Neuropathic pain other than CRPS in children and adolescents: incidence, referral, clinical characteristics, management, and clinical outcomes.

BACKGROUND AND OBJECTIVES: Chronic pain in children and adolescents is common, but proportion of neuropathic pain (NP), a heterogeneous group of diseases with major impact on health-related quality of life, significant economic burden, and limited treatment options, is unclear. Many studies have focused only on complex regional pain syndrome (CRPS). Our aim was to examine the incidence, clinical features, management, and outcome of non-CRPS NP in patients referred to a chronic pediatric pain clinic (CPPC) at a tertiary-care hospital. METHODS: Retrospective analyses of the patient's files with non-CRPS NP from 2008 until 2012. RESULTS: Twenty patients (9.9-22.0 years; 10.7% of new referrals) were treated with non-CRPS NP (postoperative 8/20, trauma-related 5/20, disease-related 7/20). The number of consultations performed and the number of medications used before CPPC were significantly higher than in CPPC (Z = 0.75, P = 0.005; Z = 1.68, P = 0.003; respectively, Wilcoxon test). The number of diagnostic procedures was not statistically significant. Invasive treatments were used in 50% of patients. Full/partial recovery was accomplished in 95%. anova with repeated measures yielded a highly significant difference between the initial and final visual analog scale (VAS) scores (8.2 ± 1.3; 1.19 ± 2.01, respectively; P < 0.001), and no effect of age, gender, time needed for referral to CPPC, and patient's categories on the change in VAS. CONCLUSIONS: Better understanding of the medical profile of pediatric patients with non-CRPS NP is crucial to timely and correct diagnosis and effective management, but even children with delayed diagnosis still have a good outcome. The management of this condition by an experienced team is recommended.

[Pain in children in the 21st century].

Pain is undertreated in children due to historical reasons. The pain afferent tracts are developed in 21 weeks of gestation and it is well documented that preterm and neonates can experience pain. Pain in neonates leads to ncreased distress and altered pain response later in life. pain assessment in children is chalLenging. In the preverbal age using scales combining physiological and behavioral parameters help estimating the pain. Older children can use VAS scales but their pain scoring is affected by developmental age changes. Children respond to pain management treatments differently than adults. Some medications are not approved for use in children. Non-pharmacologic treatment is more effective, while invasive treatment such as regional nerve blocks for chronic pain is Less effective in children. Chronic pain is ignored or overlooked in children. This can lead to physicaL, emotional, psychological and social effects. Children may be absent from school and withdraw from their friends. Children with chronic pain will most likely become adults with chronic pain. Accepting chronic pain in children as a real problem and attempting to treat it at a young age may help decrease rates of adult pain in the future. The family doctor may be looking for serious causes for the pain. Referrals to specialists can Leave children without proper pain management or treatment. The Pediatric Pain Clinic is a multidisciplinary program specifically aiming to provide treatment and support for acute and chronic pain in children to conquer pain, help children to cope with chronic pain and avoid future complications.

Histology proved malpositioning of dextranomer/hyaluronic acid in submucosal ureter in patients after failed endoscopic treatment of vesicoureteral reflux.

PURPOSE: We histologically investigated the cause of failed endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. MATERIALS AND METHODS: A total of 192 children underwent dextranomer/hyaluronic acid injection at our institution between January 2008 and September 2010. The study population consisted of 13 children (22 ureters) with vesicoureteral reflux who underwent ureteroneocystostomy following failed endoscopic injections (1 to 2) of dextranomer/hyaluronic acid. In all cases the dextranomer/hyaluronic acid was implanted in the mucosa of the mid to distal ureteral tunnel following hydrodistention of the ureter. The medical records were reviewed, and specimens of the archived distal ureters removed during surgery were examined histologically. RESULTS: Mean patient age was 4.1 years. Mean dose of dextranomer/hyaluronic acid was 0.9 ml (both treatments) and mean lag between treatments was 13.4 months. Indications for open surgery were recurrent urinary tract infections and/or residual or aggravated reflux grade IV or higher. Histological study revealed that the dextranomer/hyaluronic acid was malpositioned in 21 of 22 ureters, residing in the muscle fibers in 2, adventitia in 14 and periureteral space in 5. CONCLUSIONS: This is the first known study to provide a histologically proved cause of failure of endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. Malpositioning of the material outside the submucosal ureter was identified in a high percentage of cases. Larger studies are needed to corroborate these findings.

Meatotomy using local anesthesia and sedation or general anesthesia with or without penile block in children: a prospective randomized study.

PURPOSE: Meatotomy is a simple, common procedure for the treatment of meatal stenosis. We compared the outcomes of meatotomy performed using local anesthesia and sedation, and general anesthesia with and without penile block. MATERIALS AND METHODS: A prospective comparative design was used. Participants included 76 boys 1.5 to 10 years old treated for meatal stenosis at a tertiary, university affiliated, pediatric medical center in 2008. Children were randomly allocated to undergo surgery with sedation and local anesthesia, or general anesthesia with or without penile block. All procedures were performed with the same method by the same surgeon. For local anesthesia EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%) covered with an occlusive dressing was applied 1 hour preoperatively, and midazolam (in patients younger than 5 years) or nitrous oxide (older than 5 years) was used for sedation. General anesthesia was induced with inhaled sevoflurane, and ropivacaine was used for dorsal penile nerve block. RESULTS: There was no difference among the groups in pain level intraoperatively (no pain in 92% to 93% of patients), 24 hours postoperatively (no pain in 81% to 88%) or after 1 month, or in complication rates (bleeding in 3 patients, laryngospasm in 2). General anesthesia with penile block was associated with a trend of less dysuria. Quality of void was excellent in 87% of patients at 24 hours and in 70% at 1 month, and parental satisfaction was high (88% to 92%). CONCLUSIONS: Meatotomy performed using local anesthesia and sedation has an equally good outcome to meatotomy performed using general anesthesia with or without penile block.

Continuous epidural versus nonepidural analgesia for post-pyeloplasty pain in children.

PURPOSE: We compared the effectiveness of post-pyeloplasty epidural and nonepidural analgesia in children. MATERIAL AND METHODS: After flank dismembered open pyeloplasty 45 children were randomly allocated to group 1-continuous epidural analgesia with a loading dose of 0.25% bupivacaine or 0.2% ropivacaine, followed by continuous drip 0.2% ropivacaine (26) and group 2-nonepidural analgesia with intraoperative morphine intravenously and postoperative oxycodone or tramadol by age plus ibuprofen or paracetamol for 48 hours. The same rescue regimen was used in each group. Pain was scored separately by parents and the ward nurse using the Face, Legs, Activity, Cry and Consolability Scale or a visual analog scale. RESULTS: In groups 1 and 2 mean age was 2.8 and 4.7 years, respectively. There was no significant between group difference in pain degree as scored by the nurse (none in 53.8% vs 36.8% of patients, mild in 26.9% vs 21.1% and moderate in 19.2% vs 42.1%) and parents (none in 40% vs 23%, mild in 20% vs 11.8% and moderate in 40% vs 65.2%) (p >0.05). Rescue treatment 48 to 72 hours after surgery was received by 80% of group 1 and 76% of group 2 for mild pain and by 4% and 30% for moderate pain (p >0.05 and 0.02, respectively). Mean time to mobilization in the 2 groups was 25 and 17 hours, and mean time to discharge home was 4.9 and 4.1 days (p = 0.05 and >0.05, respectively). CONCLUSIONS: Nonepidural analgesia is as effective as continuous epidural analgesia to control post-pyeloplasty pain in children. A noninvasive analgesic regimen is recommended when there is a relative contraindication to line insertion, a less experienced anesthetist is available or parents prefer it.

Complex regional pain syndromes in children and adolescents.

BACKGROUND: The purpose of the present paper was to assess efficiency of treatment and long-term functional outcome of complex regional pain syndromes (CRPS) in children who were treated in the chronic pain clinic at a major tertiary hospital in Israel. METHODS: The files of 14 children with CRPS were analyzed retrospectively. Demographic data, initiating event, referring source, time needed for referral to pain clinic, clinical evaluation, treatment, recurrence and complications were recorded. RESULTS: Fourteen children with CRPS types I and II were included in the study. Girls were affected in 71%. Lower extremities were affected in 57%. The median time from onset of symptoms to seeking medical help was 4.46 weeks (range 2-82 weeks). The median time to referral to pain clinic was 24.51 weeks (range 1.2-94). In 45% the referral source was the pediatrician. A total of 85.8% of patients were referred to various consultations before the pain clinic. Most children had reduced pain and improved function on non-invasive treatment approach. Invasive treatments were used in 28.5%. Full or partial recovery was accomplished in 93%. Recurrence was observed in 29%. CONCLUSIONS: CRPS in children and adolescents is still underdiagnosed, although many of the epidemiologic features of pediatric CRPS are similar in different countries/cultures. Early recognition and management is the major factor in improving outcome and preventing resistant CRPS, but even children with delayed diagnosis still have a good outcome. The management of this disease by an experienced multidisciplinary team is recommended. Because psychosocial factors play an important role, it is recommended to provide psychological evaluation and cognitive behavioral treatment as soon as possible.

Spinal anesthesia in neonates and infants - a single-center experience of 505 cases.

BACKGROUND: Our aim was to assess the safety and efficacy of spinal anesthesia (SA) in newborns and infants undergoing surgery appropriate for this technique. METHODS: The files of 505 patients who underwent surgery under spinal anesthesia since 1998 at a major tertiary hospital in Israel were analyzed retrospectively. SA was performed with bupivacaine 5 mgxml(-1) by attending pediatric anesthesiologists or an anesthesia resident. Demographic data, prematurity history, comorbidities, technical data, cardiovascular stability, complications and supplementary drugs were documented. The surgeon assessed the quality of anesthesia at the end of surgery. RESULTS: Appropriate SA was achieved in 95.3% of cases; in 69.9% at the first attempt. The mean number of attempts per patient was 1.41 and mean dose of bupivacaine was 0.66 +/- 0.16 mgxkg(-1). Intravenous sedation, usually with midazolam (dose 0.1-0.2 mgxkg(-1)) was required in 28.1% of children because of crying/restlessness. Intraoperative conversion to general anesthesia was necessary in five patients (1.04%). The main side effect was bradycardia (<100 bxmin(-1)) without desaturation which occurred in nine patients (1.8%). In three patients (0.62%), high spinal block occurred without bradycardia and hypotension. None of the patients had postoperative meningitis. CONCLUSIONS: SA is safe and effective in newborns and infants undergoing low abdominal, perineal and orthopedic surgery. In order to save time, our advice is to attempt SA after the surgeon is scrubbed, and minimize surgical teaching activity. The need to deal with a small and sometimes sick patient independent of the type of anesthesia requires the presence of an experienced pediatric anesthesiologist.

Propofol-ketamine mixture for anesthesia in pediatric patients undergoing cardiac catheterization.

OBJECTIVE: To evaluate the safety of a propofol-ketamine mixture to induce and maintain anesthesia in spontaneously breathing pediatric patents during cardiac catheterization. DESIGN: Prospective clinical study. SETTING: Departments of Cardiothoracic Surgery, Anesthesiology, and Pediatric Anesthesiology in a university hospital. PARTICIPANTS: Forty-five children aged 6 months to 16 years with ASA grade II to III undergoing cardiac catheterization. INTERVENTIONS: Continuous intravenous infusion of a mixture of propofol (4 mg/mL) and ketamine (2 mg/mL) with spontaneous ventilation. The infusion rate was changed and additional boluses of propofol or/and ketamine were given as needed. Hemodynamic, respiratory, and other variables were recorded during the procedure and recovery. RESULTS: Mean dose of ketamine was 26 +/- 8.3 microg/kg/min and of propofol, 68.3 +/- 21.7 microg/kg/min. Changes in heart rate and mean arterial pressure of more than 20% from baseline were observed in 4 and 5 patients, respectively. A transient reduction in oxygen saturation because of hypoventilation was observed in 3 patients and responded to oxygen administration and manual assisted ventilation. No other complications were observed. CONCLUSIONS: The propofol-ketamine mixture is a safe, practical alternative for general anesthesia in pediatric patients undergoing cardiac catheterization.

Premedication with midazolam in young children: a comparison of four routes of administration.

BACKGROUND: We undertook a study to determine the effects of four routes of administation on the efficacy of midazolam for premedication. METHODS: In a randomized double-blind study, 119 unmedicated children, ASA I-II, aged 1.5-5 years, who were scheduled for minor elective surgery and who had been planned to received midazolam as a premedicant drug, were randomly assigned to one of four groups. Group I received intranasal midazolam 0.3 mg.kg-1; group II, oral midazolam 0.5 mg x kg(-1); group III, rectal midazolam 0.5 mg x kg(-1); and group IV, sublingual midazolam 0.3 mg x kg(-1). A blinded observer assessed the children for sedation and anxiolysis every 5 min prior to surgery. Quality of mask acceptance for induction, postanaesthesia care unit behaviour and parents' satisfaction were evaluated. Thirty patients were enrolled in each of groups I, III and IV. Twenty-nine patients were enrolled in group II. RESULTS: There were no significant differences in sedation and anxiety levels among the four groups. Average sedation and anxiolysis increased with time, achieving a maximum at 20 min in group I and at 30 min in groups II-IV. Patient mask acceptance was good for more than 75% of the children. Although the intranasal route provides a faster effect, it causes significant nasal irritation. Seventy-seven percent of the children from this group cried after drug administration. Most parents in all groups (67-73%) were satisfied with the premedication. CONCLUSIONS: Intranasal, oral, rectal and sublingual midazolam produces good levels of sedation and anxiolysis. Mask acceptance for inhalation induction was easy in the majority of children, irrespective of the route of drug administration.