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Editorial

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Open AccessEditorial

Pediatric Pain Management: The Time for Action Is Now

by Alessandro Vittori

Children 2023, 10(12), 1894; https://doi.org/10.3390/children10121894 - 6 Dec 2023

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Abstract

Pediatric anesthesia is a field of research and assistance in which more specialization needs are emerging [...] Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

Research

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13 pages, 1329 KiB

Open AccessArticle

Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study

by Eleanor Dawson, Katie Greenfield, Bernie Carter, Simon Bailey, Anna-Karenia Anderson, Dilini Rajapakse, Kate Renton, Christine Mott, Richard Hain, Emily Harrop, Margaret Johnson and Christina Liossi

Children 2024, 11(4), 485; https://doi.org/10.3390/children11040485 - 18 Apr 2024

Viewed by 2292

Abstract

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and [...] Read more.

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals’ insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: ‘the elusive nature of breakthrough pain’, ‘breakthrough pain assessment’, ‘positive attitudes towards’, ‘reservations towards’ and ‘features to include in’ a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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12 pages, 231 KiB

Open AccessArticle

Non-Pharmacologic Intensive Interdisciplinary Pain Treatment in Pediatrics: Impact on Symptoms, Daily Functioning, and the Family Unit

by Jessica Campanile, Becky Wu, Maitry Sonagra, Mackenzie McGill, Daneka Stryker, Jamie Bradford, Jennifer Sherker, Tami Konieczny, David D. Sherry and Sabrina Gmuca

Children 2024, 11(2), 197; https://doi.org/10.3390/children11020197 - 4 Feb 2024

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Abstract

Objectives: To assess non-pharmacologic treatment outcomes pertaining to health-related quality of life (HRQoL) in youth with chronic idiopathic pain and their families. Methods: We conducted a retrospective cohort study of 115 youth with chronic idiopathic pain enrolled in a non-pharmacologic, hospital-based intensive interdisciplinary [...] Read more.

Objectives: To assess non-pharmacologic treatment outcomes pertaining to health-related quality of life (HRQoL) in youth with chronic idiopathic pain and their families. Methods: We conducted a retrospective cohort study of 115 youth with chronic idiopathic pain enrolled in a non-pharmacologic, hospital-based intensive interdisciplinary pain treatment (IIPT) program. HRQoL measures for the patient (Pediatric Quality of Life Inventory [PedsQL] short form) and family unit (PedsQL Family Impact) were collected on admission and discharge as part of routine clinical care. Changes in PedsQL scores were calculated using the Wilcoxon signed-rank test. Multivariable linear regression was used to explore factors associated with patient-level HRQoL. Results: Both individuals and the family unit reported that their HRQoL improved in all domains by program completion. Improvements in pain and allodynia were present for program participants at the time of completion as well as at the 3-month follow-up, suggesting durability of these effects. Conclusions: A non-pharmacologic IIPT program is a compelling treatment for pediatric and adolescent chronic idiopathic pain, for both patients and the family unit. Patients participating in this program had positive treatment outcomes with significantly improved subjective and objective measures of physical, emotional, social, and cognitive function. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

11 pages, 3538 KiB

Open AccessArticle

Ultrasound-Guided Dorsal Penile Nerve Block in Children: An Anatomical-Based Observational Study of a New Anesthesia Technique

by Markus Zadrazil, Georg Feigl, Philipp Opfermann, Peter Marhofer, Daniela Marhofer and Werner Schmid

Children 2024, 11(1), 50; https://doi.org/10.3390/children11010050 - 29 Dec 2023

Cited by 2 | Viewed by 2397

Abstract

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without [...] Read more.

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without general anesthesia and secondary airway manipulation in a consecutive case series. Under ultrasound guidance and utilizing an in-plane needle guidance technique, the dorsal penile nerve block was administered with slight sedation, and spontaneous respiration was maintained in all cases. To investigate the underlying anatomy for dorsal penile nerve blockade, we dissected three cadavers. The primary study endpoint was the success rate of surgical blockade, meaning that the surgical procedure could be performed without additional general anesthesia and invasive airway management. The secondary endpoint was the requirement of analgesics until discharge from the post-anesthesia care unit. The primary endpoint was successfully met in all patients according to our strict definition without additional general anesthesia or airway manipulation. In addition, no child received analgesics until discharge from the recovery room. The anatomical investigation clarified the specific anatomy as baseline knowledge for an ultrasound-guided dorsal penile nerve blockade and enabled successful performance in 20 consecutive children where penile surgery was possible in light sedation without additional airway manipulation. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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13 pages, 815 KiB

Open AccessArticle

The Effects of an Order-Assist Mobile Application on Pediatric Anesthesia Safety: An Observational Study

by Jung-Woo Shim, Chang-Jae Kim, Ji-Yeon Kim, Ji-Yeon Choi and Hyungmook Lee

Children 2023, 10(12), 1860; https://doi.org/10.3390/children10121860 - 27 Nov 2023

Viewed by 1003

Abstract

Pediatric anesthesia requires the rapid creation, communication, and execution of anesthesia orders, and there is a risk of human error. The authors developed an order-assisted mobile application (app) to reduce human error during pediatric anesthesia preparation. The authors conducted an observational study that [...] Read more.

Pediatric anesthesia requires the rapid creation, communication, and execution of anesthesia orders, and there is a risk of human error. The authors developed an order-assisted mobile application (app) to reduce human error during pediatric anesthesia preparation. The authors conducted an observational study that compared the effects of the application by comparing anesthesiologists’ errors, nurses’ errors, nurses leaving the operating room, and delays in surgery, between the Conventional group (n = 101) and the App group (n = 101). The app was associated with reduced human error by anesthesiologists and nurses, and it lowered the frequency and duration of nurses leaving the operating room during anesthesia. In addition, the authors surveyed anesthesia nurses regarding the effectiveness of the app. The nurses confirmed that the app was convenient and reduced human error. This study revealed that the order-assisted mobile app developed by a pediatric anesthesiologist could reduce human errors by anesthesiologists and nurses during pediatric anesthesia preparation. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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9 pages, 389 KiB

Open AccessArticle

Efficacy of Infrared Vein Visualization versus Standard Technique for Peripheral Venous Cannulation in Infant and Toddler Populations: A Randomized Study

by Graham Fehr, Marisa Rigali, Gregory Weller, Shannon M. Grap, Melissa Coleman, Uma Parekh, Vernon M. Chinchilli and Priti G. Dalal

Children 2023, 10(10), 1652; https://doi.org/10.3390/children10101652 - 5 Oct 2023

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Abstract

Establishing intravenous (IV) access in younger patient populations via the traditional cannulation technique for procedures requiring anesthesia is often challenging. Infrared (IR) vein visualization is a modality that aids venous cannulation; however, few reports of this technique exist in the infant and toddler [...] Read more.

Establishing intravenous (IV) access in younger patient populations via the traditional cannulation technique for procedures requiring anesthesia is often challenging. Infrared (IR) vein visualization is a modality that aids venous cannulation; however, few reports of this technique exist in the infant and toddler population. The primary aim of this study was to compare the efficacy of IR vein visualization to the standard cannulation technique for obtaining peripheral IV access in infant and toddler populations. Following Institutional Review Board (IRB) approval and written informed consent, children were randomly assigned to either a standard cannulation technique group or an IR vein visualization device group for venous cannulation. The primary outcome variable was the success rate of IV cannulation, and the secondary variables were the total number of attempts and the time to successful cannulation. No difference was noted between either group for first-attempt success rate (standard versus IR: 61.25% vs. 54.4%; p = 0.4) or time to establish IV cannulation (standard versus IR: median [interquartile range], 40 s [24–120] vs. 53 s [26–106]; p = 0.55). The anesthesiologist’s grading of the anticipated difficulty of IV cannulation was a significant predictor of cannulation success (p = 0.0016). Our study demonstrated no significant benefit in utilizing the IR vein visualization device in terms of the overall success rate, number of attempts, and time to establish successful IV cannulation when compared to the standard technique. However, in difficult IV access situations, this device proved to be a valuable rescue adjunct. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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12 pages, 550 KiB

Open AccessArticle

Ultrasonographic Evaluation of Gastric Content and Volume in Pediatric Patients Undergoing Elective Surgery: A Prospective Observational Study

by Asiye Demirel, Şeyda Efsun Özgünay, Şermin Eminoğlu, Ayşe Neslihan Balkaya, Tuğba Onur, Nermin Kılıçarslan and Mehmet Gamlı

Children 2023, 10(9), 1432; https://doi.org/10.3390/children10091432 - 23 Aug 2023

Cited by 2 | Viewed by 2014

Abstract

Anesthesia-related complications, such as pulmonary aspiration of gastric contents, occur in approximately 0.02–0.1% of elective pediatric surgeries. Aspiration risk can be reliably assessed by ultrasound examination of the gastric antrum, making it an essential non-invasive bedside tool. In this prospective observational study, since [...] Read more.

Anesthesia-related complications, such as pulmonary aspiration of gastric contents, occur in approximately 0.02–0.1% of elective pediatric surgeries. Aspiration risk can be reliably assessed by ultrasound examination of the gastric antrum, making it an essential non-invasive bedside tool. In this prospective observational study, since most of our patients are immigrants and have communication problems, we wanted to investigate gastric contents and the occurrence of “high risk stomach” in children undergoing elective surgery for the possibility of pulmonary aspiration, even if the children and/or parents reported their last oral intake time. This risk is defined by ultrasound findings of solid content in the antrum and/or a calculated gastric volume exceeding 1.25 mL/kg. Children aged 2–18 were included in the study. Both supine and right lateral decubitus (RLD) ultrasound examinations were performed on the antrum before surgery. Using a qualitative grading scale from 0 to 2, we evaluated the gastric fluid content. The cross-sectional area (CSA) of the antrum was measured in the RLD position, aiding the calculation of the gastric fluid volume according to an established formula by Perlas. Ultrasound measurements of 97 children were evaluated. The median fasting duration was 4 h for liquids and 9 h for thick liquids and solids. Solid content was absent in all the children. Five children (5.2%) exhibited a grade 2 antrum, implying that fluid content was visible in both the supine and RLD positions. The median antral CSA in the RLD was 2.36 cm², with a median gastric volume of 0.46 mL/kg. For patients with a grade 0 antrum, a moderate and positive correlation was observed between the antral CSA and BMI, and a strong and positive correlation was evident between the antral CSA and age, similar to a grade 1 antrum. Only a single child (1%) had a potentially elevated risk of aspiration of gastric contents. Hence, the occurrence of a “high risk stomach” was 1% (95% confidence interval: 0.1–4.7%) and is consistent with the literature. As a necessary precaution, we propose the regular use of ultrasound evaluations of gastric contents, given their non-invasive, bedside-friendly, and straightforward implementation, for identifying risks when fasting times are uncertain and for ruling out unknown risk factors in each potential patient. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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Review

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28 pages, 2702 KiB

Open AccessReview

A Systematic Review and Meta-Analysis of Conditioned Pain Modulation in Children and Young People with Chronic Pain

by Christina Liossi, Helen Laycock, Kanmani Radhakrishnan, Zara Hussain and Daniel Eric Schoth

Children 2024, 11(11), 1367; https://doi.org/10.3390/children11111367 - 11 Nov 2024

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Abstract

Background/Objectives: Conditioned pain modulation (CPM) is a psychophysical experimental measure of the endogenous pain inhibitory pathway in humans, wherein one pain stimulus (the conditioning stimulus) is used to inhibit an individual’s perception of a second painful (test) stimulus. Research provides evidence of impaired [...] Read more.

Background/Objectives: Conditioned pain modulation (CPM) is a psychophysical experimental measure of the endogenous pain inhibitory pathway in humans, wherein one pain stimulus (the conditioning stimulus) is used to inhibit an individual’s perception of a second painful (test) stimulus. Research provides evidence of impaired endogenous inhibitory pain responses in adults with chronic pain. CPM is now increasingly applied in paediatric research and clinical practice. The primary aim of this systematic review was to examine the efficacy of CPM in paediatric chronic pain populations (6–24-year-olds) compared to pain-free children and young people (CYP). Methods: The protocol was registered on PROSPERO (CRD42020221927). A systematic search of seven databases was conducted from database inception to 20th June 2024. Study inclusion criteria were as follows: (i) recruited a sample of CYP aged 6 to 24 (inclusive) with chronic pain or who were pain-free; and (ii) applied a CPM paradigm comprising both a painful test and conditioning stimuli that were sufficiently detailed to allow for replication,(iii) adhered to a study design of randomised control trial, case control or cohort study, including cross-sectional or longitudinal; (iv) available in the English language. Study exclusion criteria were: (i) The CPM paradigm used a non-painful test or conditioning stimulus only; and (ii) was only available as an abstract, letter, poster, editorial, case report, or review with or without meta-analyses. Risk of bias was assessed using the Appraisal Tool for Cross Sectional Studies (AXIS). Meta-analyses were conducted in Comprehensive Meta Analysis 3.0 using random effects models to compare the overall CPM responses in CYP with chronic pain conditions to healthy control CYP. Results: Thirty-two studies were eligible for inclusion, six of which were included in one or more meta-analysis (n = 407 chronic pain, n = 205 control). Meta-analysis revealed significantly weaker CPM responses in CYP with a variety of chronic pain conditions compared to healthy controls (standardized mean difference (SMD) = 0.352), and significantly weaker CPM responses in CYP with abdominal pain conditions compared to healthy controls (SMD = 0.685). No significant difference in CPM response was found between CYP with migraine and healthy controls (SMD = −0.201). Conclusions: Variable results were found across individual studies, and the meta-analysis of the small number of eligible studies provides tentative evidence for impaired CPM in CYP with chronic pain compared to healthy controls. Further research is clearly needed. In particular, studies should present CPM results separately for different age groups, ethnic groups, and sexes, as these variables shape clinical pain responses. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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10 pages, 441 KiB

Open AccessReview

Updating Clinical Practice: Improving Perioperative Pain Management for Adeno-Tonsillectomy in Children

by Juan Manuel Redondo-Enríquez, María Rivas-Medina and Manuel María Galán-Mateos

Children 2024, 11(10), 1190; https://doi.org/10.3390/children11101190 - 29 Sep 2024

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Abstract

Background/Objective: Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics is still preponderant in [...] Read more.

Background/Objective: Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics is still preponderant in pediatric perioperative management. We performed a comprehensive review on adeno-tonsillectomy perioperative pain management in children. We developed and implemented a multimodal analgesia protocol aimed to improve patients’ pain management while consistently reducing opioids use. Methods/Results: relevant Information was summarized, then compared to our clinical needs. Learnings were used to create and implement a multimodal analgesia protocol that we use in patients 3–9 years-old undergoing adenoidectomy/tonsillectomy. The full protocol is presented. Analgesic strategies have emerged to reduce or avoid the use of opioids. Among these strategies, combining different non-opioid analgesics (Ibuprofen, Paracetamol, Metamizole) has been shown to be an effective and safe pharmacological strategy when implemented as part of perioperative multimodal analgesia protocols. Considerable evidence associating the use of NSAIDs with a bigger risk of postoperative bleeding does not exist. Conclusions: Perioperative management of adenotonsillectomy pain should include preventive and multimodal analgesia, which have shown to provide significantly more effective analgesia than some opioid regimens. Ibuprofen offers highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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Other

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10 pages, 1523 KiB

Open AccessCase Report

A Rare Case of Posterior Fossa Syndrome Associated with Neuropathic Pain Successfully Treated with a Combination of Gabapentin, Diazepam and Baclofen—A Case Report and Literature Review

by Mariateresa Giglio, Alberto Corriero, Teresa Perillo, Giustino Varrassi and Filomena Puntillo

Children 2024, 11(12), 1410; https://doi.org/10.3390/children11121410 - 21 Nov 2024

Viewed by 386

Abstract

Background: Posterior fossa syndrome (PFS), also known as cerebellar mutism syndrome, occurs in about 25% of pediatric patients undergoing resection of a posterior cranial fossa medulloblastoma. It is characterized primarily by mutism or reduced/impaired speech and may include variable symptoms such as motor [...] Read more.

Background: Posterior fossa syndrome (PFS), also known as cerebellar mutism syndrome, occurs in about 25% of pediatric patients undergoing resection of a posterior cranial fossa medulloblastoma. It is characterized primarily by mutism or reduced/impaired speech and may include variable symptoms such as motor dysfunction (apraxia, ataxia, hypotonia), supranuclear cranial nerve palsies, neurocognitive changes, and emotional lability. Long-term multidisciplinary rehabilitation is typically required, with recovery taking approximately six months, though many children experience long-term residual deficits. Neuropathic pain associated with PFS is rarely reported in pediatric patients, and evidence for its management is limited. Methods: This case report describes a 10-year-old boy who developed PFS following incomplete resection of a medulloblastoma. Clinical presentation included mutism, irritability, emotional lability, sleep disturbances, and neuropathic pain localized at the C5 level. The patient was treated with a combination of gabapentin, diazepam, and baclofen. Results: The combined pharmacological approach resulted in successful management of the patient’s neuropathic pain and other symptoms associated with PFS, improving his overall condition. Conclusions: This case highlights the potential effectiveness of a multimodal pharmacological regimen for treating neuropathic pain and associated symptoms in pediatric patients with PFS. Further research is needed to explore optimal treatment strategies for this rare but challenging complication. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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12 pages, 2642 KiB

Open AccessSystematic Review

The Effects of Dexmedetomidine on Children Undergoing Magnetic Resonance Imaging: A Systematic Review and Meta-Analysis

by Valentina-Anastasia Angelopoulou, Abraham Pouliakis, Nikolaos Alexiou, Parthena Ioannidi, Dimitra Vagiona, Konstantinos Ekmektzoglou, Theodoros Xanthos, Theodora Boutsikou, Zoi Iliodromiti and Nikoletta Iacovidou

Children 2023, 10(6), 948; https://doi.org/10.3390/children10060948 - 26 May 2023

Cited by 1 | Viewed by 1873

Abstract

Background: Magnetic Resonance Imaging (MRI) is a valuable diagnostic tool but often requires sedation to complete, especially in children. Dexmedetomidine (DEX) is an a2 agonist, for which there are experimental findings that support its potential neuroprotective effects. Given the potential risks of anesthetic [...] Read more.

Background: Magnetic Resonance Imaging (MRI) is a valuable diagnostic tool but often requires sedation to complete, especially in children. Dexmedetomidine (DEX) is an a2 agonist, for which there are experimental findings that support its potential neuroprotective effects. Given the potential risks of anesthetic drugs, we ran this study to examine DEX’s effectiveness and cardiopulmonary safety as a sedative drug for children undergoing MRI. Material and Methods: Systematic research was conducted in PubMed, Google Scholar, Scopus and Cochrane databases for randomized controlled trials published between 2010 and 6th/2022 and involving children undergoing MRI who received DEX as sedative medication. The records which met the including criteria, after indexing via the PRISMA chart and assessing for bias, were processed, and a meta-analysis was carried out with the random effects method. Results: Thirteen studies were included. Out of 6204 measurements obtained, in 4626, it was planned for the participants to only receive DEX (measure group) as an anesthetic drug throughout the procedure. The participants’ mean age was 57 months (Ι² = 4%, τ² = 0.5317, p = 0.40). A total of 5.6% (95% CI: 0.6–14.1%, I² = 98%, p < 0.01) of the patients needed a second dose of DEX. In total, 6% (95% CI: 1–15%, I² = 93%, τ² = 0.0454, p < 0.01) required the administration of another drug, besides DEX, to complete the imaging (sedation failure). The effectiveness of the only-DEX method was 99% (95% CI: 97.5–100%, I² = 81%, τ² = 0.0107, p < 0.01). The whole rate of adverse events was 15% (95% CI: 9.3–21.5%, I² = 92%, p < 0.01). Hypotension was reported in 8.7% of the cases (95% CI: 3.1–16.4%, I² = 84%, p < 0.01), hypertension in 1.1% (95% CI: 0–5.4%, I² = 89%, p < 0.01), bradycardia in 10% (95% CI: 4–18%, I² = 95%, p < 0.01) and desaturation in 1.2% (95% CI: 0–4%, I² = 68%, p < 0.01). There was no statistically significant incidence in respiratory rate decrease (comparing the children who received DEX to their baseline). Five cases of vomiting and one of apnea were recorded. Conclusions: Given that DEX seems to be an effective as well as respiratory and hemodynamically safe drug, it may be a future spotlight in (pediatric) sedation for imaging procedures such as MRI. Full article

(This article belongs to the Special Issue Advances in Pediatric Anesthesia, Pain Medicine and Intensive Care)

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