A systematic review of interventions for reducing pain and distress in children undergoing voiding cystourethrography

Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria. CONCLUSION: Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.     

Clinical approach to recurrent abdominal pain in children

Recurrent abdominal pain of childhood is a frequent complaint that is often difficult for the physician to manage. This paper outlines the various psychological and physiological factors that have been implicated in causing recurrent abdominal pain and in difficulties in coping with the disorder. Guidelines for diagnosis and management are offered.     

Psychological treatment of distress, pain, and anxiety for young children with cancer

The study compared the efficacy of hypnotic "imaginative involvement," behavioral distraction and standard medical practice for the reduction of pain, distress and anxiety in children with leukemia, during bone marrow aspirations. Two age groups of children, 3 to 6, and 7 to 10 years, were randomized to the three treatment groups. Two intervention sessions were given. At first intervention, observational ratings of distress indicated significant reductions for the younger group in the hypnotic treatment, whereas the older group achieved significant reductions in both treatment conditions for observer-rated pain and anxiety. At second intervention, all groups showed reductions and the control group appeared to be contaminated. The hypnotic method with its internal focus had an all-or-none effect, whereas distraction appeared to require that coping skills be learned over one session or more.     

Clinical implications of pulmonary function testing in preschool children

There is increasing recognition of the need for objective physiological measurements of lung function during the preschool years in order to identify and treat early lung disease before irreversible structural changes occur; monitor disease progression and efficacy of therapeutic interventions and distinguish the various wheezing phenotypes that occur in this age group, all of which require different management strategies. While preschool pulmonary function tests are undoubtedly excellent research tools , their role in the clinical management of the individual young child remains more controversial. In particular, further work is required to establish information on the within-subject, between occasion variability and the relative sensitivity and specificity of each technique, as well as developing more appropriate prediction equations for this age group, before they can be used confidently in the clinical management of individual child. This review examines the various challenges facing paediatricians who are responsible for children with respiratory diseases such as asthma, wheezing, cystic fibrosis and chronic lung disease following preterm delivery and summarises recent recommendations from an ATS/ERS Task Force.     

Clinical aspects and treatment of pain in children and adolescents with cancer

BACKGROUND: The aim of this study was to characterize the clinical aspects and the treatment of mild to severe pain in Brazilian children and adolescents with cancer. We evaluated the importance of classifying patients according to the phase of cancer treatment (diagnosis, treatment, recurrence, and end-of-life palliative care) and the opioid-related side effects. METHODS: An institutional prospective study of 184 episodes of pain in children and adolescents with cancer was conducted. Pain was classified according to its cause, physiopathology and intensity. Treatment was based on the WHO guidelines for cancer pain relief. RESULTS: Pain scales were completed by 77% of the patients. Numerical scales were used by 49% of them. Morphine was given in 111 episodes for 2,758 patient days. Morphine doses had to be escalated when it was given to patients during end-of-life palliative care. Opioids were well tolerated with no severe side effects. Psychological dependence on morphine was found in 2% (2/111) of the cases. Pain control was satisfactory in 97% of the episodes. CONCLUSIONS: The WHO guidelines for cancer pain relief were effective in controlling pain in children and adolescents with cancer. Despite their low socioeconomic level, patients were able to quantify their pain using rating scales.     

Clinical implications of immune-mediated diseases in children with Down syndrome

Children with Down syndrome have changes in their innate and adaptive immunity, which contribute to increased rates of infections, autoimmune diseases, and haematological malignancies. While improved care for congenital heart disease has decreased mortality and morbidity, complications related to immune-mediated diseases continue to limit the life expectancy in Down syndrome. Infectious diseases are common and have a significant effect on development, behaviour and quality of life. Infection frequency and severity are influenced by various anatomical and physiological alterations in addition to immunological changes in Down syndrome. Thus, prevention of respiratory tract infections requires a multifactorial approach. This could include additional active and/or passive immunizations, prophylactic antibiotics, immunoglobulin replacement and ear, nose and throat surgical interventions. Autoimmune conditions like coeliac disease, type I diabetes mellitus and thyroid disease are classically mentioned in the context of Down syndrome. However, autoinflammatory conditions are more prevalent as well. Screening for autoimmune diseases is required and immunosuppression has to be used with caution. Future studies should address optimal screening programmes for immune-mediated diseases in individuals with Down syndrome, as well as the effect of immune modulation, to further decrease morbidity and mortality, and improve the quality of life of individuals with Down syndrome.     

Clinical and laboratory findings in 220 children with recurrent abdominal pain

Aim: To investigate the clinical and laboratory findings in children with recurrent abdominal pain (RAP). Methods: Consecutive patients with RAP (Apley criteria), age 4–16 years, referred to a secondary medical centre were evaluated by a standardized history, physical examination and laboratory tests. The tests encompassed Helicobacter pylori (Hp), gastrointestinal bacterial infections, protozoa, coeliac disease, carbohydrate malabsorption, food intolerance, abdominal ultrasound and plain abdominal X‐ray. More investigations were obtained if indicated. Patient characteristics were compared with surgical patients without abdominal pain (control group). Results: A total of 220 consecutive patients were included (92 M, mean age 8.8 years [4.1–16.0 years]). In 88% of the patients, abnormalities were found that refer to possible causes. Especially, protozoa were present in 33% of the patients, mostly Dientamoeba fragilis, Yersinia enterocolitica in 12% and endoscopically proven infection with Hp in 11%. In 36%, a plain abdominal X‐ray raised suspicion of constipation. Conclusion: In 220 consecutive patients with RAP, referred to secondary care, a standardized work‐up yielded abnormal results in a high percentage. The clinical significance of these findings remains to be established.     

Clinical implications of inducible beta-lactamase activity in Gram-negative bacteremia in children

BACKGROUND: Organisms of the spp., indole-positive spp., spp. and (ESCaPPM) group are a common cause of hospital-acquired bacteremia and share the potential to develop beta-lactam resistance during therapy. The emergence of such resistance may have adverse consequences, but the frequency with which this occurs has not been studied in children. It has been suggested that such organisms should be treated with combination antimicrobials or carbapenems, but the optimal regimen is uncertain.AIM To determine the frequency with which beta-lactam resistance develops during ESCaPPM sepsis in children and the optimal treatment of such sepsis. METHODS: A review of the case notes and microbiologic records of all cases of ESCaPPM bacteremia and meningitis managed at a tertiary children's hospital during a 6-year period. RESULTS: Fifty-eight cases were identified, and in three (5%) cases beta-lactam resistance emerged during treatment, with adverse clinical consequences in two cases. Clinical and microbiologic outcome was similar in those treated with carbapenems and in those treated with a beta-lactam and aminoglycoside combination. Cefotaxime resistance was found in 57, 30, 24 and 7% of children who had received carbapenems, cephalosporins, penicillins or no/other antimicrobials in the month before ESCaPPM sepsis, respectively. CONCLUSIONS: The emergence of beta-lactam resistance during treatment of ESCaPPM sepsis is uncommon in our hospital but can have adverse consequences. Where isolates are reported as susceptible to both classes of drugs, an extended spectrum penicillin in combination with an aminoglycoside may be preferable first line treatment of ESCaPPM sepsis to a carbapenem or quinolone.     

Bodily pain, sleep problems and mental distress in schoolchildren

It has been suggested that childhood pain could be the beginning of a career with chronic disabling pain. Bodily pain is frequent in children. We examined the association between self-reported bodily pain, mental distress and sleep problems in schoolchildren to test the following hypotheses: (i) that self-reported bodily pain is associated with mental distress and sleep problems, (ii) that the association is dependent on the localization of pain, and (iii) that the association increases with number of painful areas. Eighty-six percent of the pupils (569) in the 4th form (mean age 10.5 y), 7th form (mean age 13.5 y) and 9th form (mean age 15.5 y) from all the schools in a local community answered a questionnaire about self-esteem, body-image, physical activity and bodily pain. We found a strong association between the reporting of pain, mental distress and sleep problems. Pain in the knees was the only problem reported more frequently by boys than by girls, and knee pain did not show the same association with mental distress and sleep problems as pain from other regions. Conclusions: A possible cause-effect relationship between pain, mental distress and sleep problems is discussed, and the possibility that all the complaints are the simultaneous signs of a multisymptom syndrome is introduced.     

Psychological distress in mothers of disabled children

We examined the impact of child disability on psychological distress in mothers, by comparing scores on two indexes of psychological distress of 369 mothers of children with cystic fibrosis, cerebral palsy, myelodysplasia, or multiple physical handicaps, with those of 456 mothers from a randomly selected sample of families ("control" subjects). Mothers of disabled children scored significantly higher than control subjects on both indexes of psychological distress. This finding persisted when the mothers' education, family income, and racial composition were controlled for. Type of disability, ie, the diagnostic classification of the disabled children, was unrelated to the mother's level of psychological distress. In contrast, the disabled child's dependence on others in daily activities had a significant effect on both measures of psychological distress; the more dependent the child, the greater was the mother's distress.     

Expression of pain and distress in children during dental extractions through drawings as a projective measure: A clinical study

AIM: To evaluate the efficacy of drawings as a projective measure of pain and distress in children undergoing dental extractions.METHODS: Children in the age range of 4-13 years with existence of untreatable caries or over-retained primary teeth, indicated for extractions were included. Pain was assessed using one behavioral [faces, legs, activity, cry and consolability (FLACC)] scale; and a self report measure; faces pain scale-revised (FPS-R), at two points of time, after completion of local anesthetic administration and after extraction. The general behavior of children was assessed with Wright’s modification of Frankl rating scale. At the end of the session, children were instructed to represent, themselves along with the dentist and their experiences of the dental treatment through drawing. The drawings were scored utilizing Child drawing: Hospital scale (CD: H) manual and correlated with FLACC, FPS-R and Frankl using Pearson correlation test.RESULTS: A positive correlation, though statistically not significant, was observed between CD: H scores and all other considered parameters (Frankl, FPS-R and FLACC) in the present study.CONCLUSION: Drawings could not act as surrogate measure of child’s pain; however, they acted as a narrative of his/her experiences and reflection of inner emotions. Hence, drawings can be used as an additional dental armamentarium.     

The PedsQL in pediatric cancer pain: a prospective longitudinal analysis of pain and emotional distress

The objective of this prospective study was to investigate the cross-sectional and longitudinal associations between pain and emotional distress in children and adolescents with cancer as measured by the Pediatric Quality of Life Inventory (PedsQL) Emotional Functioning and Pain Scales. The PedsQL 1.0 Generic Core Scales are multidimensional scales developed as the generic core measure to be integrated with the PedsQL Disease-Specific Modules. The PedsQL 1.0 Cancer Module was designed to measure pediatric cancer-specific health-related quality of life. The PedsQL Generic Core Scales, Emotional Functioning Scale and Cancer Module Pain Scale, were administered to 69 children and 59 adolescents and their parents at Time 1 and Time 2, which was 6 months on average after Time 1. Prospective hierarchical multiple regression analyses supported a longitudinal predictive model with Time 1 pain predicting Time 2 pain and Time 1 emotional distress predicting Time 2 emotional distress, respectively. Time 1 emotional distress did not predict Time 2 pain, and Time 1 pain did not predict Time 2 emotional distress. The results demonstrate that pediatric cancer pain and emotional distress, although associated cross-sectionally, are differentially predictive in prospective longitudinal analyses. These results suggest that both pain and emotional distress should be targeted for treatment interventions concurrently to enhance long-term health-related quality of life of the pediatric patient with cancer.     

Perception of fear, distress and pain by parents of children undergoing a micturating cystourethrogram: a prospective study

OBJECTIVES: To investigate whether parents' expectations of their child's fear, distress or pain during a micturating cystourethrogram (MCU) are realized. METHODOLOGY: Prospective study in which parents were asked to fill out two questionnaires using a visual analogue scale, one before (pre) and the other after the MCU procedure (post), was conducted at a tertiary level paediatric hospital in Sydney, Australia. The questionnaires were designed to compare the parents' anticipated and experienced anxiety about their child's procedure and their perception of fear, distress and pain in their child during and after the procedure. The parents' satisfaction with information provided to them on the procedure was also recorded. Twenty-five parents participated in the study. RESULTS: There were significant differences between anticipated and experienced parental anxiety. Parents' reporting of fear, distress and pain in their child during the MCU and after the procedure was lower than they had anticipated. There was a significant correlation between the parents' anxiety and their perception of severity of their child's fear (r = 0.52, P = 0.009), distress (r = 0.48, P = 0.017) and pain (r = 0.50, P = 0.01) during the procedure, but less so with the child's distress after the procedure (r = 0.39, P = 0.059). The parents were satisfied with the information given to them regarding the MCU procedure. CONCLUSIONS: Parents' perception of their child's fear, distress and pain during the MCU, as well as distress following the MCU, was not as severe as they had anticipated. Parental anxiety is an important factor in the perception of fear, distress and pain in children during and after the procedure.     

Foot pain in children

A general approach to the child with foot pain has been described. In that the pediatrician is so often the recipient of parent's questions about children's shoes, he or she should be aware of problems relating to poorly fitting shoes, probably the most common source of complaints of foot pain in children. With a systematic approach, the pediatrician is very capable of managing the majority of such complaints.