The management of pain in children with life-limiting illnesses

The management of pain in children with life-limiting illnesses is complex and unfortunately not often done effectively. Pain is a multidimensional symptom that can overshadow all other experiences of both the child and family. This article focuses on topics common to practitioners caring for children with lifelimiting illnesses, including a review of myths and obstacles to achieving adequate pain control, a review of the pathophysiology of pain, an overview of the use of opioids in children, an approach to the management of neuropathic pain, and a brief discussion of nonpharmacologic pain management strategies.     

Impaired growth plate chondrogenesis in children with chronic illnesses

In mammals, statural growth is primarily accomplished by endochondral ossification, which takes place at the growth plate. Growth plate chondrocyte proliferation, hypertrophy/differentiation, apoptosis, and cartilage matrix synthesis all contribute to chondrogenesis or cartilage formation, a process tightly coupled to the simultaneous remodeling of the cartilage into bone at the metaphyseal border of the growth plate. Growth plate chondrogenesis is regulated by the complex interaction of molecular signals acting systemically as well locally within the growth plate. This network is often dysregulated during chronic illnesses, thus resulting in impaired growth plate chondrogenesis and, in turn, growth failure. The principal events responsible for altered growth plate chondrogenesis in chronic illness are inflammation, protein/calorie deprivation, uremia/metabolic acidosis, glucocorticoids, and impaired GH/IGF-I axis.     

Concepts of illness and perception of control in healthy children and in children with chronic illnesses

Healthy children, children with seizure disorders, and children with orthopedic conditions, ranging in age from 5 to 16 years old, were questioned about their knowledge of disease etiology, treatment, and prevention, and their health locus of control beliefs, to explore the relationship between illness-related concept attainment and perceived control over health. Children who perceived greater personal control over health demonstrated a more sophisticated conceptual understanding of disease than did children with a more external orientation. Healthy children scored significantly higher on the illness concepts questions and expressed significantly more internal health locus of control beliefs than did their peers with a chronic physical illness. Perceived control over health appears to be one factor that mediates the relationship between illness experience and understanding.     

Anxiety in children and adolescents with chronic physical illnesses: a meta-analysis

To compare levels of anxiety of children with chronic illness with healthy peers and population norms. Meta-analysis integrated results from 332 studies. Children with chronic illness had elevated levels of anxiety (d=0.18 standard deviation units). Strongest elevations were found for chronic fatigue syndrome, migraine/tension headache, sensory impairment and epilepsy. Paediatricians should screen for anxiety symptoms in children at risk and offer interventions, if needed.     

Psychological consequences of chronic physical illnesses in children and adolescents

Chronic illnesses in children and adolescents have devastating influence on them and their families. The patients have to cope up with illness, medication and it’s influence on their development. Consequently a large number of them have emotional disorders which influence the course and outcome of physical disorder. In recent few years, research has shifted its focus from merely figuring out the prevalence of the emotional disorders to understanding the adjustment to chronic illness under defined theoretical constructs. Apart from temperamental variation, family burden and functioning have been identified as factors operating in determining adjustment. Distress experienced by the family and disturbed family functioning directly influences the emotional outcome in physically disordered children. Comprehensive coordinated care services are required for integration of these patients into the community.     

Maternal reports of raising children with chronic illnesses:the prevalence of positive thinking.

OBJECTIVE: To examine maternal reports of the positive impact and potential benefits of a child's chronic health condition. DESIGN AND METHODS: A total of 190 mothers and their children with chronic illnesses, including sickle cell disease, cystic fibrosis, diabetes mellitus, and asthma, were recruited from 12 specialty or general pediatric clinics in Baltimore, Md. Standardized interviews were conducted with the mothers and included demographics, condition-related variables, and positive aspects of raising a child with a chronic condition. RESULTS: Eighty-eight percent of the mothers felt better about themselves by learning to manage their child's chronic condition; 70% felt that their families were stronger because of their child's condition; and 80% felt that their family had benefited in some way from having a child with a chronic illness. Ninety-eight percent of the mothers endorsed at least 1 positive item; 58% endorsed all 3. CONCLUSIONS: Asking mothers about the positive impact on a family of a child's chronic illness captures an important part of the experience of caregiving. Physicians' recognition and encouragement of this positive outlook may help families continue to face the challenges of raising a child with a chronic illness.     

Assessment and management of chronic and recurrent pain in children with chronic diseases

This paper provides an overview to the assessment and management of chronic and recurrent pain in children with chronic diseases. Relevant clinical research studies are cited, and practical guidelines are provided for the differential assessment and management issues inherent in the comprehensive care of chronic and recurrent pain in children and adolescents with hemophilia, juvenile rheumatoid arthritis, sickle cell disease, and cancer.     

The emergency physician's role in injury prevention

New Mexico's successful campaign in establishing seat belt legislation is described, as is a unique program of alcohol and substance abuse prevention based in the emergency department. Results of a local study investigating hospital and emergency department costs of victims injured in automobile crashes are presented. A strategy is proposed that encourages joint efforts to influence public opinion and awareness, support necessary legislation, develop epidemiologic and intervention research, and encourage emergency medicine practitioners to act as a clearing house for outreach and prevention activities.     

Assessing psychosocial adjustment of children with chronic illnesses: a review of the technical properties of PARS III

Four groups of investigators in the Research Consortium on Chronic Illness in Childhood have used the Personal Adjustment and Role Skills Scale (PARS) III to assess the psychosocial adjustment of children with chronic physical illnesses and no mental impairment. The PARS III consists of 28 items that measure psychosocial functioning in six areas: peer relations, dependency, hostility, productivity, anxiety-depression, and withdrawal. Analyses of the measure's reliability and validity, using a total combined sample of 450 school-age children (ages 5-18 years) with a variety of chronic illnesses and three comparison samples of healthy children, provide evidence that the PARS III can be used successfully to assess psychosocial adjustment of children with chronic illnesses and no cognitive impairments.     

Diagnosis and management of chronic blepharokeratoconjunctivitis in children

PURPOSE: To describe the history, symptoms, and clinical signs and discuss the treatment of blepharokeratoconjunctivitis. METHODS: Eight children (five girls and three boys), ranging in age from 3.5-13 years, were clinically diagnosed with blepharokeratoconjunctivitis. Microbiology studies were performed in four of the eight children. Treatment consisted of lid hygiene, oral erythromycin suspension, and preservative-free steroids. Duration of therapy was directed by clinical improvement. RESULTS: Average age at onset was 3.2 years (range: 0.5-8 years). Lid disease, conjunctival redness, and inferior superficial corneal vascularization were consistent features (100%). Other signs were punctate corneal epithelial staining, inferior subepithelial vascularization and infiltrate, conjunctival phlyctenules, corneal phlyctenules, and circumferential pannus. Microbiology testing demonstrated coagulase-negative staphylococcus and Propionibacterium acnes. Average follow-up was 8.3 months (range: 2-23 months). All patients had relief of symptoms within 2-3 weeks. Clinical signs took more time to regress but all had progressive improvement of the ocular surface by 2 months. Blepharokeratoconjunctivitis reactivated in all patients during follow-up, and repeat therapy was administered. CONCLUSION: Blepharokeratoconjunctivitis in childhood is a chronic inflammatory process that can have different presentations. It can be successfully treated with oral erythromycin and topical steroids.     

The role of Helicobacter pylori in children with chronic idiopathic thrombocytopenic purpura

Recent reports have suggested that Helicobacter pylori infection may be a causative agent of adult chronic idiopathic thrombocytopenic purpura (cITP) and antimicrobial treatment may increase platelet counts. As there is limited experience in pediatric age, we investigated the prevalence of H. pylori infection and the effects of H. pylori eradication therapy in a series of children with cITP. Twenty-four children with cITP were investigated for H. pylori infection using the C-urea breath test or H. pylori fecal antigen. In cases of H. pylori infection, antimicrobial treatment was given with amoxicillin, clarithromycin, and proton pump inhibitors. Response was assessed at 6 months and defined as complete (platelet count >150x10/L) or partial (platelet count between 50 and 150x10/L). H. pylori infection was found in 8 patients (33%) and 3 of them showed a response after eradication therapy, but 2 of them relapsed later on. Two patients had a spontaneous increase in platelet count in the group of H. pylori-negative patients. Given that spontaneous improvements in platelet count can occur in children with cITP, we were unable to demonstrate that H. pylori plays a major role in cITP occurring in pediatric age.     

The physician's role in delivering sensitive information to families with handicapped infants

The critical nature of the physician's role in delivering sensitive information to families with handicapped infants is discussed. A review of research and teaching practices associated with conveying serious diagnoses is presented. Specific suggestions are described, to be followed when delivering disturbing diagnostic information.     

The investigation and management of chronic neutropenia in children

Unravelling the cause of a neutropenia poses a complex diagnostic challenge. The differential diagnosis ranges from life threatening disease to transient benign causes of little clinical significance. This review offers a practical guide to investigating the neutropenic child, and highlights features that merit specialist referral. Therapeutic options, the role of long term follow up, and the complications of severe chronic neutropenia are considered.