6][7]. ...
... On the other hand, the behavior of parents who accompany the child during the procedure and their stay in the emergency department can influence the perception and experience of the situation, which can generate great variability in the perceived intensity of pain and anxiety experienced by children [12][13][14][15]. The emotional response of the parents depends on the experience and the level of anxiety that they themselves feel during the stay in the emergency room and when the procedure is performed, sometimes requiring that health professionals establish strategies to prevent or control negative or blocking situations [1,15]. ...
... They were a total of 3.20 min long and had sequential repetitions [Figs. [1][2][3][4]. ...
Article
Aim: To evaluate the effectiveness of virtual reality to reduce pain and anxiety in pediatric patients during venipuncture procedure in emergency care and the behavioral response of their parents/companions. Background: Virtual reality is being used as a source of distraction in children undergoing invasive procedures. Methods: Quasi-experimental study with 458 children (from 2 to 15 years) who attended a pediatric emergency service from September 2019 to April 2021. An intervention based on virtual reality as a distraction method during venipuncture procedure was applied. The level of pain and anxiety of children and attitude of parents/ companions were assessed. Ordinal and binary logistic regressions were applied. Results: A protective effect of using virtual reality was observed in the intervention group both for the absence of pain (− 4.12; 95 % CI: − 4.85 to − 3.40) and anxiety (− 1.71; 95 % CI: − 2.24 to − 1.17) in children aged between 2 and 15 years. A significant reduction in the blocking response of the accompanying parents (− 2.37; 95 % CI: − 3.017 to − 1.723) was also observed. Conclusions: VR is effective in reducing pain and anxiety in children during venipuncture in emergency care. A positive attitude of the parents during the invasive procedure to their children was found.
... Both pharmacological and nonpharmacological methods are extensively used in clinical settings. However, the former has weaker effects than expected on pain remission and is associated with more adverse reactions [9][10][11]. In contrast, nonpharmacological methods seem to be safe and effective for pain-related outcomes [9,11]. ...
... However, the former has weaker effects than expected on pain remission and is associated with more adverse reactions [9][10][11]. In contrast, nonpharmacological methods seem to be safe and effective for pain-related outcomes [9,11]. Furthermore, nonpharmacological methods can be quickly and extensively used in urgent settings [12]. ...
Article
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Background The ability of socially assistive robots (SARs) to treat dementia and Alzheimer’s disease has been verified. Currently, to increase the range of their application, there is an increasing amount of interest in using SARs to relieve pain and negative emotions among children in routine medical settings. However, there is little consensus regarding the use of these robots. Objective This study aimed to evaluate the effect of SARs on pain and negative affectivity among children undergoing invasive needle-based procedures. Design This study was a systematic review and meta-analysis of randomized controlled trials that was conducted in accordance with the Cochrane Handbook guidelines. Methods The PubMed, CINAHL, Web of Science, Cochrane Library, Embase, CNKI, and WanFang databases were searched from inception to January 2024 to identify relevant randomized controlled trials (RCTs). We used the Cochrane Risk of Bias tool 2.0 (RoB2.0) to assess the risk of bias among the included studies, and we used RevMan 5.4 software to conduct the meta-analysis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to assess the quality of the evidence. Results Ten RCTs involving 815 pediatric subjects were selected for this review and reported outcomes related to pain and emotions during IV placement, port needle insertion, flu vaccination, blood sampling, and dental treatment. Children undergoing needle-related procedures with SARs reported less anxiety (SMD= -0.36; 95% CI= -0.64, -0.09) and fewer distressed avoidance behaviors (SMD= -0.67; 95% CI= -1.04, -0.30) than did those receiving typical care. There were nonsignificant differences between these groups in terms of in pain (SMD = -0.02; 95% CI = − 0.81, 0.78) and fear (SMD = 0.38; 95% CI= -0.06, 0.82). The results of exploratory subgroup analyses revealed no statistically significant differences based on the intervention type of robots or anesthetic use. Conclusions The use of SARs is a promising intervention method for alleviating anxiety and distress among children undergoing needle-related procedures. However, additional high-quality randomized controlled trials are needed to further validate these conclusions. Trial registration The protocol of this study has been registered in the database PROSPERO (registration ID: CRD42023413279).
... Infants and young children express pain through observed behaviors, which can be a challenge for general ED triage nurses who may not be comfortable with such assessments. Finally, there are physiological parameters which reflect the stress response from pain resulting in changes in some of the vital signs, including heart and respiratory rates [9]. ...
... Pediatric patients presenting to the ED in Italy must undergo pain assessment completed at first contact and be treated promptly. Previous studies have shown that the rate of pain assessment or treatment is poor in pediatric patients presenting to the ED in small cohort, and only a few studies have identified the predictors of both outcomes [3,5,9,12,[18][19][20]. Furthermore, these studies are based on specialized pediatric centers, which do not make them generalizable to community EDs. ...
Article
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Background Pediatric patients with pain of various causes present to the emergency department. Appropriate assessment and management of pain are important aspects of emergency department treatment. However, only a few studies have identified the predictors of both outcomes. This study aimed to evaluate the rate of pain assessment at triage and subsequent management and to identify the predictors of each outcome. Methods This was a multi-center retrospective study based at five community emergency departments. Pediatric patients (< 18 years) with pain or injury who presented to the emergency department between February 2018 and May 2018 were included. In addition to patient demographics, the initial pain assessment at triage, reason for visit, and time to analgesia were determined. Further, the type and route of analgesia were identified in patients who received analgesia. Univariate and multivariable regression models were used to identify predictors of pain assessment and management. Results There were 4,128 patients with an average age of 9.6 years, and 49.1% of them were female. Only 74.2% of the patients underwent assessment for pain at triage, and 18.3% received analgesia. The median time to analgesia was 95 (IQR: 49–154) min. Most patients presented with head/neck (36.1%), upper limb (21.6%), and lower limb (19.9%) pain. The oral route was the most common analgesia delivery method (67.4%), and ibuprofen and acetaminophen were the primary agents used. Younger age, higher acuity, and presenting with head or neck pain were independent predictors of pain assessment at triage, while children 3–5 years and those with lower extremity pain were more likely to receive analgesia. Conclusion Although pain assessment at triage has improved in pediatric patients, there is still a major deficiency in adequate pain management. Our study highlights predictors of pain assessment and management that can be considered for improved pediatric care.
... Nyeri merupakan salah satu gejala yang umum dirasakan oleh anak yang mendapatkan perawatan di rumah sakit. Layaknya orang dewasa, nyeri merupakan salah satu masalah kesahatan yang utama pada anak 1 . Nyeri adalah apa pun yang dikatakan oleh seseorang tentang nyeri tersebut, keberadaan dan intensitas nyeri diukur dari laporan pasien 2 . ...
... Nyeri adalah apa pun yang dikatakan oleh seseorang tentang nyeri tersebut, keberadaan dan intensitas nyeri diukur dari laporan pasien 2 . International Association for Study of Pain (IASP) menjelaskan bahwa nyeri merupakan suatu pengalaman perasaan emosional yang tidak menyenangkan akibat terjadinya kerusakan aktual maupun potensial, atau menggambarkan kondisi terjadinya kerusakan 1 . ...
Article
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Pencegahan nyeri pada bayi dan anak sudah seharusnya menjadi tujuan utama dalam perawatan bagi perawat. Penulisan ini bertujuan untuk mengetahui cara memaksimalkan peran perawat dalam memberikan asuhan keperawatan berupa manajemen nyeri pada anak. Metode yang digunakan adalah pencarian literature menggunakan PICO. Hasilnya didapatkan 2 jurnal yang sesuai untuk membahas masalah. Faces, legs, activity, crying, dan FLACC scale adalah beberapa alat penilaian nyeri yang paling banyak digunakan diberbagai rumah sakit.
... Pain is among a common symptoms in hospitalized children (33). Assessment of pain and optimal treatment in pediatric patients is critical, as inadequate acute pain management can cause chronic pain (34,35), which lead to morbidities like posttraumatic stress symptoms (36). ...
... In the management of pain, a multimodal approach with two or more medications has been recommended in pediatric patients with persistent underlined pain (45), as well as for those with acute and post-operative pain (31)(32)(33). In contradiction to the evidence, a higher proportion of the patients in this study received a single acetaminophen-based analgesia than the majority of pain medications. ...
Article
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Background As the evidence showed, despite the magnitude of the effects that pain can have on a child, it is often inadequately assessed and treated. However, whether pain is adequately treated or not, evidence is lacking in the study setting.Objectives This study assessed pain management adequacy among hospitalized pediatric patients at the University of Gondar Comprehensive Specialized Hospital, Ethiopia.Methods An institution-based cross-sectional study was conducted among pediatric patients admitted to the University of Gondar Comprehensive and Specialized Hospital between June and August 2021. Eligible patients were enrolled in the study using consecutive sampling techniques. Data were collected using a structured interview-based questionnaire and a review of the patient's medical records that were prepared after reviewing earlier studies. Pain management adequacy was determined using the pain management index (PMI) score. Statistical Software for Social Sciences (SPSS) version 22 was used for data entry and analysis. Descriptive statistics such as frequencies, percentages, and means with standard deviation were used to describe the respective variables. Logistic regression was used to assess predictor variables of pain management adequacy. A p-value <0.05 at a 95% CI was considered statistically significant.ResultsOf the 422 participants enrolled in the study, most (58.1%) were males, with a mean age of 3.9 ± 0.8 years. Pain medication was prescribed to 62.8% (95% CI: 57.3–68.2) of the participants. About 63.3% (95% CI: 58.8%–68%) received inadequate analgesics. The type of painkillers administered also did not match the severity of the pain. Pediatric patients less than 1 month and between 1 month and 1 year (AOR = 2.891, 95% CI: 1.274–12.899 and AOR = 2.657, 95% CI: 1.350–5.175), respectively, and patients with severe and moderate levels of pain (AOR = 3.448, 95% CI: 1.902–6.251 and AOR = 5.345, 95% CI: 1.956–9.828), respectively, were found to have inadequate pain medication compared with their counterparts.Conclusion This study revealed that pain was hardly managed based on its severity. Overall, two-thirds of pediatric patients received inadequate pain medication. This indicates majority of patients experienced pain did not manage appropriately.
... However, literature data suggest that the actual use of algometric scales in the Pediatric ED is limited. Major critical issues are related to environmental factors specific to triage, heterogeneity of scales used, and training deficiencies [7][8][9]. Among objective pain scales, the Face, Legs, Activity, Cry, and Consolability (FLACC) is based on the detection of behavioral parameters and has been validated for children less than 3 years also in the emergency setting [10]. ...
... Pain assessment in the pediatric ED is an essential part of triage evaluation and is considered as the fifth vital sign [9]. Rapid and standardized assessment is crucial, but environmental and cultural factors may limit optimal performance on most occasions [7][8][9]. The standard practice to evaluate pain in children who are not able to make self-assessment is based on the observation made by caregivers and healthcare professionals through validated scales that sometimes fail to meet psychometric standards and requires continuous monitoring. ...
Chapter
Acute pain is a frequent symptom in children who access the Emergency Department (ED). Its measurement through validated tools compatible with the time of triage is essential to develop the most appropriate pain-relieving strategy. The algometric scales that can be used in children in whom self-assessment is not possible are based on the evaluation of behavioral and physiological parameters. However, the actual use of algometric scales in the ED is scarce due to environmental factors, heterogeneity of the scales and lack of training, thus making automated pain assessment desirable. In this study, we propose a camera-based system to provide an objective and contactless pain assessment in children aged less than 3 years, through the automatic detection of behavioral parameters from video recordings. To investigate the feasibility of its usage in the ED environment, we collected video recordings of healthy children aged 3–36 months admitted to the ED with acute pain as the main or accompanying symptom, while pain was measured by a healthcare professional according to the Face, Legs, Activity, Cry, and Consolability (FLACC) pain scale. For the recorded videos, we compared the scores for the items Face (F), Legs (L) and Activity (A) given by the operator with the ones given by our system, analyzing the potentiality and limitations of our approach. By showing that automatic pain assessment in young children in the ED could integrate human evaluation to make it easier and faster, without substituting it, we provide the basis for further research in this field.KeywordsAutomatic pain assessmentCamera-based approachChildrenPainPediatric emergency departmentAlgometric scaleFLACCGoogle Mediapipe
... Patient education: Discuss age appropriate care of the patients to ensure compliance to medications.familial compliance with proper dosing of antibiotics when choosing an appropriate oral regimen[9]. ...
Article
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Background: Chronic pain is a persistent and among most prevalence issue in childhood the bio psychosocial model of pain which is a complex interplay contributes to pain symptoms. Disability has guided our understanding and treatment of pediatric pain. The exact cause of chronic pain is sometimes infectious. Introduction: The inclusion of chronic pain and rehabilitation terms resulted in a search to treat pediatric pain, treatment requires a comprehension and multi-disciplinary approaches mostly relieved by psychological intervention. Currently it is unclear how accurate diagnosis is made by general practitioners and specialists and how evaluation is made by pain specialists can affect patient’s outcomes. Case: A young adult female whose chronic hip and knee pain from several months was treated for pain, and osteoporosis, and osteomalacia, with calcium supplements, once Magnetic resonance imaging was done, it revealed that the patient is having fluid filled space in left hip when biopsied revealed chronic osteomyelitis. Conclusion: Chronic pain in pediatrics may be associated to osteomalacia, or osteopenia, it may be infectious, may be due to malignancy or fracture, but it shall be investigated with MRI na biopsy if the pain persists and not reliving with analgesics and supplements. Ignorance of chronic osteomyelitis can have poor outcomes.
... Pain is the symptom most frequently reported by children and adolescents accessing the paediatric emergency department (PED). 1 Appropriate pain management is considered one of the most important goals in PED care. Pharmacological analgesia is the most commonly used analgesic strategy for children and adolescents with acute pain in the PED. ...
Article
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Background Despite evidence showing that the intranasal and sublingual routes are safe and effective in providing analgesia, no data are available about their day-to-day use in the emergency department (ED). The aim of this study was to assess the frequency of the use of the intranasal and sublingual routes, and the clinical characteristics of the patients receiving analgesia through these routes. Methods A multicentre study was performed in the EDs participating in the Pain in Paediatric Emergency Room research group. It included a survey and a retrospective data collection in which the medical records of all patients who received analgesia from 1 April 2022 to 31 May 2022 were collected. Results 48 centres (91%) answered the survey. The intranasal and sublingual routes were used in 25 centres (52%). 13 centres (27%) used both routes, 9 centres (19%) used only the sublingual and 3 centres (6%) used only the intranasal route. 12 centres (48%) participated in the retrospective study. Data about 3409 patients, median age 9 years (IQR 5–12), were collected. Among them, 337 patients (9.6%) received sublingual analgesia, and 87 patients (2.5%) received intranasal analgesia. The intranasal route was employed for injuries in 79 (90.8%) cases, and fentanyl was the drug delivered in 85 (97.7%) cases. The sublingual route was used mainly for injuries (57.3%), but also for abdominal pain (15.4%), musculoskeletal pain (14.5%) and headache (10.7%). Paracetamol, ketorolac and tramadol were administered through this route. Conclusions The use of the intranasal and sublingual routes for analgesia in the paediatric ED is still limited.
... Nyeri merupakan gejala yang sering terjadi pada setiap individu yang merasakan sakit. Nyeri juga tak jarang terjadi pada anak usia remaja, yang lebih umum didapati pada anak yang menerima perawatan di rumah sakit (Krauss et al., 2016). Perawatan nyeri yang optimal pada anak-anak dan remaja adalah yang paling penting, karena nyeri akut yang tidak dikelola dengan baik dapat menyebabkan nyeri kronis (Rabbitts et al., 2017). ...
Article
Full-text available
Latar belakang: Nyeri merupakan gambaran umum yang terus menerus terjadi dan erat kaitannya dengan angka kesakitan pada remaja. Tujuan penelitian ini adalah untuk mendeskripsikan dan mendeskripsikan prevalensi nyeri, pengetahuan terkait manajemen nyeri dan kepatuhan terhadap pedoman pengobatan nyeri pada remaja. Metode: Desain penelitian kuantitatif dan pendekatan deskriptif analitik, penelitian ini dilakukan pada 461 anak remaja. Remaja diberi kuesioner yang diadopsi dari Nursing Outcome Classification mengenai pengetahuan manajemen nyeri. Analisis data menggunakan analisis deskriptif untuk melihat gambaran dari setiap poin pernyataan dalam angket. Hasil: penelitian ini menunjukkan bahwa masih terdapat 45,3% remaja yang kurang pengetahuannya dalam manajemen nyeri. Kurangnya pengetahuan pada remaja akan mempengaruhi cara penanganan nyeri akibat berbagai penyakit. Kesimpulan: Hampir dari setengah remaja tidak memahami cara manajemen nyeri sehingga diharapkan remaja diberikan edukasi tentang penanganan sehingga dapat meningkatkan derajat kesehatannya.
... Ultrasound can be employed to locate the catheter tip for further study. 26,27 In our study, as part of a multimodal approach for this traumatic surgery, paracetamol and ibuprofen 28,29 were prescribed to most of the patients, if pain control was still not enough or breakthrough pain still existed, tramadol orally or intramuscular was used. There is no difference between the two groups for the medications taken, and no difference between tramadol uses in subgroup analysis. ...
Article
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Purpose Although pediatric epidural analgesia is a well-established technique used perioperatively. It is unclear whether a lumbar or caudal epidural is suitable for osteogenesis imperfecta (OI) patients, which may be associated with brittle bones and spine deformity. We conducted a retrospective study to investigate and compare the efficacy of the two continuous epidural techniques in pediatric patients undergoing lower extremity osteotomy surgery using a propensity score-matched analysis (PSMA). Patients and Methods A total of 274 patients were included. Patients’ age, weight, and height were adjusted using PSMA. 90 patients were matched for further analysis, with 45 patients in the lumbar epidural group (Group L) and 45 patients in the caudal epidural group (Group C). Pain scores were categorized into three grades: mild (0–3), moderate (4–6), and severe (7–10), and compared between the two groups. Additionally, operation time, operation site, blood loss, scoliosis, oral analgesic medications, and catheter or nerve-related complications were compared. Results There were no significant differences in operation time, operation site, scoliosis, and blood loss between the two groups. The percentage of moderate to severe pain during movement was significantly higher in Group L than in Group C, with 37.5% versus 17.5% on the second-day post-operation (P=0.039). However, no statistically significant difference was observed on other days. Additionally, there was no significant difference in oral medication consumption and complications between the two groups. Conclusion Both lumbar and caudal epidural analgesia can be effectively used postoperatively, and a caudal epidural should be considered where performing a lumbar epidural is challenging in OI pediatric patients.
... A list of 86 potentially painful experiences was compiled and reviewed by pediatric pain researchers (KAB, MN, SLO, MP) (see Table S1, Supplementary Materials). Through expert opinion supported by existing research, the research team reduced the list to 70 variables representing experiences that are likely painful as supported by previous research [27][28][29][30][31][32][33][34]. The variables were subsequently grouped according to the type of painful experience (see Table S1, Supplementary Materials). ...
Article
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Background Pediatric chronic pain (i.e., pain lasting ≥ 3 months) is prevalent, disabling, and costly. It spikes in adolescence, interrupts psychosocial development and functioning, and often co-occurs with mental health problems. Chronic pain often begins spontaneously without prior injuries and/or other disorders. Prospective longitudinal cohort studies following children from early childhood, prior to chronic pain onset, are needed to examine contributing factors, such as early pain experiences and mental health. Using data from a longitudinal community pregnancy cohort (All Our Families; AOF), the present study examined the associations between early developmental risk factors, including early childhood pain experiences and mental health symptoms, and the onset of pediatric chronic pain at ages 8 and 11 years. Methods Available longitudinal AOF data from child age 4 months, as well as 1, 2, 3, 5, 8, and 11 years, were used. Mothers reported their child’s pain experiences (e.g., hospitalizations, vaccinations, gut problems) at each timepoint from 4 months to 8 years, child chronic pain at age 8, and child mental health symptoms at ages 5 and 8 years. Children reported their chronic pain frequency and interference at age 11. Adaptive least absolute shrinkage and selection operator (LASSO) regressions were used to select predictor variables. Complete case analyses were complemented by multiple imputation using chained equation (MICE) models. Results Gut problems, emergency room visits, frequent pain complaints, and headaches at age 5 or earlier, as well as female sex, were associated with increased risk of maternal reported child chronic pain at age 8. Maternal reported chronic pain at age 8 was associated with higher levels of child-reported pain frequency and pain interferences at age 11. Boys self-reported lower levels of pain interference at age 11. Conclusions Some, but not all, painful experiences (e.g., gut problems, ER visits, pain complaints) in early life contribute to pediatric chronic pain onset and should be considered for screening and early intervention.
... Their job has been mostly connected to the development of non-pharmacological interventions and techniques. Such activities have proven to be effective in supporting young patients during hospital routines, promoting compliance and facilitating the work of the medical staff (Vagnoli et al., 2005, 2010Caprilli et al., 2007;Viggiano et al., 2015;Antonelli et al., 2019;Dionigi, 2017;Dionigi et al., 2013;Krauss et al., 2016). These promising studies have paved the way for future research to determine how non-pharmacological interventions can enhance physical, mental and emotional wellness as well as happiness, which may also foster patient resilience (Peterson, 2006;Wong, 2011Wong, , 2016. ...
Chapter
This study focuses on the use of humour and amateur dubbing as a non-pharmacological technique to help children and adolescents who have had to be hospitalised during their development. The project was developed and carried out at Meyer Children’s Hospital in Florence, Italy. Its main objective is to involve patients in a playful, social and creative activity like dubbing and put them at the centre of this process to elicit humour and foster positive emotions, thus also distracting them from the difficult moment they are facing. In this chapter, we describe the activity, the rationale behind its organisation, the professionals involved and, most importantly, the feedback of six adolescents who took part in a semi-structured interview regarding their experience as amateur dubbers. The adolescents’ comments confirm the effectiveness of this approach, and their insights and suggestions will be taken into account to enhance the future development of this non-pharmacological therapy.
... Studies conducted in North American hospitals have found pain to be often undertreated [6,7]. This is also the case for children who visit the emergency department (ED); they are often in pain or will experience a painful procedure as part of their diagnostic journey [8]. When children visit the ED, the treatment of their presenting and procedural pain is essential to avoid long-term negative consequences such as increased length of stay in hospital, increased likelihood of complications, and development of needle fear or phobia [9][10][11]. ...
Article
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Introduction Pain affects all children, and in hospitals across North America, this pain is often undertreated. Children who visit the emergency department (ED) experience similar undertreatment, and they will often experience a painful procedure as part of their diagnostic journey. Further, children and their caregivers who experience social injustices through marginalization are more likely to experience healthcare disparities in their pain management. Still, most of our knowledge about children’s pain management comes from research focused on well-educated, white children and caregivers from a middle- or upper-class background. The aim of this scoping review is to identify, map, and describe existing research on (a) how aspects of marginalization are documented in randomized controlled trials related to children’s pain and (b) to understand the pain treatment and experiences of marginalized children and their caregivers in the ED setting. Methods and analysis The review will follow Joanna Briggs Institute methodology for scoping reviews using the Participant, Concept, Context (PCC) framework and key terms related to children, youth, pain, ED, and aspects of marginalization. We will search Medline, Embase, PsychInfo, CINAHL, Web of Science, Cochrane Library Trials, iPortal, and Native Health Database for articles published in the last 10 years to identify records that meet our inclusion criteria. We will screen articles in a two-step process using two reviewers during the abstract and full-text screening stages. Data will be extracted using Covidence for data management and we will use a narrative approach to synthesize the data. Ethics and dissemination Ethical approval is not required for this review. Findings will be disseminated in academic manuscripts, at academic conferences, and with partners and knowledge users including funders of pain research and healthcare professionals. Results of this scoping review will inform subsequent quantitative and qualitative studies regarding pain experiences and treatment of marginalized children in the ED.
... La letteratura suggerisce che, soprattutto in età prescolare, la distrazione e l'appropriato posizionamento del bambino con l'aiuto del genitore sono molto più utili a ridurre l'ansia procedurale rispetto a qualsiasi spiegazione 16 . ...
Article
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Venipuncture and peripheral intravenous access are the painful procedures more com- monly performed in children. The aim of this article is to present the techniques availa- ble and more commonly employed to decrease pain and distress during these procedures. Evidence shows that pharmacological techniques, such as the application of anaesthetic creams or topical anaesthesia, have the best pain-relieving effect. Nevertheless, considering that the painful experience during venipuncture and vascular access are related both to perceived pain and procedural anxiety, the integrated use of pharmacological and non-pharmacological techniques is warranted. In this sense, the appropriate preparation is a cornerstone of the procedure. In the article, brief management strategies, with easily implemented techniques to improve daily practice are provided.
... On a broader perspective, several causes of pain in healthy children are age-related, with a peak of frequency in specific ages of childhood, such as infantile abdominal colic in infancy, earache in toddler and nursery school age, migraine, and functional abdominal pain in adolescents, or with different ages related to the locations of osteochondritis. Therefore, considering the different prevalence of pain causes according to the age of children is a common practice for physicians (17). To our knowledge, no study in the literature investigated whether there is a specific timing for different pain causes in children with SNI, nor for acute, recurrent, chronic, or procedural pain. ...
Article
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Objective Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children. Methods We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0–24 months), preschool children (3–5 years), schoolchildren (6–12 years), and adolescents (13–17 years). Results Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001). Conclusions Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.
... Children commonly rate needles as the most painful health-care experience, second only to their chief complaints [32]. Pediatric patients often have poor control over fear, and needle phobias typically develop around 5.5 years of age [33,34]. If pediatric pain is poorly controlled during these needle-based procedures, life-long aversions to medical care can develop in addition to the acute increase in procedural difficulty for providers [35,36]. ...
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Purpose of Review This paper will review the published literature involving virtual reality as a tool for distraction during emergency department waiting periods and minor procedures, with a special emphasis on virtual reality’s analgesic and anxiolytic potential. Recent Findings With virtual reality becoming increasingly accessible and affordable, clinicians have started utilizing virtual reality as an intervention in the emergency department for pediatric and adult patients. These interventions have been implemented during waiting periods and minor procedures, showing promise for anxiolysis, analgesia, and distress management. Summary This paper summarizes the evolution of virtual reality use in patient interventions, with a focus on emergency department applications, logistical considerations, and future directions. Virtual reality is not discussed as a replacement for pharmaceuticals; rather, it is compared against inconsistent standard-of-care distractions (e.g., televisions, tablets) as a more immersive option. Positive findings with this technology are tempered by the limitations of current research, but VR still holds great potential.
... But the relevance of the child's emotional state extends beyond the procedure at hand because heightened fear and anxiety increase perception of pain in children (Ross and Ross 1984; Downloaded from https://academic.oup.com/applij/advance-article/doi/10.1093/applin/amad080/7471409 by guest on 13 December 2023 Ullán et al. 2014;Dionigi and Gremigni 2017), lead to less positive health outcomes, and remain in the child's memory for years (Stuber et al. 1996;Poot et al. 2023). The negative spiral continues because patients who recall painful childhood clinical encounters avoid seeking healthcare as adults, leading to delays in diagnoses and to avoidable treatments becoming necessary (Cohen 2008;Krauss et al. 2016). Thus, discussion on how best to communicate with child patients so as to promote their emotional well-being and reduce their fear and experience of pain is time well spent. ...
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When a paediatrician establishes a trusting relationship with their patient, the chance of a positive outcome multiplies. A calm child, who participates fully in the communicative exchange is more receptive to the clini-cian's requests and reports weaker sensations of pain. This experience stays with the child, shaping how they approach their health care as adults. Our qualitative case study unpacks the linguistic aspects of a 32-minute videoed and transcribed exchange between a paediatrician (co-author) and a five-year-old boy she is preparing for a risky procedure. It asks: what linguistic strategies reduce his anxiety? Non-pharmacological methods are key here, as deep sedation is problematic. Our study explains the communicative techniques that the paediatrician exploits. We identify how they function, and how seemingly disconnected strategies group naturally under a few general principles. This is important for professional development because fewer overarch-ing principles are easier to grasp and subsequently to deploy. Our interdisciplinary approach, which relies on real data, can be replicated and expanded with health care professionals to enable them to act concretely on their language productions.
... The most common causes of acute pain in children are sore throat (72%), respiratory tract infections (71%), stomachache (64%), pain associated with immunization (59%), headaches (54%), earache (54%), toothache (53%), muscle ache (47%), tension headache (39%), and postsurgical pain (39%) [5]. Children suffering from sickle cell disease, hemophilia, juvenile idiopathic arthritis, inflammatory bowel disease, hereditary angioedema, cancer, Mediterranean fever, Fabry's disease, and Gaucher's disease are those at increased risk of chronic pain [6]. ...
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Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.
... Neonates and infants have a positive feedback (lowering of painscores, cry duration and heart rate variation) to oral stimulation as well as physical contact or touch during painful procedures. Distracting activities include bubble blowing, sound and music, controlled deep breathing, art, puppets, imitation play, interactive games, books, guided imagery (32). This kind of approach plays a major role especially when a pharmacological treatment is not feasible. ...
Article
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Differently from the adult patients, in paediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, a selection of appropriate pain assessment tools should consider the age, the cognitive level, the presence of eventual disability, the type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drug pharmacokinetics should facilitate a better management of childhood pain. The objective of this update is to discuss the current practice and the recent advances in pediatric pain management. Using PubMed and the Cochrane Library we conducted an extensive literature analysis on pediatric pain assessment and commonly used analgesic agents in this kind of patients. According to our results, a multimodal analgesic regimen provides a better pain control and a functional outcome in children. Cooperation and communication among the anaesthesiologist, the surgeon and the paediatrician remains essential for successful anaesthesia and pain management in childhood.
... Various factors make it challenging for children to accurately describe their pain, such as their cognitive abilities, behavioral responses, and emotional expressions that differ with age [20,21]. Additionally, the scales cannot continuously assess pain in children. ...
Article
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Pain management is a crucial concern in medicine, particularly in the case of children who may struggle to effectively communicate their pain. Despite the longstanding reliance on various assessment scales by medical professionals, these tools have shown limitations and subjectivity. In this paper, we present a pain assessment scheme based on skin potential signals, aiming to convert subjective pain into objective indicators for pain identification using machine learning methods. We have designed and implemented a portable non-invasive measurement device to measure skin potential signals and conducted experiments involving 623 subjects. From the experimental data, we selected 358 valid records, which were then divided into 218 silent samples and 262 pain samples. A total of 38 features were extracted from each sample, with seven features displaying superior performance in pain identification. Employing three classification algorithms, we found that the random forest algorithm achieved the highest accuracy, reaching 70.63%. While this identification rate shows promise for clinical applications, it is important to note that our results differ from state-of-the-art research, which achieved a recognition rate of 81.5%. This discrepancy arises from the fact that our pain stimuli were induced by clinical operations, making it challenging to precisely control the stimulus intensity when compared to electrical or thermal stimuli. Despite this limitation, our pain assessment scheme demonstrates significant potential in providing objective pain identification in clinical settings. Further research and refinement of the proposed approach may lead to even more accurate and reliable pain management techniques in the future.
... It is a known fact that a proportion of children who access the pediatric ED live a painful and unpleasant experience [1,9,10], not only related to the reason of the medical consultation, but also due to medical procedures performed during the clinical evaluation and treatment. At the same time, pain is one of the most frequent reasons of referral to pediatric EDs, especially in younger children and in those with special needs, a category in which undertreatment of pain (the so-called "oligoanalgesia") is very frequent [1,11,12]. Given that oligoanalgesia is related to long-terms negative behavioral and psychological consequences, [1,13,14] and that the management of pain and anxiety could help the entire medical team in the evaluation and treatment of a child, we identify this gap as a major source of potential improvement, in a continued effort to make pediatric EDs pain-free or at the very least free of iatrogenic traumatic experiences. ...
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To date, pain and anxiety are the most common symptoms reported by children who refer to pediatric emergency department. Despite it is well known that the undertreatment of this condition has some negative consequences in a short term and long term of time, gaps in the management of pain in this setting still persist. This subgroup analysis aims to describe the current state of art of pediatric sedation and analgesia in Italian emergency departments and to identify existing gaps to solve. This is a subgroup analysis of a cross-sectional European survey of pediatric emergency departments sedation and analgesia practice undertaken between November 2019 and March 2020. The survey proposed a case vignette and questions addressing several domains, like the management of pain, availability of medications, protocols and safety aspects, staff training and availability of human resources around procedural sedation and analgesia. Italian sites responding to the survey were identified and their data were isolated and checked for completeness. Eighteen Italian sites participated to the study, the 66% of which was represented University Hospitals and/or Tertiary Care Centers. The most concerning results were an inadequate sedation to 27% of patients, lack of availability of certain medications like nitrous oxide, the lack of use of intranasal fentanyl and topical anesthetics at the triage, the rare use of safety protocols and preprocedural checklists, lack of staff training and lack of space. Furthermore, the unavailability of Child Life Specialists and hypnosis emerged. Despite procedural sedation and analgesia in Italian pediatric emergency departments is progressively more used than previously, several aspects still require an implementation. Our subgroup analysis could be a starter point for further studies and to improve and make the current Italian recommendations more homogeneous.
... According to the recommended posology, and following the Italian Drug Agency (AIFA) indications, we decided to give a dose of 10 mg/kg of ibuprofen with a maximum of 600 mg [20] and 0.5 mg/kg of ketorolac with a maximum of 10 mg [6]. We are fully aware that the single dose of ketorolac may be 30 mg, as this was the maximum quantity administered in previous investigations that employed sublingual ketorolac [7,19]. ...
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This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4–6) and severe (NRS 7–10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0–4.0) for ibuprofen and 1.0 (IQR 1.0–3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623. What is Known: • Limb trauma is one of the most common causes of paediatric emergency department visits. Non-steroidal anti-inflammatory drugs are the most frequently used analgesics in this clinical setting. In particular ibuprofen is the first over the counter non-steroidal anti-inflammatory drug in terms of use. Ketorolac is considered the most effective non-steroidal anti-inflammatory drug for severe pain. What is New: • This study directly compared oral ibuprofen and ketorolac for moderate and severe acute traumatic pain in children and adolescents. Both drugs were similarly effective in children and adolescents with severe pain, and ketorolac was not superior to Ibuprofen for moderate pain.
... Les mesures d'observation de la douleur L'évaluation de signes comportementaux comme l'expression faciale, les pleurs (ou cris), l'irritabilité, l'alimentation insuffisante, les troubles du sommeil et l'inactivité peuvent contribuer à décoder le taux d'inconfort de l'enfant qui est au stade préverbal ou qui est non verbal (21). Des fluctuations des signes vitaux peuvent être corrélées avec la douleur chez le nourrisson, mais ne constituent pas des indicateurs fiables chez les enfants plus âgés (4,21,22). Notamment, l'absence de fluctuations des signes vitaux n'est pas indicatrice de l'absence de douleur chez l'enfant. ...
Article
Résumé L’évaluation et le traitement de la douleur sont des aspects essentiels des soins pédiatriques. L’évaluation de la douleur adaptée au développement représente une première étape importante pour en optimiser la prise en charge. L’autoévaluation de la douleur est à prioriser. Si c’est impossible, des outils appropriés d’évaluation du comportement, adaptés au développement, doivent être utilisés. Des directives et stratégies de prise en charge et de prévention de la douleur aiguë, qui combinent des approches physiques, psychologiques et pharmacologiques, doivent être accessibles dans tous les milieux de soins. Le meilleur traitement de la douleur chronique fait appel à une combinaison de modalités thérapeutiques et de counseling, dans l’objectif premier d’obtenir une amélioration fonctionnelle. La planification et la mise en œuvre de stratégies de prise en charge de la douleur chez les enfants doivent toujours être personnalisées et axées sur la famille.
... For pre-verbal and non-verbal children, evaluating behavioural signs such as facial expression, cry, irritability, poor feeding, sleep disturbance, and inactivity can help decode a child's discomfort level (21). Changing vital signs may be correlated with pain in infants, but are not reliable indicators in older children (4,21,22). Notably, an absence of change in vital signs does not indicate lack of pain in children. ...
Article
Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first step in optimizing pain management. Self-reported pain should be prioritized. Alternatively, developmentally appropriate behavioural tools should be used. Acute pain management and prevention guidelines and strategies that combine physical, psychological, and pharmacological approaches should be accessible in all health care settings. Chronic pain is best managed using combined treatment modalities and counselling, with the primary goal of attaining functional improvement. The planning and implementation of pain management strategies for children should always be personalized and family-centred.
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Background There is little experience on the use of the WHO Standards for improving the quality of care (QOC) for children. We describe the use of four prioritised WHO Standard-based Quality Measures to assess the provision of care for children with pain in emergency departments (EDs). Methods In a multicentre observational study in 10 EDs with different characteristics in Italy, we collected data on 3355 children accessing the EDs between January 2019 and December 2020. The association between children and facility characteristics and quality measures was analysed through multivariate analyses. Results The proportion of children whose pain was measured was 68.7% (n=2305), with extreme variations across different centres (from 0.0% to 99.8%, p<0.001). The proportion of children treated for pain was 28.9% (n=970) again with a wide range (5.3%–56.3%, p<0.001). The difference between the frequency of children with pain measured and pain treated varied widely between the facilities (ranging from −24.3 to 82). Children with moderate and severe pain were more frequently treated (48.9% and 62.9% of cases, respectively), although with large variations across centres (ranges: 0%–74.8% and 0%–100% respectively, p<0.001). After correction for children’s characteristics, the variable more strongly associated with analysed outcomes was the facility which the child accessed for care. Being a facility in Northern Italy was associated with a higher rate of pain measurement (67.3%–95% CI: 39.9% to 94.6%, p<0.001) compared with facilities in South Italy (−22.1% lower (95% CI: −41.7% to −2.50%, p=0.03). Conclusions The use of few WHO Standard-based measures related to pain can help identifying priority gaps in QOC for children and in monitoring it over time. There is a need for more implementation research to establish which are the most sustainable and effective interventions to improve the QOC for acute pain in children.
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Trust forms the bedrock of the doctor-patient relationship. While establishing trust is a foundational skill for healthcare providers who care for children, there is no systematic approach to teaching this skill set, nor is there formal training during medical school or residency. Traditionally, these skills have been taught by example, in an unstructured and ad hoc manner, with trainees picking it up along the way by observing and modeling their instructors. Here, we define and examine the elements of establishing trust and describe a methodology for establishing trust and managing a child’s emotional state during medical encounters.
Article
Background: Effective pain management for adolescents is essential because it significantly affects their quality of life and can prevent the development of chronic pain. Although there have been advancements in this field, managing pain effectively remains challenging, highlighting the need for innovative approaches that combine technology with clinical practice. Objective: This study aimed to assess adolescents’ pain management knowledge and evaluate the effectiveness of the PASHA (Pain Assessment Stimulation and Healing Application) in reducing pain intensity among adolescents. Methods: A combination of a cross-sectional design (N = 461) and one group pretest-posttest approach (N = 60) were employed in a Junior High School at Bukittinggi, West Sumatera, Indonesia. Data were collected from June to August 2022 using the Nursing Outcomes Classification (NOC) to assess pain management knowledge and the Numeric Rating Scale (NRS) to measure pain intensity. The intervention involved using the PASHA application for three days, with pain intensity assessed before and after. Descriptive statistics and Paired t-test were used for data analysis. Results: Headaches were the most prevalent pain type among adolescents (60.5%). Many adolescents lacked adequate knowledge about pain management (57.7%) and self-medication practices (49.2%). Massage/acupressure therapy was the most recognized pain management strategy (39.1%), while aromatherapy was the least known (4.8%). The PASHA application significantly reduced pain intensity (Mean difference = 0.567, p <0.001). Conclusion: Adolescents had moderate knowledge gaps in pain management, particularly in chronic pain and non-pharmacological strategies. The PASHA application effectively reduced pain intensity, suggesting its potential to enhance pain management outcomes. Future research is necessary to validate the findings.
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Objectives The objective of this study was to measure the impact of an intervention on pain treatment in a pediatric emergency department (ED). The application of interventions to improve pain management in DE has demonstrated diverse effects so far, most of them successful. Methods This is a quasi-experimental before-and-after, longitudinal, prospective study. Patients were collected between January 2020 and December 2021. Principal outcome was the number of patients with moderate or severe pain who received analgesia before 30 minutes to the ED arrival. The intervention consisted of several training sessions for nursing staff, pediatricians, and trauma physicians. Results A total of 515 patients were enrolled, 230 during preintervention period and 285 during postintervention period. The percentage of patients receiving analgesia before 30 minutes increased from 24% to 29% and before 60 minutes increased from 31% to 42%. Time to analgesia administration decreased from 43 to 39 minutes. Only 254 patients (49%) received analgesia at some point during their stay in the ED, 137 (26.6%) before 30 minutes and 193 (37.5%) before 60 minutes. The probability of receiving analgesia was greater in patients seen by a pediatrician rather than an orthopedist (59%–37%). Metamizole was the most commonly used drug (48%), followed by ibuprofen and acetaminophen. Conclusions The application strategies to enhance early pain treatment in the ED can improve analgesia administration. Training strategies aimed at healthcare personnel working in the ED can change the way they work and achieve clear benefits for the patient. The treatment of pain in the ED should begin as soon as possible, and in this objective, the involvement of the nursing staff is a priority, because they are the professional who has the best opportunity for the detection and treatment of pain from the moment of triage.
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BACKGROUND: In children, injuries are the focus of attention both for the increasing incidence and necessity of pain management, and pain can be indicate the severity of injuries or serious complications that worsens the treatment results. Despite the obvious problem, information available in the literature regarding the theoretical and practical aspects of acute pain in children is often contradictory and needs to be systematized. AIM: To present current information about the epidemiology, physiology, diagnosis, and treatment of acute pain in children to pediatric orthopedic and trauma specialists. MATERIALS AND METHODS: Selective analysis and narrative review of relevant studies analyzing the epidemiology, diagnosis, and management of acute pain in children were performed. RESULTS: Although various pain assessment tools are available, the clinical assessment of acute pain in children remains challenging. The use of these tools depends on the child’s age, cognitive and communication skills, and pain location. The term oligoanalgesia has been used to describe inadequate pain relief in the emergency department. Oligoanalgesia in children has negative physiological and psychological effects, sometimes with long-term consequences, and may negatively affect their future pain experiences. Parents often underestimate their child’s pain level and have serious misunderstandings about how children express pain. The World Health Organization has developed recommendations for pain management in children. Ibuprofen and paracetamol are recommended as analgesics for mild-to-moderate pain in children aged 3 months. This choice considered extensive data on the effectiveness and safety. CONCLUSIONS: Personalized management strategies utilizing biopsychosocial approach will ensure that children are treated comprehensively according to their unique pain status.
Article
Introduction Flexible nasolaryngoscopy (FNL) is a common, uncomfortable procedure performed to assess the upper airway in infants. Oral sucrose is used during various painful procedures in infants but has not been used during FNL. Our objective was to understand the impact of oral sucrose on discomfort in infants undergoing FNL. Methods Infants (<12‐months‐old) undergoing FNL in the otolaryngology clinic were randomized to treatment (0.5 mL 24% oral sucrose) or standard management (no sucrose). Sucrose was administered <2 min prior to FNL performed by a single endoscopist. Outcome measures included: EVENDOL pain scale and cry duration and visit duration. Infant discomfort was measured by a second observer who was blinded to treatment group. Results Forty‐seven infants were included, 23 were treated with sucrose and 24 with standard management. The median (IQR) age was 3.0 (2–5.7) months. There were no significant differences in age, weight, or sex across groups. The median (IQR) duration of FNL was 35.2 (26.5–58.4) and 36.4 (28.9–51.8) seconds for treatment and standard management groups, respectively. Mean (SD) EVENDOL scores were significantly lower in the sucrose group [4.9 (2.0)] than standard group (6.7 [2.1]) ( p = 0.003). Mean cry duration after FNL was significantly shorter in the sucrose group (29.9 [20.4] seconds) than the standard group (52.7.0 [40.6] seconds) ( p = 0.02). Median (IQR) visit duration did not differ across groups (1.1 [0.9–1.3] vs. 1.1 [0.7–1.4] h [ p = 0.15]). Conclusion Oral sucrose given before FNL reduced EVENDOL scores and cry duration after FNL and did not prolong clinic visits in this randomized pilot study. Level of Evidence 2 Laryngoscope , 2024
Chapter
Acute pain is a common presenting symptom in children in the emergency setting and can be classified as mild, moderate or severe. Asssessment of pain is the first step to development of effective pain management strategies. Measures of pain include physiologic, observational/behavioural and self report which is considered the gold standard and can be used in children as young as 4 years of age. There are multiple validated tools for pain assessment that are both age and developmentally appropriate. Management interventions are most effective when they are multi-modal and incorporate physical, psychological and pharmacological techniques. Common pharmacological agents for mild pain include acetaminophen and/or ibuprofen with the addition of oral or intranasal opioids for moderate pain and intravenous opioids for severe pain. Procedures in the emergency department are often anxiety provoking and can be managed with a variety of techniques including use of procedural sedation. Indications for procedural sedation include non-invasive procedures requiring the child to be motionless as well as procedures with high level of anxiety and low to high level of pain. When procedural sedation is utilized, it is imperative to ensure that appropriate sedation guidelines and policies are implemented to minimize potential adverse effects.
Article
Background Many studies have been conducted recently to identify biomarkers that could potentially be used to objectively evaluate pain. Objective To synthesize and critically analyze primary studies of endogenous biomarkers and their associations with pain to identify suitable biomarkers for the objective evaluation of pain in critically ill children. Methods PubMed, Scopus, and Ovid databases were searched; searches were restricted by publication date, language, species, and participant age. Critical appraisal tools and the Strengthening the Reporting of Observational Studies in Epidemiology checklist were used to evaluate quality of evidence. Results All included articles were coded according to methods and findings. Saliva, blood, cerebrospinal fluid, and gingival crevicular fluid were used to detect biomarkers. Enzyme-linked immunosorbent assays were used in most studies (64%). Appropriate statistical analyses were performed at a significance level of P < .05 in included studies. Cytokines, peptides, and hormones were associated with pain, stress, and inflammatory response, suggesting that they can be used to screen for pain in children during painful conditions. Only 1 study in neonates did not show any correlation between saliva biomarkers and pain. Conclusion According to this literature review, various biomarkers that are easily obtained and measured in a clinical setting are associated with pain in children. Further investigation of these biomarkers through observational studies is suggested to evaluate their suitability for pain assessment in critically ill children.
Article
Aim: To determine the effect of distraction with a finger puppet for venous blood collection in the pediatric emergency department on children’s pain and emotional manifestation. Methods: Randomized controlled trial with 80 children (aged 3–6 years) who applied to the pediatric emergency department between October 2021 and March 2022. The attention of child was distracted from the procedure by playing with finger puppets before and during the venous blood collection in the finger puppet group. The children in the control group underwent routine blood collection. The procedural pain was measured with the Face, Legs, Activity, Cry, Consolability Scale (FLACC) and the emotional response was measured with the Children’s Emotional Manifestation Scale (CEMS). Results: The mean FLACC pain scores of the children in the finger puppet group were statistically significantly lower than the children in the control group (p < 0.001). It was also found that the finger puppet group’s mean scores of CEMS before and during the procedure were statistically lower than those of the control group (p < 0.001). Conclusions: Finger puppets can be used to reduce pain and positively change children’s emotional responses during painful procedures such as blood collection.
Article
Background: Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates that parents experience anxiety surrounding their children's medical procedures, less is known about parental anxiety and factors that contribute to higher parental anxiety in the ED. This study aimed to assess parental anxiety in families presenting to a paediatric ED with a variety of presenting concerns and examine demographic and psychological factors associated with parental anxiety. Methods: This cross-sectional study included parents of children <18 years old presenting to a paediatric ED in Orange County, California, USA, for a non-psychiatric complaint between 20 January 2021 and 26 March 2021. Parents were, on average, 34.76±9.10 years old, 87.5% were mothers, 59.2% identified as non-Latinx and parents reported average levels of mental health (T-score=51.21±9.84). Parent state anxiety was assessed via the State-Trait Anxiety Inventory and validated instruments were used to measure child temperament (ie, emotionality, activity, sociability, shyness), previous medical anxiety, and parent physical and mental health. Data were analysed using multiple linear regression models. Results: Out of 201 families screened, 150 were eligible, and 120 enrolled. In the sample, 42.5% of parents endorsed clinically significant levels of anxiety in the ED. Regression analyses indicated that lower child activity temperament (ie, tendency to be less active/energetic; B=-3.20, 95% CI -5.70 to -0.70, p=0.012) and poorer parent mental health (B=-0.31, 95% CI -0.52 to -0.09, p=0.006) were independently associated with higher parent anxiety (F(5, 99)=6.77, p=0.004). Conclusion: Over 40% of parents sampled endorsed clinically significant anxiety in the paediatric ED. Child temperament, specifically lower activity temperament, and poorer parental mental health were identified as contributors to parent anxiety, whereas clinical condition or severity did not influence parent anxiety. Current results may help identify families in need of additional intervention and may improve patient outcomes.
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Background: reducing anxiety and pain during an invasive procedure like venipuncture is crucial for preventing the onset of stress and making the nurse’s procedures faster and smoother. Distraction techniques appear to be a viable solution. The aim of this study is to compare the effectiveness of two different distraction methods in terms of cost-effectiveness and time to perform venipuncture in a hospital setting. Materials and Methods: a randomized, controlled, interventional-blinded 3-arm parallel-group study with inpatients aged 3 to 18 years old, awake and conscious, at the first venipuncture attempt and only after children and parents signed informed consent. The pain rating scales Wong-Baker FACES, Numerical Rating Scale, and Children’s Fear Scale will be used. Conclusions: pediatric pain is a challenge for medical professionals as well as a health need that must be addressed rapidly. It is crucial to assess and apply the most effective methods for adequate analgesia in shorter periods, while also reducing healthcare costs.
Article
Bu çalışma ile IV kateter uygulanan 7-12 yaş grubu çocuk hastalarda uygulama öncesi verilen eğitimin, onların ağrı ve fizyolojik parametreler üzerindeki etkilerini incelemek amaçlanmıştır. Araştırma, deney-kontrol çalışması olarak planlanmıştır. Araştırmanın evrenini çalışmanın yapılacağı Nisan-Haziran 2016 tarihleri arasında Eğitim ve Araştırma Hastanesinde çocuk servisine yatan 7-12 yaş grubundaki çocuk hastalar oluşturmuştur. Araştırmada veriler, “Çocuğu Tanıtıcı Bilgi Formu”, “Wong Baker Yüz Ağrı Skalası” ve “Çocukların İşlem Öncesi-Sonrası Fizyolojik Parametreleri İzlem Formu” ile toplanmıştır. Verilerin değerlendirilmesinde Independent-samples t-test, Paired sample t-test, Wilcoxon signed rank test, Mann Whitney U test, ANOVA, Kruskal-Wallis testi ve Ki-kare testi kullanılmıştır. Araştırmada çalışma ve kontrol grubundaki çocukların Wong Baker Yüz Ağrı Skalası’na göre ağrı puanları karşılaştırıldığında; kontrol grubundaki çocukların ağrı puan ortalaması çalışma grubundaki çocuklara göre daha yüksek olup, aralarındaki fark anlamlıdır (p
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Objective: Anxiety and pain during medical procedures may have adverse short and long-term consequences. We summarize the effectiveness of hospital clown interventions, as compared with medication, the presence of a parent, standard care, and other non-pharmacological distraction interventions on anxiety and pain in minors undergoing medical procedures. Method: Randomized trials were identified in PsycINFO, MEDLINE, Embase, Scopus and CINAHL, and previous reviews. Screening of titles and abstracts and full-texts, data extraction and risk of bias assessment was done by two independent reviewers. We conducted random-effects network and pairwise meta-analyses based on a frequentist framework. Results: Our analyses with 28 studies showed significantly lower anxiety scores in clowning and other distraction interventions as compared with the presence of parents. No differences were observed between clowning, medication, and other distraction interventions. Clowning interventions were superior to standard care in our main analyses, but non-significant in some of the sensitivity analyses. Furthermore, clowning led to significantly lower pain as compared with presence of parents and standard care. No differences were observed between clowning interventions and the other comparators. For both outcomes, large between study heterogeneity was present but no significant inconsistency between designs. Risk of bias was mainly high and accordingly the certainty of evidence is considered moderate to low. Conclusions: We found no significant difference between medication, other non-medical distraction interventions and hospital clown interventions. Hospital clowns and other distraction interventions were more effective in reducing anxiety and pain in children undergoing medical procedures than the presence of parents alone. In order to allow for better insights regarding the comparative effectiveness of clowning interventions future trials should include detailed descriptions about the clowning intervention itself and the comparator. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Article
Objectives: The aim of this study was to compare the effectiveness of 3 methods (Buzzy, ShotBlocker, and DistrACTION Cards) in reducing pain and anxiety while taking venous blood samples in children. Methods: The study population consisted of children aged 9 to 12 years admitted to the Child Health and Diseases Department in a Faculty of Medicine in Turkey. The sample of the study consisted of 242 children (Buzzy = 60, ShotBlocker = 61, DistrACTION Cards = 60, control = 61) who met the patient selection criteria and agreed to participate in the study. The data were obtained using an Information Form, the State-Trait Anxiety Inventory for Children, visual analog scale, and the Faces Pain Scale-Revised. Design: This article is an experimental randomized controlled study. Results: During venous blood collection, the scores of visual analog scale were significantly lower in ShotBlocker, Buzzy, and DistrACTION Cards groups than the control group. It was also observed that the control group experienced more anxiety than the other groups. Conclusions: Methods such as Buzzy, ShotBlocker, and DistrACTION Cards can be used to reduce the anxiety and pain of children during painful procedures such as blood collection and vascular access. Among these methods, "Buzzy" and "DistrACTION Cards" can be preferred as it is equally effective, and then ShotBlocker can be preferred.
Article
Objectives: To identify the core components of acute pain management in children, re-conceptualise the process and update the existing model to inform nursing research and clinical practice. Background: Acute pain in hospitalised children remains suboptimal, despite extensive nursing research and education. Improvements require a patient-centred approach and a conceptual model which includes the role of parents and partnership. Design: Using Rodgers' Evolutionary method, a concept analysis was conducted to define the core components for effective acute pain management in children. Methods: A scoping review of peer-reviewed literature from 1990 through 2020 was conducted using the terms "pain management," "pain control," "pain treatment," "multi modal," and "concept*". Abstracts from 85 articles were initially reviewed with 30 articles retained for analysis. Core concepts were identified, defined and synthesised. The PRISMA 2020 checklist was used. Results: A new model was developed from a synthesis of past work which incorporates the role of parents, the complexity of the process and definitions for shared decision-making. Trust, safety, collaborative communication and genuine partnership were identified as the core components for effective pain management in children, with the triadic relationship of nurses, patients and parents in genuine partnership foundational to the nursing process. Conclusion: The new model for acute pain management in children transforms the nurse's role from gatekeeper to facilitator, shifting the process from nurse driven to patient-centred. The new collaborative model will promote shared decision-making for individualised pain assessments, interventions and evaluations. Relevance to clinical practice: Establishing the nurse, child, parent partnership as an essential foundation to pain management has the potential to expand pain assessments, optimise treatment selections, advancing clinical practice, patient outcomes and nursing science. No Patient or Public Contributions were included in this paper as this was a concept analysis pulling from past works.
Article
Inflammatory bowel diseases (IBDs) are chronic, immune-mediated disorders that include Crohn's disease and ulcerative colitis. A pediatric onset of disease occurs in about 10% of all cases. Clinical presentation of IBD with rectal bleeding or perianal disease warrants direct referral for endoscopic evaluation. In the absence of red-flag symptoms, a combination of patient history and blood and fecal biomarkers can help to distinguish suspected IBD from other causes of abdominal pain or diarrhea. The therapeutic management of pediatric IBD has evolved by taking into account predictors of poor outcome, which justifies the upfront use of anti-tumor necrosis factor therapy for patients at high risk for complicated disease. In treating patients with IBD, biochemical or endoscopic remission, rather than clinical remission, is the therapeutic goal because intestinal inflammation often persists despite resolution of abdominal symptoms. Pediatric IBD comes with unique additional challenges, such as growth impairment, pubertal delay, the psychology of adolescence, and development of body image. Even after remission has been achieved, many patients with IBD continue to experience nonspecific symptoms like abdominal pain and fatigue. Transfer to adult care is a well-recognized risk for disease relapse, which highlights patient vulnerability and the need for a transition program that is continued by the adult-oriented IBD team. The general pediatrician is an invaluable link in integrating these challenges in the clinical care of patients with IBD and optimizing their outcomes. This state-of-the-art review aims to provide general pediatricians with an update on pediatric IBD to facilitate interactions with pediatric gastrointestinal specialists.
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To improve the time taken for children arriving to the accident and emergency (A&E) department in pain to receive analgesia. Delivery within 30 minutes of triage was taken as an achievable goal. 262 children who had received analgesia in the "minor injuries" area of West Middlesex University Hospital A&E department were studied over a four month period. Current practice was indicated over the first two months by retrospectively looking at data from 129 children's A&E cards. A Paediatric Pain Protocol was then introduced and another 133 children's cards studied to see if this had made an improvement. The protocol for those children aged over 4 years differed to that for children aged 4 years and under. For children aged 4 years and over, the introduction of the protocol significantly increased the number that received analgesia within 30 minutes of triage: 55.3% (n=54) post-protocol versus 34.0% (n=33) pre-protocol (p=0.003). However, for children aged 4 years and under there was no change in the proportion that received analgesia within 30 minutes of triage: 56.7% (n=17) postprotocol versus 59.4% (n=19) pre-protocol (p=0.829). The introduction of a simple Paediatric Pain Protocol has improved the time taken to deliver analgesia to children arriving in this A&E department.
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BMC Neurology 2010, 10:20 doi:10.1186/1471-2377-10-20 Published: 31 March 2010 Abstract Background Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I. Method A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment. Results For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I. Conclusions Based on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.
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Objective: To examine the effect of psychologic and pharmacologic interventions on children's expectations and 6-month recollections of painful procedures. Methods: A repeated measures design allowed examination of 22 fourth graders' expectations, experiences, and memories of distress across three conditions (typical care, distraction, topical anesthetic) for a three-injection vaccination series. All participants were African American and from urban, low-income families. Results: Across conditions, children's expectations of distress were significantly higher than their experience of distress. Distress ratings did not differ among conditions prior to or immediately following the injections; however, children later recalled that the treatment conditions were superior to control for distress relief. Analyses of recall accuracy suggest that the interventions buffered the children from forming negative recollections that occurred with typical care. Conclusions: Children have negative expectations prior to a procedure despite knowing that a distress management intervention will be employed. However, interventions may thwart the development of negative memories of distress.
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Objective To determine the prevalence and associations of self- and parent-reported pain in young people with cerebral palsy (CP). Design and setting Cross-sectional questionnaire survey conducted at home visits in nine regions in seven European countries. Participants were 13 to 17-year-olds (n=667) drawn from population CP registers in eight regions and from multiple sources in one region. 429 could self-report; parent-reports were obtained for 657. Data were collected on: severity, frequency, site and circumstances of pain in previous week; severity of pain associated with therapy in previous year. Results The estimated population prevalence of any pain in previous week was 74% (95% CI 69% to 79%) for self-reported pain and 77% (95% CI 73% to 81%) for parent-reported pain. 40% experienced leg pains, 34% reported headaches and 45% of those who received physiotherapy experienced pain during therapy. Girls reported more pain than boys (OR=2.1, 95% CI 1.5 to 3.0) and young people reported more pain if they had emotional difficulties (comparing highest and lowest quartiles: OR=3.1, 95% CI 1.7 to 5.6). Parents reported more pain in children with emotional difficulties (OR=4.2, 95% CI 2.7 to 6.6), or with more impaired walking ability. Conclusions Pain in young people with CP is highly prevalent. Because pain causes immediate distress and is associated with lower subjective well-being and reduced participation, clinicians should routinely assess pain. Clinical interventions to reduce pain should be implemented and evaluated. The efficacy of medical and therapeutic interventions causing pain should be re-examined to establish if their benefit justifies the pain and fear of pain that accompany them.
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Objective To evaluate the risk of upper gastrointestinal complications (UGIC) associated with drug use in the paediatric population. Methods This study is part of a large Italian prospective multicentre study. The study population included children hospitalised for acute conditions through the emergency departments of eight clinical centres. Patients admitted for UGIC (defined as endoscopically confirmed gastroduodenal lesions or clinically defined haematemesis or melena) comprised the case series; children hospitalised for neurological disorders formed the control group. Information on drug and vaccine exposure was collected through parental interview during the children's hospitalisation. Logistic regression was used to estimate ORs for the occurrence of UGIC associated with drug use adjusted for age, clinical centre and concomitant use of any drug. Results 486 children hospitalised for UGIC and 1930 for neurological disorders were enrolled between November 1999 and November 2010. Drug use was higher in cases than in controls (73% vs 54%; p<0.001). UGICs were associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted OR 2.9, 95% CI 2.1 to 4.0), oral steroids (adjusted OR 2.9, 95% CI 1.7 to 4.8) and antibiotics (adjusted OR 2.3, 95% CI 1.8 to 3.1). The duration of use of these drug categories was short (range 1–8 days). Paracetamol showed a lower risk (adjusted OR 2.0, 95% CI 1.5 to 2.6) compared to ibuprofen (adjusted OR 3.7, 95% CI 2.3 to 5.9), although with partially overlapping CIs. Conclusions NSAIDs, oral steroids and antibiotics, even when administered for a short period, were associated with an increased risk of UGIC.
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<⁄span> Complex regional pain syndrome (CRPS) is a painful disorder without a known unifying mechanism. There are little data on which to base evaluation and treatment decisions, and what data are available come from studies involving adults; however, even that literature is relatively sparse. Developing robust research for CRPS in children is essential for the progress toward optimal treatment. <⁄span> To determine potential avenues of research in pediatric CRPS based on a review of the literature. Areas of concern include diagnostic criteria, peripheral mechanisms, central nervous system mechanisms, the role of the autonomic nervous system, possible risk factors, options for prevention and potential avenues of treatment. <⁄span> A literature review was performed and the results applied to form the hypotheses posited in the form of research questions. <⁄span> CRPS is a complicated entity that is more than a painful sensory condition. There is evidence for peripheral inflammatory and neurological changes, and reorganization in both sensory and motor cortexes. In addition, a significant motor component is frequently observed and there appear to be tangible risk factors. Many of these pieces of evidence suggest options for prevention, treatment and monitoring progress and outcome. Most of the data are derived from adult studies and need to be replicated in children. Furthermore, there may be factors unique to pediatrics due to developmental changes in neuroplasticity as well as somatic, endocrinological and emotional growth. Some of these developmental factors may shed light on the adult condition.
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Administration of oral sucrose or glucose with and without non-nutritive sucking is frequently used as a non-pharmacological intervention for needle-related procedural pain relief in infants. To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data. Randomised-controlled trials using a sweet-tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle-related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra-pubic bladder aspiration were not included as they are more severe and painful than needle-related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet-tasting solution, a pharmacological pain-relieving method (e.g. paracetamol, topical anaesthetic cream), non-pharmacological pain-relieving method (e.g. distraction method, non-nutritive sucking). Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed-effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi(2) test and I(2) statistic were used to assess between-study heterogeneity. Sixty-five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet-tasting solution [MD -13.47 (95% CI -16.80 to -10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I(2) = 94%) that we were unable to explain. Meta-analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine-prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet-tasting solutions in infants aged one to 12 months. Further large RCTs are needed. There is insufficient evidence to confidently judge the effectiveness of sweet-tasting solutions in reducing needle-related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta-analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects.
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Introduction: After decades of research, the importance of psychological factors in child and adolescent headache is no longer in doubt. However, it is not clearly understood whether different types of headache are comorbid with specific kinds of psychopathology. To address this issue, we set out to establish whether young patients with migraine do or do not show significant levels of psychopathological symptoms compared with age-matched healthy controls and patients with tension-type headache (TTH). Methods: Ten studies were selected on the basis of a widely used psychodiagnostic tool (the Child Behavior Checklist (CBCL)) and by applying rigorous criteria: The studies were compared in a meta-analysis in order to evaluate the presence of Internalizing (mainly anxiety and depression) and Externalizing (mainly behavioral problems) symptoms in different types of headache (and versus healthy controls). Findings: Patients with migraine showed more psychopathological symptoms than healthy controls. TTH patients also had more psychopathology than controls, although the difference was more marked in the area of Internalizing disorders. Finally, no differences emerged between migraine and TTH. Discussion and conclusion: Psychopathological symptoms affect children with migraine, but also children with TTH. Biological, pathophysiological and clinical links need to be established. Effective treatment of affected children and adolescents is imperative in order to prevent chronic evolution. In this context, the CBCL may be a good screening instrument with a view to developing a tailored clinical approach.
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This target article presents a theory of human cultural learning. Cultural learning is identified with those instances of social learning in which intersubjectivity or perspective-taking plays a vital role, both in the original learning process and in the resulting cognitive product. Cultural learning manifests itself in three forms during human ontogeny: imitative learning, instructed learning, and collaborative learning – in that order. Evidence is provided that this progression arises from the developmental ordering of the underlying social-cognitive concepts and processes involved. Imitative learning relies on a concept of intentional agent and involves simple perspective-taking. Instructed learning relies on a concept of mental agent and involves alternating/coordinated perspective-taking (intersubjectivity). Collaborative learning relies on a concept of reflective agent and involves integrated perspective-taking (reflective intersubjectivity). A comparison of normal children, autistic children and wild and enculturated chimpanzees provides further evidence for these correlations between social cognition and cultural learning. Cultural learning is a uniquely human form of social learning that allows for a fidelity of transmission of behaviors and information among conspecifics not possible in other forms of social learning, thereby providing the psychological basis for cultural evolution.
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The objective of this study was to measure the impact of a structured intervention on pain management in a pediatric emergency department (ED). Data were prospectively collected from children presenting to an urban tertiary care pediatric ED before and after intervention. Data were collected on the rate and timeliness of analgesic administration, the assessment and reassessment of pain, periprocedural anesthesia, and patient satisfaction. The intervention was developed by a multidisciplinary committee composed of physicians, nurses, and child life specialists and was focused on correcting deficiencies identified before intervention data collection. It consisted of a policy defining pain, pain-appropriate analgesia, age-appropriate pain assessment, and adequate preprocedural and periprocedural analgesia. Implementation occurred through provider education, organizational changes, and patient empowerment. One hundred two patients were enrolled during the preintervention period, and 109 were enrolled in the postintervention period. The percentage of patients in pain receiving any analgesic increased from 34% to 50%, an increase of 16% (95% confidence interval [CI], 1%-30%). The median time to medication administration decreased from 97 minutes to 57 minutes, a decrease of 40 minutes (95% CI, -84 to 4 minutes). The percentage of children receiving preprocedural analgesia increased from 10% to 62%, an increase of 52% (95% CI, 12%-74%). Reassessment of pain by physicians increased from 6% to 76%, an increase of 70% (95% CI, 59%-78%). A structured intervention, tailored to pain management shortcomings commonly found in the pediatric ED, can lead to improvements in the treatment and prevention of pain in childhood emergencies.
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Extant research comparing laboratory pain responses of children with chronic pain with healthy controls is mixed, with some studies indicating lower pain responsivity for controls and others showing no differences. Few studies have included different pain modalities or assessment protocols. To compare pain responses among 26 children (18 girls) with chronic pain and matched controls (mean age 14.8 years), to laboratory tasks involving thermal heat, pressure and cold pain. Responses to cold pain were assessed using two different protocols: an initial trial of unspecified duration and a second trial of specified duration. Four trials of pressure pain and of thermal heat pain stimuli, all of unspecified duration, were administered, as well as the two cold pain trials. Heart rate and blood pressure were assessed at baseline and after completion of the pain tasks. Pain tolerance and pain intensity did not differ between children with chronic pain and controls for the unspecified trials. For the specified cold pressor trial, 92% of children with chronic pain completed the entire trial compared with only 61.5% of controls. Children with chronic pain exhibited a trend toward higher baseline and postsession heart rate and reported more anxiety and depression symptoms compared with control children. Contextual factors related to the fixed trial may have exerted a greater influence on pain tolerance in children with chronic pain relative to controls. Children with chronic pain demonstrated a tendency toward increased arousal in anticipation of and following pain induction compared with controls.
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As important users of health care, adolescents with chronic conditions deserve to be consulted about their experiences and expectations. This study aimed to explore chronically ill adolescents' preferences regarding providers' qualities, and outpatient and inpatient care. Furthermore, suggestions for improvement of service delivery were collected. This research was a sequential mixed methods study in adolescents aged 12-19 years with various chronic conditions treated in a university children's hospital. Methods comprised 31 face-to-face interviews at home, a hospital-based peer research project in which nine adolescents interviewed 34 fellow patients, and a web-based questionnaire (n = 990). Emerging qualitative themes were transformed into questionnaire items. Having "a feeling of trust" and "voice and choice" in the hospital were central to these adolescents. Regarding providers' qualities, "being an expert" and "being trustworthy and honest" were ranked highest, followed by "being caring and understanding", "listening and showing respect", and "being focused on me". Regarding outpatient consultations, preferences were ranked as follows: "answering all questions"; "attending to my and my parents' needs"; and "clear communication", while "limited waiting times" and "attractive outpatient surroundings" scored lowest. Regarding hospitalization, adolescents most preferred to "avoid pain and discomfort", "keep in touch with home", and "be entertained", while "being hospitalized with peers" and "being heard" were least important. Regarding priorities for improvement, 52% of the respondents felt that more attention should be paid to older children, followed by enabling more contact with family and friends (45%), shorter waiting times (43%), and more activities to meet fellow patients (35%). Adolescents prefer technically competent providers, who are honest and trustworthy, and attend to their needs. As they gradually grow out of the pediatric environment, they desire staff attitudes to become less childish and more age-appropriate, and welcome being treated as an equal partner in care. Health care professionals should inquire into preferences and adjust their communication style accordingly.
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Acetaminophen is widely used in children, because its safety and efficacy are well established. Although the risk of developing toxic reactions to acetaminophen appears to be lower in children than in adults, such reactions occur in pediatric patients from intentional overdoses. Less frequently, acetaminophen toxicity is attributable to unintended inappropriate dosing or the failure to recognize children at increased risk in whom standard acetaminophen doses have been administered. Because the symptoms of acetaminophen intoxication are nonspecific, the diagnosis and treatment of acetaminophen intoxication are more likely to be delayed in unintentional cases of toxicity. This statement describes situations and conditions that may contribute to acetaminophen toxicity not associated with suicidal intentions.
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OBJECTIVE: To compare the effectiveness of nasal diamorphine spray with intramuscular morphine for analgesia in children and teenagers with acute pain due to a clinical fracture, and to describe the safety profile of the spray. DESIGN: Multicentre randomised controlled trial. SETTING: Emergency departments in eight UK hospitals. PARTICIPANTS: Patients aged between 3 and 16 years presenting with a clinical fracture of an upper or lower limb. MAIN OUTCOME MEASURES: Patients' reported pain using the Wong Baker face pain scale, ratings of reaction to treatment of the patients and acceptability of treatment by staff and parents, and adverse events. RESULTS: 404 eligible patients completed the trial (204 patients given nasal diamorphine spray and 200 given intramuscular morphine). Onset of pain relief was faster in the spray group than in the intramuscular group, with lower pain scores in the spray group at 5, 10, and 20 minutes after treatment but no difference between the groups after 30 minutes. 80% of patients given the spray showed no obvious discomfort compared with 9% given intramuscular morphine (difference 71%, 95% confidence interval 65% to 78%). Treatment administration was judged acceptable by staff and parents, respectively, for 98% (199 of 203) and 97% (186 of 192) of patients in the spray group compared with 32% (64 of 199) and 72% (142 of 197) in the intramuscular group. No serious adverse events occurred in the spray group, and the frequencies of all adverse events were similar in both groups (spray 24.1% v intramuscular morphine 18.5%; difference 5.6%, -2.3% to 13.6%). CONCLUSION: Nasal diamorphine spray should be the preferred method of pain relief in children and teenagers presenting to emergency departments in acute pain with clinical fractures. The diamorphine spray should be used in place of intramuscular morphine.
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A Young Mind in a Growing Brain summarizes some initial conclusions that follow simultaneous examination of the psychological milestones of human development during its first decade and what has been learned about brain growth. This volume proposes that development is the process of experience working on a brain that is undergoing significant biological maturation. Experience counts, but only when the brain has developed to the point of being able to process, encode, and interact with these new environmental experiences. This book's aim is to acquaint developmental biologists and neuroscientists with what has been learned about human psychological development and to acquaint developmental psychologists with the biological evidence. The hope is that each group will gain a richer appreciation of both knowledge corpora. The authors hope to appeal to neuroscientists, psychologists, psychiatrists, pediatricians, and their students. The idea for this book was born in 1993 when the authors--a leading developmental psychologist and a pediatrician--met for the first time and recognized the complementarity of their backgrounds and the utility of a collaboration. The reception of their first two papers motivated this attempt to synthesize the available information over a longer developmental era. Learning a great deal over the past decade, the authors hope that their enthusiasm provokes an equally intense curiosity in readers. © 2005 by Lawrence Erlbaum Associates, Inc. All rights reserved.
Article
Background: Differently from the adult patients, in pediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, selection of appropriate pain assessment tools should consider age, cognitive level and the presence of eventual disability, type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drugs pharmacokinetics should facilitate a better management of childhood pain. Aim: The objective of this review is to discuss current practice and recent advances in pediatric pain management. Methods: Using PubMed we conducted an extensive literature review on pediatric pain assessment and commonly used analgesic agents from January 2000 to January 2012. Conclusions: A multimodal analgesic regimen provides better pain control and functional outcome in children. Cooperation and communication between the anaesthesiologist, surgeon, and paediatrician are essential for successful anaesthesia and pain management.
Article
AimPain is a neglected problem in children with cognitive impairments and few studies compare the clinical use of specific pain scales. We compared the Non-Communicating Children's Pain Checklist Postoperative Version (NCCPC-PV), the Echelle Douleur Enfant San Salvador (DESS) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The first two were developed for children with cognitive impairment and the third is a more general pain scale.Methods Two external observers and the child's caregiver assessed 40 children with cognitive impairment for pain levels. We assessed inter-rater agreement, correlation, dependence on knowledge of the child's behaviour, simplicity and adequacy in pain rating according to the caregiver for all three scales.ResultsThe correlation between the NCCPC-PV and the DESS was strong (Spearman correlation coefficient = 0.76) and better than between each scale and the CHEOPS. Although the DESS showed better inter-rater agreement, it was more dependent on familiarity with the child and was judged more difficult to use by all observers. The NCCPC-PV was the easiest use and the most appropriate for rating the child's pain.Conclusion The NCCPC-PV was the easiest to use for pain assessment in cognitively impaired children and should be adopted in clinical settings.This article is protected by copyright. All rights reserved.
Article
The European Medicine Agency recommendations limiting codeine use in children have created a void in managing moderate pain. We review the evidence on the pharmacokinetic, pharmacodynamic and safety profile of tramadol, a possible substitute for codeine.Conclusion Tramadol appears to be safe in both pediatric inpatients and outpatients. It may be appropriate to limit the current use of tramadol to monitored settings in children with risk factors for respiratory depression, subject to further safety evidence.This article is protected by copyright. All rights reserved.
Article
Unlabelled: Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever in children. This drug has multiple mechanisms of action, but its pharmacodynamic is still not well known. The central nervous system is the main site of action and it mirrors the paracetamol effect compartment. The recommended dosages and routes of administration should be different whether paracetamol is used for the treatment of pain or fever. For example, the rectal route, while being efficacious for the treatment of fever, should be avoided in pain management. Paracetamol is a safe drug, but some clinical conditions and concomitant drugs, which are frequent in clinical practice, may increase the risk of paracetamol toxicity. Therefore, it is important to optimize its administration to avoid overdoses and maximize its effect. The principal mediator of the paracetamol toxicity is the N-acetyl-p-benzo-quinone imine (NAPQI), a toxic product of the paracetamol metabolism, which could bind cysteine groups on proteins forming paracetamol-protein adduct in the liver. Conclusion: Although frequently prescribed, the concept of "effect compartment concentration" and the possible co-factors that could cause toxicity at recommended doses are not familiar to all pediatricians and general practitioners. We reviewed the literature concerning paracetamol mechanisms of action, we highlighted some relevant pharmacodynamic concepts for clinical practice, and we summarized the possible risk factors for toxicity at therapeutic dosages.
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This review article explores the need for specialized pain care for children and adolescents and provides some historical context for our current knowledge base and clinical practice. Pediatric patients have specialized needs with respect to assessment and management of pain. Acute pain care is modified by developmental considerations in both these areas; chronic pain encompasses a wide range of complex developmental, social, and psychological factors requiring the skills of different health disciplines to provide the best care. Awareness of children's pain has increased dramatically over the past three decades, and Canadians have performed a leadership role in much of the research. Specific multidisciplinary teams are a more recent phenomenon, but they are shown to be more effective and probably more cost effective than traditional treatment models. Important gaps in availability of resources to manage these patients remain.
Article
There is a lack of knowledge about pain reactions in children with autism spectrum disorders (ASD), who have often been considered as insensitive to pain. The objective of this study was to describe the facial, behavioral and physiological reactions of children with ASD during venipuncture and to compare them to the reactions of children with an intellectual disability and nonimpaired control children. We also examined the relation between developmental age and pain reactions. The sample included 35 children with ASD, 32 children with an intellectual disability, and 36 nonimpaired children. The children were videotaped during venipuncture and their heart rate was recorded. Facial reactions were assessed using the Child Facial Coding System (CFCS) and behavioral reactions were scored using the Noncommunicating Children's Pain Checklist (NCCPC). A linear mixed-effects model showed that children's reactions increased between baseline and venipuncture and decreased between the end of venipuncture and the recovery period. There was no significant difference between groups regarding the amount of facial, behavioral and physiological reactions. However, behavioral reactions seemed to remain high in children with ASD after the end of the venipuncture, in contrast with children in the 2 other groups. Moreover, we observed a significant decrease in pain expression with age in nonimpaired children, but no such effect was found regarding children with ASD. The data reveal that children with ASD displayed a significant pain reaction in this situation and tend to recover more slowly after the painful experience. Improvement in pain assessment and management in this population is necessary.
Article
The study aims to evaluate the impact of a nurse-initiated analgesia pathway (NIAP) intervention for paediatric patients in the ED. We undertook a pre- and post-intervention trial in a large, tertiary referral, mixed ED. The intervention comprised development and implementation of a comprehensive NIA Standing Order. In addition to paracetamol, which nurses could initiate pre-intervention, they were authorised to administer ibuprofen, paracetamol/codeine combinations and topical local anaesthetics prior to a doctor assessing the patient. All nurses were trained and credentialed prior to administering the NIAP. Patients aged 5-17 years with a triage pain score of ≥4 (Wong-Baker or numerical rating scale) were eligible for enrolment. The primary outcome was time to analgesia. Secondary outcomes were the proportion of patients who received 'adequate analgesia' and parental satisfaction with ED pain management (measured 48 h post-discharge). Fifty-one children were enrolled in both the pre- and post-intervention periods. Patient sex and mean age, weight and triage pain score did not differ between the groups (P > 0.05). At post-intervention, significantly more patients received nurse-initiated analgesia (3.0% vs 43.9%; P < 0.001) and the median time to analgesia was significantly reduced (58 min vs 23 min; P < 0.01). Also, significantly more patients received 'adequate analgesia' post-intervention (41.2% vs 72.5%; P < 0.001). At follow up, the proportion of parents who were very satisfied with their child's overall pain management trended upwards in the post-intervention period (47.1% vs 66.7%; P = 0.07). No adverse events were observed during either period. The NIAP significantly reduced time to analgesia. It was associated with high levels of parental satisfaction.
Article
Children and adolescents with chronic abdominal pain pose unique challenges to their caregivers. Affected children and their families experience distress and anxiety that can interfere with their ability to perform regular daily activities. Although chronic abdominal pain in children is usually attributable to a functional disorder rather than to organic disease, numerous misconceptions, insufficient knowledge among health care professionals and inadequate application of knowledge may contribute to a lack of effective management. This clinical report accompanies a technical report on childhood chronic abdominal pain and provides guidance for the clinician in the evaluation and treatment of children with chronic abdominal pain. The conclusions are based on the evidence reviewed in the technical report and on consensus achieved among subcommittee members.
Article
Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.
Article
Pain assessment is an integral component of comprehensive pain management of children. Assessing pain in infants and children can be challenging because of the multiple factors that can modify a child's perception and expression of pain, as well as the wide range of developmental and cognitive levels of infants and children. Numerous measures and scales for assessing children's pain have been developed in the last 20 to 30 years, although there is no one ideal scale for every child and every situation. Because the emergency department is a common setting where children experience pain in a multitude of different scenarios, it is extremely important for all health care providers to be familiar with the basic concepts and tools of pain assessment. This report will discuss some general principles of pain assessment and measurement tools and a general approach to pain assessment. Selected physiologic, behavioral, and self-report assessment measures will be discussed and illustrated. Finally, challenging issues and suggested strategies for assessing children's pain in the emergency department setting will be presented.
Article
Background Children often experience pain from needle insertion procedures; therefore, several topical anaesthetics have been developed. Objectives To compare the topical anaesthetics amethocaine and an eutectic mixture of local anaesthetics (EMLA) in terms of anaesthetic efficacy, ease of needle insertion and adverse events when used for intravenous cannulation and venipuncture in children. Search strategy An exhaustive search that included over 30 databases and handsearching reference lists and journals. Language restrictions were not imposed. Selection criteria Randomized controlled trials were selected that compared EMLA and amethocaine for relieving children's pain from intravenous cannulation or venipuncture. Data collection and analysis Two review authors independently determined eligibility for inclusion by assessing trial quality. Details of eligible studies were summarized. One author was contacted for additional information. Information about adverse events was obtained from the text of the trial reports. Review Manager 4.2 was used to perform a meta‐analysis and compute relative risks (RR) with 95% confidence intervals. Main results Six trials consisting of 534 children, three months to 15 years of age, were included in this review. A meta‐analysis was done comparing amethocaine with EMLA on anaesthetic efficacy, ease of needle procedure and resultant skin changes. For anaesthetic efficacy, amethocaine significantly reduced the risk of pain compared to EMLA when all pain data were combined into a common pain metric (RR 0.78, 95% CI 0.62 to 0.98); when pain was self‐reported by children (RR 0.63, 95% CI 0.45 to 0.87); or when pain was observed by researchers (sensitivity analysis: RR 0.71, 95% CI 0.52 to 0.96). Compared to EMLA, amethocaine significantly reduced the risk of pain when drugs were applied for the following durations: for 30 to 60 minutes (RR 0.61, 95% CI 0.41 to 0.91); when applied according to manufacturer's instructions (sensitivity analysis: RR 0.64, 95% CI 0.46 to 0.89); and when applied for over 60 minutes (RR 0.70, 95% CI 0.51 to 0.96). Amethocaine was also significantly more efficacious than EMLA when used specifically for intravenous cannulation (RR 0.70, 95% CI 0.55 to 0.88). Insufficient data were available to compare anaesthetic efficacy for venipuncture. A comparison of amethocaine and EMLA for ease of a needle procedure was not significant; only one trial reported data that could be included. For skin changes, EMLA was favoured in the analysis of erythema (RR 14.83, 95% CI 2.28 to 96.36). Erythema was observed after use of amethocaine whereas blanching was observed after using EMLA. Adverse effects included itching and one case of conjunctival irritation. Authors' conclusions Although EMLA is an effective topical anaesthetic for children, amethocaine is superior in preventing pain associated with needle procedures. Plain language summary Comparison of a eutectic mixture of local anaesthetics (EMLA) in a cream and amethocaine for relieving the pain children experience when they have needles. When children must give a blood specimen or have an intravenous drip inserted many feel pain. Drugs like EMLA and amethocaine have been developed to numb the skin and prevent or ease pain caused by needle insertion. EMLA is generally applied for 60 minutes before the procedure, whereas amethocaine is applied for 30 minutes before drawing a blood specimen and 45 minutes before insertion of an intravenous drip. Doctors, nurses and parents question which is better for relieving children's pain associated with needle insertion, EMLA or amethocaine? Also of importance is which of these drugs works best when recommended application times cannot be met? This review took six trials into account (534 children aged three months to 15 years). We considered how well EMLA and amethocaine eased pain from needles for three application times: when the drugs were applied for a short time, a long period of time and when applied for the recommended time. Although EMLA is effective in relieving children's pain amethocaine is superior no matter what the duration of time it is applied. Considering how well EMLA and amethocaine ease pain from giving blood specimens and having an intravenous drip inserted, we found that amethocaine is superior to EMLA for intravenous drip insertion. We were unable to compare EMLA and amethocaine for relieving children's pain when giving blood specimens because of a lack of research with this type of needle insertion.
Article
Objectives: To assess the effectiveness of sublingual ketorolac versus sublingual tramadol in reducing the pain associated with fracture or dislocation of extremities in children. Patients and methods: A double-blind, randomised, controlled, non-inferiority trial was conducted in the paediatric emergency department of a research institute. One hundred and thirty-one children aged 4-17 years with suspected bone fracture or dislocation were enrolled. Eligible children were randomised to ketorolac (0.5 mg/kg) and placebo, or to tramadol (2 mg/kg) and placebo by sublingual administration, using a double-dummy technique. Pain was assessed by the patients every 20 min, for a maximum period of 2 h, using the McGrath scale for patients up to 6 years of age, and the Visual Analogue Scale for those older than 6 years of age. Results: The mean pain scores fell significantly from eight to four and five in the ketorolac and tramadol groups, respectively, by 100 min (Wilcoxon sign rank test, p<0.001). The mean pain scores for ketorolac were lower than those for tramadol, but these differences were not significant at any time point (Mann-Whitney U Test, p values: 0-20 min: 0.167; 20-40 min: 0.314; 40-60 min: 0.223; 60-80 min: 0.348; 80-100 min: 0.166; 100-120 min: 0.08). The rescue dose of paracetamol-codeine was administered in 2/60 children in the ketorolac group versus 8/65 in the tramadol group (Fisher exact test, p=0.098). There were no statistically significant differences between the two groups in the frequency of adverse effects. Conclusions: Both sublingual ketorolac and tramadol were equally effective for pain management in children with suspected fractures or dislocations.
Article
During the past 10 years, efforts in pharmacogenomics have generated insights into the efficacy and safety of drugs, enhancing our understanding of the safety profile of even some of the oldest drugs, such as codeine sulfate, an opioid analgesic first approved in 1950 for relief of mild or moderate pain. Simultaneously, an increased awareness of the value of both personalized medicine and the reporting of rare adverse outcomes has resulted in the publication of information on adverse events that previously might not have been reported. These developments, in turn, led the Food and Drug Administration (FDA) to reanalyze the safety . . .