Procedural Pain Management During Tenotomy for Congenital Talipes Equinovarus.

The majority of infants with congenital talipes equinovarus (CTEV) require tenotomy of the tendoachilles. The pain response of this procedure in the awake infant has not been previously reported. In this observational study, multimodal pain management strategies, including oral sucrose, oral paracetamol, topical anesthetic, local anesthetic, a pacifier (dummy), and swaddling, were used. Physiological responses and pain were recorded. Pain was rated out of 10 at regular intervals, using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Ninety-one infants (65 men, mean age = 53 days, range = 19-217 days) were observed. At baseline, median FLACC, heart rate (HR), and oxygen saturation (Spo2) were 1, 159, and 97% respectively. Peak median FLACC and HR were 9 and 200, respectively, and lowest median Spo2 was 92%. The median (interquartile range) time for FLACC to return to 3 or less was 2 (2-5) minutes. Achilles tenotomy for CTEV in the awake infant is associated with high pain levels despite provision of multimodal pain relief measures.

Teaching Manually Assisted Cough to Caregivers of Children With Neuromuscular Disease.

BACKGROUND: Cough augmentation techniques are taught by health-care providers to improve secretion clearance and to help prevent respiratory infections in children with neuromuscular disease. There is some evidence of the effectiveness of a manually assisted cough when applied by health-care providers. However, it is unknown whether parents and caregivers may also be effective in applying manually assisted cough. The aim of this study was to evaluate whether parents and caregivers are effective at applying a manually assisted cough to a child with neuromuscular disease after being taught by a health-care provider. METHODS: For this prospective cohort study, children and their parents or caregivers were recruited from neuromuscular clinics in the Sydney Children's Hospitals Network. Cough peak flow was the outcome measure for the strength of the child's cough. Children were eligible to participate if their unassisted cough peak flow at baseline was <270 L/min. Parents and caregivers were taught a manually assisted cough by a physiotherapist before being measured. The cough peak flow was measured in the following order: (1) during an unassisted cough as baseline, (2) during a manually assisted cough performed by a physiotherapist, (3) during a manually assisted cough performed by a parent or caregiver, and (4) during an unassisted cough after intervention. RESULTS: Twenty-eight children (24 boys, 4 girls; mean ± SD age, 12 ± 3 y) completed the study. No clinically or statistically significant changes were found in the cough peak flow after the application of a manually assisted cough by parents or caregivers (95% CI -11 to 11 L/min) or by physiotherapists (95% CI -6 to 14 L/min). CONCLUSIONS: Parents and caregivers and health-care providers were ineffective at increasing cough peak flow in children with neuromuscular weakness when applying a manually assisted cough. A single training session was insufficient for a parent or caregiver to be able to apply a manually assisted cough effectively on his or her child with neuromuscular weakness. Further research is warranted to guide recommendations on how best to equip parents and caregivers with the skills to help manage children with neuromuscular disease.