Guidelines of the French Society of Otorhinolaryngology (SFORL): Nonsteroidal anti-inflammatory drugs (NSAIDs) and pediatric ENT infections. Short version.

OBJECTIVES: To present the guidelines of the French Society of Otolaryngology-Head and Neck Surgery concerning the use of non-steroidal anti-inflammatory drugs (NSAIDs) in pediatric ENT infections. METHODS: Based on a critical analysis of the medical literature up to November 2016, a multidisciplinary workgroup of 11 practitioners wrote clinical practice guidelines. Levels of evidence were classified according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system: GRADE A, B, C or "expert opinion". The first version of the text was reworked by the workgroup following comments by the 22 members of the reading group. RESULTS: The main recommendations are: NSAIDs are indicated at analgesic doses (e.g. 20-30 mg/kg/day for ibuprofen) in combination with paracetamol (acetaminophen) in uncomplicated pediatric ENT infections (acute otitis media, tonsillitis, upper respiratory infections, and maxillary sinusitis) if: o pain is of medium intensity (visual analogue scale (VAS) score 3-5 or "Evaluation Enfant Douleur" (EVENDOL) child pain score 4-7) and insufficiently relieved by first-line paracetamol (residual VAS≥3 or EVENDOL≥4); o pain is moderate to intense (VAS 5-7 or EVENDOL 7-10). When combined, paracetamol and ibuprofen are ideally taken simultaneously every 6h. It is recommended: (1) o not to prescribe NSAIDs in severe or complicated pediatric ENT infections; (2) o to suspend NSAIDs treatment in case of unusual clinical presentation of the infection (duration or symptoms); (3) o not to prescribe NSAIDs for more than 72h.

[Management of neuropathic pain in children: guidelines for good clinical practice]. / Prise en charge des douleurs neuropathiques chez l'enfant: recommandations de bonne pratique clinique.

Neuropathic pain exists in children and its incidence is often underestimated due to the lack of knowledge on the existence and the diagnosis of this pain. Although the semiological characteristics can be compared to those of the adult (allodynia, hypoesthesia, burning and stabbing sensations), their etiology often differs, and pain treatments are more limited because of a lack of pharmacological data and the absence of clinical studies. Therapeutic management is sometimes insufficient and requires better knowledge of this entity. Based on the June 2009 recommendations of the French Agency for Food and Drug Safety (Afssaps) (drug therapy in acute and chronic pain in children), this article presents a review of the data available in the literature on the subject, taking into account expert opinion and proposing clinical recommendations of good practice for the recognition and the treatment of neuropathic pain in children.

[Patient controlled analgesia in children]. / L'analgésie autocontrôlée ou PCA chez l'enfant.

Patient Controlled Analgesia is a useful technic to deliver morphine analgesia via a programmable pump: the patient himself choose to self-administer a bolus dose (usually morphine); the dosage is calculated and prescribed according to the level of pain, limits of dose and period of interdiction are planned. After initial bolus to decrease severe pain (titration), the patient from the age of 6 years can manage his analgesia. This method of administration of the analgesic allows to adapting at best the posology of morphine to the level of pain and has a high safety level. A continuous flow can be prescribed if the pain is severe, but requires a greater level of surveillance of the essential parameters: breath and sedation, in order to avoid any overdose. As for any morphine analgesia, the unwanted effects must be prevented or treated. If the child cannot handle the pump (young age, handicap, tiredness) the nurse or sometimes the relative can activate the delivery of bolus after a specific training. The education of the relatives (parents) and the child is essential. This simple and efficacious method of analgesia requires an adequate training of the nursing staff.

[Analgesics in pediatrics. Before prescribing: recognize and evaluate pain, reassure]. / Antalgiques en pédiatrie. Avant la prescription: reconnaître et évaluer la douleur, rassurer.

CAREFUL ASSESSMENT: In pediatric clinics, it has become habitual to prescribe analgesics in all painful situations. Particular attention must be paid to pain experienced by the child and obtaining objective evidence allowing valid assessment prior to treatment. ACUTE PAIN: Usually clearly expressed by crying screams, agitation, retraction and protection of the painful area, signs of acute pain are nonspecific and not proportional to its intensity. PROLONGED PAIN: Sadness and depression confound the expression of prolonged pain. Diagnosis may be difficult; an association between a potentially painful situation, pain relieving positions, and retraction behavior is specific. ESTABLISH CONFIDENCE: For both the child and his family, an atmosphere of confidence and a clear explanation of the lesions and their treatments are essential to break the viscious cycle of pain and anxiety. EXAMINING A CHILD WITH PAIN: Patience is the essence of examining children, facial mimics, reactions, movements and positions all provide essential information. ASSESSING PAIN INTENSITY: Using the visual analogue scale, VAS, children over 5 years of age can show where the pain is on a drawing of the body. For those under 5, questioning the family and looking for specific signs is an essential source of information. The DEGR scale can be used to score prolonged pain in children from 2 to 6 or 8 years of age.

[Analgesics in pediatrics. Drugs for pain relief in children]. / Antalgiques en pédiatrie. Les médicaments de la douleur chez l'enfant.

FUNDAMENTAL: Analgesia is a fundamental part of management as it helps avoid the morbid effects of pain itself and improves confidence so the child and his parents can accept more easily the diagnosis and proposed treatment. The World Health Organization has established a classification of analgesics. USE OF PLACEBOS: The placebo effect depends on several factors including anxiety, confidence, and the patient's- and prescriber's-expectations and convictions). It is observed early in the first years of childhood. Use of placebos is not recommended as a favorable reaction can be interpreted wrongly, disqualifying the complaint. EFFICACY LEVELS: For level 1, paracetamol has little toxicity and is easily managed for first line use; aspirin and nonsteroid antiinflammatory drugs can also be used if there are no contraindications. Level 2 drugs, codeine or dextropropoxyphene (which is not available in a pediatric formulation) are required for any manifestation of pain not relieved by level 1 drugs. Level 3 corresponds to strong central analgesics, mainly morphine. SPECIFIC PAIN: Antispasmodic agents in combination with paracetamol give partial relief of visceral pain without masking symptoms. Local anesthetics improve comfort without compromising safety. Neurogenic pain does not respond to usual analgesics and can be relieved with tricyclic antidepressors for burning sensations or antiepileptic drugs for fulgurant pain. TREATMENT-RELATED PAIN: Iatrogenic pain, by definition, must be systematically anticipated and prevented.

[Ambulatory 24-hour home pH-metry: parental and familial reactions. Prospective study of 100 cases]. / La pHmétrie de 24 heures en ambulatoire à domicile: vécu parental et familial. Etude prospective de 100 cas.

BACKGROUND: The ambulatory twenty-four hour esophageal pHmetry is nowadays a common mode of assessment of gastro-esophageal reflux in children. The aim of this study was to evaluate the impact of the test on child and family's ordinary daily life. MATERIAL AND METHODS: One-hundred children (64 boys, 36 girls) were included in this study during a 10-month period from August 1992 until May 1993. Mean age was 2 years 9 months (range: 22 days--12 years). Forms with a list of questions concerning parental understanding of the test, child's reaction after introduction of the pH-electrode, general reactions in the household, and eventual disturbance of the child's temper and appetite, were given to the parents. Six months later, 81 families were contacted by telephone and asked the same questions. Children were divided into three groups: those under 1 year of age (n = 38), from 1 to 4 years (n = 35), and more than 4 years (n = 27). RESULTS: One child aged 2 months had to be admitted to hospital due to the mother's overanxiety. The majority of parents (80%) assumed they knew about the principles of the test, with little change once the test was over. Those whose child had previously been submitted to the test were less apprehensive. When the test was first initiated, 81% of parents feared it would cause some discomfort, either due to pain (69%), or to poor acceptance at home (25%) with the risk of having the catheter accidently removed. Once the catheter had been positioned with the parents close to the child at that time, its presence was judged by them tolerable in 88.9% of cases. Once at home, 84.8% of the parents were not worried, as the child was calm (83.8%) and also due to the possibility for them to get in touch with the physician if necessary (86.9%). No change in routine daily life was reported by 80.8% of the families; in only 19.2% was the child reported to be overwhelmed with the test. When asked if the test should be undertaken another time, 91.9% would still prefer it as a home procedure, the only families requesting it be done in hospital being those with a history of sudden death syndrome. CONCLUSION: pHmetry test as a 24-hour procedure done at home may be the source of some discomfort and anxiety both to the child and parents; yet it appears to be generally well-accepted, both for its non-aggressive and diagnostic value.

[Pain in children: specific aspects]. / La douleur chez l'enfant: aspects spécifiques.

Childhood pain is still poorly understood, neglected and undertreated. The neurophysiological mechanisms of nociception exist before birth. The experience of pain develops during childhood. Its symptomatology has been detailed: sharp emotional reactions and signs of stress during acute pain, antalgic posture, psychomotor atony and denial when pain is prolonged. Specific tools for evaluation are available. Treatment generally calls for the use of peripheral analgesics, and increased intensity of pain can require administration of morphine.