Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children

To determine whether the tetracaine component traditionally used in tetracaine-adrenaline-cocaine (TAC) is necessary to obtain effective topical anesthesia, a prospective study was performed to compare TAC and adrenaline-cocaine preparations for the repair of facial lacerations in children. Physicians were "blind" to which preparation was being used. Of 55 patients studied, 24 received TAC (103 sutures placed) and 31 received adrenaline-cocaine (151 sutures placed). The anesthetic efficacy of each preparation was approximately 95%; there were no adverse reactions related to administration of either medication or complications of wound healing noted in either group. The tetracaine component of TAC is superfluous for obtaining topical anesthesia of minor dermal lacerations of the face in children. The TAC formulation can be simplified by omitting tetracaine without compromising anesthetic efficacy.     

A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children

A randomized, prospective, double-blind study comparing three formulations of the topical anesthetic solution TAC for laceration repair was undertaken in 250 children. The children's wounds were anesthetized with either TAC I (original formulation--0.5% tetracaine, 1:2000 Adrenalin, 11.8% cocaine), TAC II (1.0% tetracaine, 1:4000 Adrenalin, 7.0% cocaine), or TAC III (1.0% tetracaine, 1:4000 Adrenalin, 4.0% cocaine) prior to repair. The solutions were compared with respect to efficacy, acceptability, wound complications, and side effects. We found comparable efficacy of the three formulations, with similar efficacy to 1% lidocaine infiltration for facial and scalp wounds. Anesthesia for extremity wounds was adequate in only 39.9% of cases, regardless of TAC strength. Wound complications and side effects were within expected and acceptable limits. Our findings support use of TAC for face and scalp lacerations and a change to a less concentrated TAC preparation, such as our "TAC III," which is presumably safer for widespread use.     

Efficacy of TAC topical anesthetic for repair of pediatric lacerations

A prospective evaluation of 103 consecutive children who received TAC (tetracaine, epinephrine [adrenaline], cocaine) liquid topical anesthetic for the repair of their minor dermal lacerations was performed. A unique method of TAC application was used that consisted of applying the medication to the inner margins of the wound cavity and allowing it to stand for several minutes prior to the application of a TAC-saturated gauze pad to the wound surface. Of 670 sutures placed, 637 (95%) were done without eliciting pain. The TAC topical anesthetic was more than 95% effective in providing complete anesthesia for wounds located on the face and lip; it was equally efficacious in anesthetizing larger wounds (greater than or equal to 5 cm in length and/or greater than or equal to 5 mm in depth). No adverse reactions resulted from the application of TAC. A single wound healing complication occurred in 103 patients. TAC is a safe, effective method for anesthetizing minor lacerations of the skin in children. Its painless method of application relieves patient discomfort and maximizes patient compliance during the repair procedure, both of which enhance the accurate approximation of lacerated tissue.     

Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations

Local anesthetic infiltration of wounds causes pain which distresses children. A painless topical anesthetic solution containing tetracaine, adrenaline, and cocaine (TAC) may reduce this distress. We hypothesized that the use of TAC for anesthesia may reduce the utilization of sedation for laceration repair. We performed a retrospective review of all pediatric emergency department (PED) patients receiving parenteral meperidine, promethazine, and chlorpromazine (DPT) during the period after TAC became routinely available. For comparison, data from a recent retrospective study of DPT (preTAC) use in the same PED were used. There was a reduction in the percent of total PED patients receiving DPT, from 1.7% preTAC to 1.2% during the TAC period (P less than 0.05). During the TAC period, there were no significant changes in patient volume or case-mix indicators. Of the major indications for DPT, there was no significant change in the percent receiving DPT for fractures, abscesses, burns, foreign body removal, or head injuries. However, there was a significant reduction in the percent of patients with lacerations receiving DPT during the experimental period, from 12% to 7.6% (P less than 0.05). There were no significant differences in laceration frequency (119/mo and 116/mo), length (2.7 and 2.7 cm), location (85% and 93% total for face and digits), or complexity (64% and 63%) for preTAC and TAC periods, respectively. We conclude that TAC used for local anesthesia may reduce the need for sedation in PED patients with lacerations that require suturing.     

Topical anesthetics in children: agents and techniques that equally comfort patients, parents, and clinicians.

Topical anesthetics are increasingly important, as the number of outpatient surgeries for dermatologic problems in infants and children is steadily growing. This noninvasive modality of anesthetic delivery in conjunction with a reassuring environment may minimize the discomfort of otherwise painful procedures. Since the 1880s, when cocaine was first used as a topical ophthalmologic anesthetic, many ester-and amide-based local anesthetics have been developed for a variety of simple and complex procedures. The pediatric dermatologist's arsenal of topical anesthetic preparations is increasing with the development of novel vehicles of transdermal delivery and the use of anesthetics in combination. Eutectic mixture of local anesthetics is currently the most frequently prescribed topical agent, though the use of ELA-max, another lidocaine-containing preparation, is gaining momentum, especially in the neonatal population. Amethocaine, tetracaine, iontophoresis, and the S-caine patch, a product on the horizon for use in the pediatric population, also are included in this discussion.     

Metal lawn and garden edging: the hidden knife?

OBJECTIVE: Lacerations account for many visits to the pediatric emergency department. We observed children presenting to local emergency departments in a large metropolitan area with lacerations incurred from metal lawn and garden edging, a landscaping tool. We sought to describe the severity of lacerations caused by metal edging, the characteristics of wound repair, and the need for subspecialty consultation. DESIGN: A retrospective chart review including all pediatric patients (< 18 years) presenting with lacerations caused by metal lawn and garden edging from January 1995 to October 1997 was performed. Patients were seen at one of three emergency departments in Colorado. RESULTS: One hundred twenty-six patients were enrolled (76% male, 24% female), with a median age of 9 years. The most frequent location of laceration was the foot (40%), followed by the knee (26%). The median length of laceration was 3 cm (range 1-22 cm). Sixteen patients (13%) received either intravenous or oral antibiotics, and six patients (5%) received orthopedic evaluation. CONCLUSIONS: Metal lawn and garden edging in landscaped neighborhoods presents a previously undescribed laceration danger to children. Some lacerations sustained from the metal lawn edging are extensive, receiving either multiple layer closure and/or the need for subspecialty consultation.     

New non-cocaine-containing topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations

OBJECTIVE: To compare the effectiveness of three new topical anesthetics that do not contain cocaine (prilocaine-phenylephrine, tetracaine-phenylephrine [tetraphen], and tetracaine-lidocaine-phenylephrine) to that of tetracaine-adrenaline-cocaine (TAC) during laceration repair in children. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: The emergency department of an urban children's hospital. PARTICIPANTS: Children 1 year of age or older with a laceration /= 5 years of age using a visual analogue scale (VAS). Suture technicians, research assistants, and parents also scored pain using a seven-point Likert scale. In addition, suture technicians completed an anesthetic effectiveness scale. RESULTS: There was consistently no difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. A statistically significant difference was seen among anesthetics when comparing VAS and Likert scale scores of suture technicians and Likert scale scores of research assistants. Based on post hoc analyses, these statistically significant differences were between TAC and prilocaine-phenylephrine (suture technician VAS and Likert scale) and between TAC and tetracaine-lidocaine-phenyl-ephrine (suture technician Likert scale), but not between TAC and tetraphen. When power analyses were performed using alpha = 0.05 and beta = 0.20, it was possible to detect a difference of 1.2 VAS units for each of the observer groups. Based on anesthetic effectiveness scale scores, the three new topical preparations collectively performed significantly better on the face and scalp than on the extremities (relative risk = 1.83; 95% confidence interval 1.20 < relative risk < 2.79). CONCLUSION: This study demonstrated the effectiveness and safety of three new non-cocaine-containing topical anesthetics. Consistently, there was no statistical difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. Tetraphen offers an effective alternative to TAC during laceration repair in children.     

Lacerations involving glass. The role of routine roentgenograms.

OBJECTIVE--To determine, when evaluating a laceration caused by glass, whether seeing that the bottom of the wound is free of glass eliminates the possibility that glass is present in the wound. RESEARCH DESIGN--Prospective patient series. SETTING--Two pediatric emergency departments. PARTICIPANTS--226 children with lacerations due to glass occurring in a period of 21 months. SELECTION PROCEDURES--Consecutive sample. INTERVENTIONS--Before obtaining a roentgenogram, the triage nurse or the managing physician visually inspected each wound and recorded whether the bottom of the wound was seen, if glass was seen in the wound, and the length and depth of the wound. Further treatment of the wound was at the discretion of the managing physician. MEASUREMENTS/MAIN RESULTS--Glass was seen in the wounds of 10 children on initial inspection. Of the remaining 216 injuries, glass was contained in 12 (21.4%) of the 56 lacerations when the bottom of the wound was not visualized, and in 11 (6.9%) of the 160 lacerations when the bottom of the wound was visualized. There was a significant association between the depth of the wound and an inability to see the bottom of the wound, and deeper wounds were significantly more likely to contain glass. All but one of the lacerations containing glass had a depth of at least 0.5 cm. CONCLUSIONS--In the population studied, seeing that the bottom of the laceration was free of glass reduced, but did not eliminate, the possibility that glass was present in the wound. In addition, superficial lacerations (less than 0.5 cm) rarely contained undetected glass fragments. We recommended that further investigation concerning the mechanism of injury, the depth of the wound, and the type of glass involved is needed before physicians abandon routine roentgenography for lacerations due to glass.     

Prediction of intravenous theophylline dosage based on a single, nonsteady-state concentration: a clinical study of childhood status asthmaticus

A pharmacokinetic model was applied to achieve therapeutic serum theophylline concentrations rapidly in 25 children with status asthmaticus. A sustained release theophylline preparation had been taken within 36 hours by 12 children; within 14 hours, seven had taken an immediate release preparation; for six children, no theophylline was taken before hospital admission. Single serum theophylline concentrations were determined at nonsteady-state conditions within 13.5 hours of admission (median 6.75 hours). An iterative program was applied to predict the steady-state theophylline concentration as well as necessary adjustments in dosage. Measured steady-state concentrations were then compared with the predicted values. The median measured steady-state concentration was 15 mg/L, and the median predicted steady-state level was 13 mg/L. The least squares regression line was: Measured = 0.738 predicted + 4.77; r = .721, P less than .01. No patient experienced symptoms of toxicity. This technique affords the possibility of accurate prediction of steady-state theophylline concentrations and dosing requirements with a minimum number of serum concentration determinations in children with status asthmaticus.     

Long‐term outcomes in pediatric liver recipients: Comparison between cyclosporin A and tacrolimus

In recent years, tacrolimus (FK506, TAC) has been increasingly utilized in liver transplantation. However, long-term risks and benefits as compared with conventional cyclosporin A (CsA) have not been fully elucidated. This retrospective study examined the potential outcome differences between TAC- and CsA-based immunosuppressive therapy in pediatric liver transplant recipients. From March 1988 to December 1996, 218 children (aged 0.1-17 yr) underwent 238 orthotopic liver transplantations; 58.7% (128/218) were under 2 yr of age at time of transplant. Initially, the maintenance immunosuppressive regimen consisted of CsA and prednisone, with antilymphocytic preparations (MALG, ATGAM, and OKT3) as induction therapy. Subsequently, TAC was used first as rescue therapy for steroid refractory rejection in CsA patients and then as maintenance immunosuppression. Fifty-seven out of the 147 CsA patients were converted to TAC for various reasons while 71 patients were placed on TAC as primary maintenance immunosuppression. 62.6 per cent (92/147) of liver recipients on CsA experienced at least one biopsy-proven acute rejection episode as compared to 50.7% (36/71) for TAC patients (p = 0.09); likewise, 34% (50/147) of CsA patients had more than one episode of rejection vs. 18.3% (13/71) for patients on TAC (p < 0.02). Rejection was the reason for conversion from CsA to TAC in 29 of 57 patients. Conversely, 19.0% (28/147) of CsA patients had to be switched to TAC for reasons not related to rejection (i.e. side-effects). The overall incidence of histologically proven chronic rejection was 7.8% (17/218). 10.9 per cent (16/147) of the children who were on CsA initially developed chronic rejection, which was significantly higher compared with one of 71 TAC recipients (p < 0.02). Of these 16 CsA patients with chronic rejection, 50.0% (8/16) underwent retransplantation for graft failure (mean interval from time of diagnosis of chronic rejection to re-transplant, 4.0 months; range 1-8 months), whereas the TAC patient has remained clinically stable with normal liver function tests after 23 months of follow-up. One year after liver transplantation, 72.8% (107/147) of CsA patients were still on steroids (mean dosage 0.20 mg/kg/d), as compared to 42.3% (30/71) of the TAC patients (mean dosage 0.14 mg/kg/d). The incidence of post-transplant lymphoproliferative disorder (PTLD) in Epstein-Barr virus (EBV)-infected patients was 2.2% (2/90), 7.0% (5/71) and 12.3% (7/57) for CsA, primary and TAC-converted groups, respectively. The overall incidence of PTLD was 6.9% (15/218). In summary, pediatric liver transplant recipients treated with TAC as primary maintenance immunosuppressive medication experienced significantly fewer episodes of rejection; especially chronic rejection, which lead to graft loss. However, the trade-off is a potential increased incidence of EBV-related PTLD in these patients.     

Anti-thymocyte globulin induction with delayed introduction of tacrolimus preserves renal function in pediatric liver transplant recipients

Background

Tacrolimus (TAC)-mediated renal disease occurs in up to 70% of pediatric liver transplant (LT) recipients. The safety and efficacy of renal-sparing immunosuppression using anti-thymocyte globulin (ATG) induction and delayed TAC administration has not been studied in children. We evaluated the safety and efficacy of ATG induction on preserving renal function in children within the first year (Y1) post-LT in a single-center retrospective cohort study.

Methods

Children under age 18 years of who received isolated LT from 2008 to 2020 with a GFR < 70 received renal-sparing (RS) protocol consisting of ATG with methylprednisolone (MP), delayed TAC administration, lower initial TAC trough goals, and mycophenolate mofetil (MMF). The RS group was matched 1:2 by age and LT indication with standard immunosuppression (SI) group. Changes in renal function as well as adverse events within Y1 post-LT were compared.

Results

Forty-four pediatric patients were included in the analysis, of which 13 received RS. As expected, the RS group had significantly lower mean TAC trough levels at 30 days (10.3 vs. 13.2, p = .001) post-LT. Renal function was significantly preserved at 6 (−0.26 vs. 0.21, p = .004) and 12 months (−0.33 vs. 0.11, p = .003) post-LT in the RS versus SI group as measured by mean change in serum creatinine, with similar trends observed in eGFR and cystatin C. ACR, sepsis, viremia, graft loss and mortality occurred at similar rates in both RS and SI groups.

Conclusion

Induction immunosuppression with ATG and delayed TAC administration in children with renal impairment is safe and effectively preserves renal function during Y1 post-LT.     

Incisional local anaesthesia versus placebo for pain relief after appendectomy in children--a double-blinded controlled randomised trial.

Incisional local anaesthesia is widely used for postoperative pain relief after surgery. We present the results of a double-blinded and randomised controlled study of incisional bupivacaine versus placebo in 68 children undergoing open appendectomy. The trial medicine (0.5 ml/kg) was infiltrated into the subcutis after wound closure. Patients with a weight below 40 kg received a bupivacaine concentration of 0.25 % and the patients above 40 kg a concentration of 0.5 %. During the first 24 hours after surgery the patients in the bupivacaine group received on average 0.065 mg morphine/kg and in the placebo group 0.073 mg/kg. This difference was not statistically significant. The patients in the bupivacaine group tended to experience pain relief for a longer period of time compared to the patients in the placebo group. However, the difference was not significant. In conclusion, the use of subcutaneous infiltration with bupivacaine in the wound after open appendectomy had no significant effect on the use of morphine during the first postoperative day in children.     

Tacrolimus withdrawal and conversion to sirolimus at three months post-pediatric renal transplantation

Nephrotoxicity caused by CNI may adversely affect long-term graft outcomes. For this reason, we have adopted a protocol for withdrawing TAC and converting to SRL at three months post-renal transplantation. All recipients received basiliximab induction and TAC, MMF, and prednisone. Patients without acute rejection by surveillance biopsy at three months were eligible for SRL conversion. Results: From August 2004 to September 2006, TAC was withdrawn and replaced by SRL in 30 first transplant recipients, who were followed for six to 39 months (mean 18 +/- 8). Renal function did not improve significantly after SRL conversion (p = 0.25). Acute rejection occurred in three patients (10%) at five to 12 months after CNI withdrawal. There were no occurrences of wound healing problems, pneumonitis or post-transplant lymphoproliferative disease. Thrombocytopenia and diabetes each occurred in one patient. Four patients received treatment for hypercholesterolemia. CNI withdrawal and replacement with SRL was an effective regimen in children who did not display biopsy evidence of acute rejection at three months post-transplant. While these early results are promising, the ultimate benefit of this protocol to enhance the long-term renal function and graft survival requires ongoing follow-up.     

Bio-availability of phenytoin free-acid serum level determinations whilst using a lactose-based tablet-preparation (author's transl)

Phenytoin serum levels were determined in 103 children during the steady state of phenytoin therapy using a radio-immuno-assay. 94% of the patients had been treated as outpatients, 54% received phenytoin in combination with other antiepileptic drugs. The preparation used was phenytoin as free acid in lactose tablets (Epilan D). A therapeutic serum level of 10-20 mcg/ml was reached by an oral intake of 6,1 +/- 1,6 mg/kg/d. 27 children had plasma levels above 20 mcg/ml, their oral dose was 7,1 +/- 1,8 mg/kg/d. Most of these children showed clinical signs of intoxication. The bioavailability of phenytoin preparations is not only depended on the type of the substance used (salt, free acid), but also on the excipients used for the preparation of tablets. Therefore, general dosage recommendations are useless and even dangerous, unless the preparations used are extensively specified.     

Early post‐operative intravenous tacrolimus in pediatric liver transplant recipients is not superior to oral tacrolimus

We aimed to compare the early results of i.v. with p.o. TAC as a primary immunosuppressant in pediatric patients undergoing LT. This retrospective study enrolled 75 children who underwent LT and received TAC‐steroid regimens as a primary immunosuppressant between September 2011 and October 2015 at our institution. Thirty‐five recipients received TAC i.v. and 40 received TAC p.o. Early results were evaluated and compared, including ACR, EBV, or CMV infection; renal adverse effects; and hospital stay. Comparisons of 90‐day post‐transplant results showed that the rates of overall viral (74% vs 40% P < 0.002), EBV (46% vs 17.5% P < 0.008), and CMV (51% vs 30% P = 0.05) infections were significantly higher in the i.v. than in the p.o. group. Neither regimen has any adverse effects on renal function. There were no between‐group differences in ACR incidence and severity, serum creatinine concentration, and hospital stay. Patient and graft survival rates at 3 months and 1 year did not differ significantly between the two groups. Compared with p.o. treatment, i.v. administration of high TAC concentration did not have beneficial post‐transplant effects on ACR incidence and severity, while increasing the incidence of viral infections in pediatric LT.     

Acetaminophen and ibuprofen dosing by parents

BACKGROUND: Acetaminophen and ibuprofen are two of the most commonly used medications in children. It is our experience that parents often misdose these medications. Misdosing may lead to unintended toxicity or inadequate symptomatic improvement. There are limited data on the extent of misdosing of these antipyretics. We sought to determine the prevalence of and risk factors for inaccurate dosing by parents seeking care for their children in the emergency department (ED). METHODS: A cross-sectional observational study was performed in an urban academic pediatric ED. Two hundred patients 10 years of age and younger who were given a known dose of acetaminophen or ibuprofen in the 24 hours prior to the ED visit were enrolled. The treating physician completed a questionnaire for each patient. Caregivers were asked about quantity and frequency of antipyretic use prior to the ED visit, the source of information used to determine dosage, and which factor (eg, age, sex, height, weight, height of fever, severity of illness) they considered most important in determining the correct dosage of medication. Doses of 10 to 15 mg/kg for acetaminophen and 5 to 10 mg/kg for ibuprofen were considered accurate. RESULTS: Overall, 51% of patients received an inaccurate dose of medication, including 62% of patients given acetaminophen and 26% of patients given ibuprofen. Infants < 1 year old were more likely to receive an inaccurate dose (RR 1.40, P < 0.04, 95% CI = 1.06-1.86). Caregivers who stated that medication dosage was based on weight were less likely to give an inaccurate dose of medication (RR 0.71, P < 0.03, 95% CI = 0.52-0.97). CONCLUSIONS: Over half of the caregivers surveyed gave an inaccurate dose of acetaminophen or ibuprofen, particularly to infants. Caregivers who reported that antipyretic dosage was based on weight were less likely to misdose medication, suggesting a valuable role for patient education.     

Single-dose, placebo-controlled comparative study of ibuprofen and acetaminophen antipyresis in children

Ibuprofen was evaluated as an antipyretic agent in 178 children (aged 3 months to 12 years) to compare dosage (5 vs 10 mg/kg), establish absolute efficacy (with a placebo control group), determine relative efficacy (ibuprofen vs acetaminophen), evaluate maximum efficacy, and identify potential confounding variables. Ibuprofen 5 mg/kg was minimally effective in children less than 6 years of age who had an initial temperature of at least 38.8 degrees C (101.9 degrees F). Ibuprofen 10 mg/kg was more effective for febrile children. The area under the curve for temperature (or change in temperature) captured the net effect of each drug and provided the best estimate for efficacy comparison during a defined period. A linear correlation between initial temperature and measures of efficacy was observed. A twofold increase in efficacy was observed for children with an initial temperature less than 38.8 degrees C. A similar effect was noted for each treatment group. Age was also found to have confounding effects on antipyretic response. A complex interaction between antipyretic response, initial temperature, and age raises questions about the pharmacodynamics of the antipyretic response. We conclude that the most important variable in antipyretic study design is initial temperature. The influence of initial temperature on the magnitude of the response to an antipyretic drug is a previously unappreciated finding with potential impact on pharmacodynamic investigations of antipyretic medications. We describe this finding as nonlinear pharmacodynamics.     

环孢霉素A与他克莫司治疗儿童难治性肾病综合征疗效及安全性对照研究

目的 评估环孢霉素A与他克莫司治疗儿童难治性肾病综合征的疗效及安全性。方法 回顾性分析2012年6月至2018年6月在上海市儿童医院接受环孢霉素A与他克莫司治疗的118例难治性肾病综合征患儿信息，包含患儿一般情况、实验室检查、肾组织病理、治疗后转归及不良反应等，并进行统计分析。采用Kaplan-Meier生存分析绘制生存曲线，行相关比较分析。结果 一般临床资料：纳入环孢霉素A治疗病例总计66例，其中18例为激素耐药型肾病综合征，45例为激素依赖型肾病综合征，3例为频反复型肾病综合征，其中56例行肾穿刺活检。52例他克莫司组中12例为激素耐药型肾病综合征，40例为激素依赖型肾病综合征，其中47例行肾穿刺活检；疗效及安全性分析：环孢霉素A与他克莫司对难治性肾病综合征维持远期完全缓解无组间差异。但治疗第6个月，难治性肾病综合征他克莫司组完全缓解率（86.5%）明显高于环孢霉素A组（68.2%），差异有统计学意义（P<0.05），其中以激素依赖型/频反复型肾病综合征疗效差异有统计学意义（P<0.05），激素耐药型肾病综合征组间疗效无统计学差异。此外，在微小病变组及非微小病变组内，环孢霉素A与他克莫司无疗效差异；副反应方面，他克莫司组多毛症发生率、牙龈增生发生率均明显低于环孢霉素A组，且有显著性差异（P<0.01），但在使用他克莫司第16个月及18个月后出现2例急性胰腺炎患儿。环孢霉素A组急性肾损伤（5/66）及慢性肾毒性改变（2/66）发生率高于他克莫司组。结论 环孢霉素A与他克莫司对难治性肾病综合征远期疗效无差异。对于激素依赖型/频反复型肾病综合征患儿，他克莫司短期疗效较环孢霉素A更好，但需警惕急性胰腺炎发生。对环孢霉素A累计治疗时间超过30个月患儿需高度警惕钙调神经磷酸酶抑制剂肾毒性发生。     

Impact of sedation and anesthesia on the rectoanal inhibitory reflex in children

OBJECTIVE: The study objective was to determine whether the rectoanal inhibitory reflex (RAIR) can be elicited during limited anorectal manometry (ARM) performed under general anesthesia (GA). METHODS: In this retrospective study, patients with intractable constipation who underwent ARM under GA from November 1999 to March 2002 were evaluated. Rectal biopsy specimens were examined for the presence of ganglion cells. RESULTS: Eighty consecutive patients aged 5 months to 16 years were evaluated. Three patients with Hirschsprung disease were excluded from analysis. Ganglion cells were found in rectal biopsy specimens from 76 patients. RAIR was positive in 69 (90%) and negative in 8 (10%). Forty-five patients received preoperative medications: midazolam (n = 36), midazolam + atropine (n = 3), atropine (n = 1), midazolam + glycopyrrolate (n = 3), and glycopyrrolate (n = 2). Different combinations of general anesthetic medications were used. Ten patients received neuromuscular blockers. The use of preoperative midazolam or atropine did not affect the presence or absence of RAIR; however, the proportion of patients with negative RAIR was higher in those receiving glycopyrrolate (P = 0.007) than in those receiving other medications. There was no significant difference in the effect of the general anesthetic agents or neuromuscular blockers used on the presence or absence of RAIR. CONCLUSIONS: The rectoanal inhibitory reflex in children can be elicited even when anorectal manometry is performed under general anesthesia. Glycopyrrolate, an anticholinergic, appears to inhibit the demonstration of the RAIR.