Opioids for Pediatric Pain Management.

OBJECTIVES: To study the efficacy and adverse effects of opioids in management of pain in children. METHODS: A descriptive study was conducted in children aged below 15 years with moderate to severe pain, and response to opioids and adverse effects were assessed at 24, 48 and 72 hours after administration. RESULTS: 100 children (68% males) with median (IQR) age of 6.5 (3.5,10) years were studied. 81% (n=81) children with moderate pain and 78.9% (n=15) with severe pain responded to opioids in 72 hours. Among children with severe pain of non-malignant origin, 80% (n=8) responded in 48 hours compared to 11.1% (n=1) with malignancy and this difference was statistically significant at 24 hours (P=0.005). Of children with severe pain 73.7% (n=14) developed adverse reactions compared to 30.9% (n=25) with moderate pain. CONCLUSIONS: Children with moderate-severe pain, either of malignant or non-malignant origin could be managed effectively with opioids without severe adverse effects.

Congenital syphilis: Need for intensification of antenatal screening and clinician awareness.

Congenital syphilis occurs due to trans-placental transmission of Treponema pallidum or rarely, intrapartum contact with infectious lesions. Even though preventable, congenital syphilis occurs sporadically in India, owing to lack of antenatal screening as well as the lack of awareness among clinicians about the burden of syphilis in the community. Since a significant overlap of clinical manifestations exists with many systemic diseases, awareness among clinicians is crucial for an early diagnosis. Renomegaly, nephrotic syndrome and nephritis can all be the signs of renal involvement in congenital syphilis, which can provide clues of the diagnosis. Direct invasion by spirochetes, hypersensitivity reactions and immune complex deposition in glomeruli contribute to the pathogenesis. We report a case of congenital syphilis characterised by delayed diagnosis with renal as well as cutaneous manifestations from missed maternal syphilis during the antenatal period and owing to the lack of antenatal screening.

Clinical profile of measles in children with special reference to infants.

This study was conducted to analyse the clinical characteristics of measles in infants and to compare them with those in older children. Clinical and sociodemographic details of all hospitalised children with suspected measles were recorded and confirmed cases were analysed further. Twenty-four infants and 34 children aged >1 year were included. Most infants were boys and 15 (62.5%) of them were aged <9 months. Early onset of rash (within three days of fever in 62.5% of cases) occurred in infants. The complications of measles in infants included bronchopneumonia (n = 17, 71%), acute diarrhoea (n = 8, 33%), meningitis (n = 1, 4%) and staphylococcal sepsis (n = 2, 8%). The number of infants with complications was significantly high (88% and 65%; P = 0.05). Measles in infants can have atypical presentations, a greater risk for complications and may occur before they are due to receive the conventional first dose of measles vaccine.

Breaking Bad News - Perceptions of Pediatric Residents.

The present study evaluated the perceptions and practice of 92 final year pediatric residents with regard to breaking bad news. Only 16% of residents had received any training in communication skills. Majority (65%) of the residents were not comfortable while breaking bad news.

Snake bite mortality in children: beyond bite to needle time.

OBJECTIVE: To study the clinical characteristics and predictors of mortality from snake bite envenomation in children. DESIGN: Prospective observational study with a one-group cohort design. SETTING: Paediatric intensive care unit of a tertiary care hospital in South India. SUBJECTS: The study cohort consisted of 145 children (55 girls and 90 boys) <12 years of age with snake bite envenomation. METHODS: Demographic and clinical details were recorded in a semistructured pro forma. Children were treated with polyvalent antisnake venom (ASV) as per WHO protocol. Details of treatment, complications and outcomes were recorded. Univariate analysis was done to identify statistical significance, and those variables found to be significant were analysed using binary logistic regression. RESULTS: Russell's viper was the most common offending snake followed by hump-nosed pit viper. Features of haemotoxicity, neurotoxicity and combined haemotoxicity and neurotoxicity occurred in 68 (47%), 39 (26.9%) and 9 (6%) children, respectively. Acute kidney injury (AKI) occurred in 36 (25%) children. The mortality rate was 10.3%. On univariate analysis, nocturnal bites, severe leucocytosis on day 1, AKI, capillary leak syndrome and a need for more than 20 vials of ASV were significantly associated with mortality. On multivariate analysis, only severe leucocytosis on day 1 (OR 35.29; 95% CI 1.37 to 911.89) and AKI (OR 35.05 95% CI 1.74 to 706.93) were found to be independent predictors of mortality. CONCLUSIONS: This study has identified two hitherto unrecognised risk factors-severe leucocytosis on day 1 and capillary leak syndrome. These findings need to be taken into consideration when planning management strategies for snake bite envenomation in children.

Prevalence and spectrum of sexual abuse among adolescents in Kerala, South India.

OBJECTIVE: To study the prevalence and spectrum of sexual abuse among adolescents in Kerala, South India. METHODS: A self- report survey was conducted among adolescents in the 15-19 y age group, studying in the plus one and plus two classes in selected schools. RESULTS: Of the 1614 respondents (688 boys and 926 girls), 36 % of boys and 35 % of girls had experienced sexual abuse at some point during their lifetime. Most instances were sexual advances while using public transport. Feelings of insecurity and isolation at home, of being disliked by parents and of being depressed were significantly more in adolescents who had experienced sexual abuse, compared to those who had not. CONCLUSIONS: Sexual abuse is widely prevalent and both boys and girls are equally susceptible. There is a need to evolve strategies to protect children from sexual abuse and the programmes should address both boys and girls.

Prevention of mother to child transmission of hepatitis B infection.

The likelihood of developing chronic hepatitis B infection and its complications is most when infection is transmitted vertically. Awareness of the current recommendations for managing babies of mothers who are hepatitis B carriers is not universal, resulting in failure of follow up, despite the serious long term implications, including development of hepatic carcinoma. We review the current guidelines of managing babies born to mothers who are hepatitis B carriers.

Effectiveness of communication skills training on perceptions and practice of pediatric residents.

OBJECTIVE: To assess the effectiveness of a structured communication skills training workshop on the perceptions and practice of pediatric residents. METHODS: The perceptions and practice of pediatric residents with regard to doctor- patient (parent) communication were evaluated before and 6 weeks after a communication skills training workshop, using a structured questionnaire. RESULTS: Twenty pediatric residents participated in the study. They included nine residents who had completed 1 year of pediatric training and 11 residents who had completed 2 years or more of pediatric training. 9 were female residents and 11 were males. Before the intervention, majority of the residents rated themselves poorly on assessment of their perceptions and practice of communication skills. After the workshop there was overall improvement in the communication skills of the residents. CONCLUSIONS: Communication skills of pediatric residents are generally inadequate. Structured training programs will help to improve their communication skills. There is a need to incorporate communication skills training in the pediatric postgraduate curriculum.

Deliberate self harm in children.

OBJECTIVE: To study the nature of deliberate self-harm (DSH) in children and to identify the associated factors. SETTING: Child Guidance Clinic attached to the Department of Pediatrics of a teaching hospital in South India. SUBJECTS: Children with history of deliberate self harm who were referred to the CGC for psychological evaluation during a 10 year period. METHODS: Children and parents were interviewed together and separately and details regarding age, sex, family and school environment, stresses and nature of self harm were documented. Psychiatric diagnosis was made based on DSM IV diagnostic criteria. RESULTS: Among the 30 children included in the study, 21 were boys and 9 were girls. Majority of children were between the ages of 11 and 13 years, the youngest being 6 years old. 76%of children had history of acute stressful life events and 62%of them had chronic ongoing stress. 62%of children had stress in the family and 41%had stress at school. Stress in the family included death of a parent, conflicts with parents or siblings, mental illness in the family, parental alcoholism and parental disharmony. Stress at school included conflicts with classmates, punishment or negative comments by teachers and learning problems. Psychiatric disorders were present in 52%of children, the commonest being depressive disorder. The commonest mode of DSH was self poisoning, and rat poison (zinc phosphide) was the commonest substance used. CONCLUSIONS: Deliberate self harm occurs in young children and the risk factors are comparable to those in adolescents.

Management of pain in leukemic children using the WHO analgesic ladder.

OBJECTIVE: To ascertain the effectiveness of WHO analgesic ladder in pain management in children with leukemia. METHODS: Children with leukemia who were referred to a pain and palliative care clinic attached to the Department of Pediatrics of a medical teaching hospital during a period of 6 months were included in the study. RESULTS: Thirty nine (39) children, who constituted 64% of children on treatment for leukemia, required referral to pain and palliative care services during the study period. Of these 92% had Acute Lymphocytic Leukemia (ALL) and 8% had Acute Non Lymphocytic Leukemia (ANLL). 95% of children had nociceptive pain and 5% had neuropathic pain. Step - 1 analgesia was effective in 12 (31%) children and 21 (54%) could be managed with Step - 2 analgesia. Step - 3 analgesia was required in only 6 (15%) children. Step 3 analgesia was required in children with neuropathic pain and bone pain. CONCLUSION: WHO analgesic ladder is effective in managing pain in children with leukemia. Majority of cases of cancer pain in children could be managed by the treating physician using non-opioids, weak opioids and adjuvants as per the WHO guidelines. Children with bone pain and neuropathic pain may require referral to specialist services and use of strong opioids like morphine. The study emphasizes the need for establishing specialist pain management services in all centres where children with cancer are treated.

Intrathecal tetanus immunoglobulins in the management of tetanus.

OBJECTIVE: To study the clinical profile, treatment and outcome of tetanus in children treated with intrathecal tetanus immunoglobulin. (TIG) METHODS: Retrospective analysis of hospital records of tetaus cases admitted to the pediatric ICU during the five year period between 1999 to 2004 was done. RESULTS: There were 66 cases of tetanus treated with intrathecal TIG. Children below 5 years formed 53% of cases and 47% were above 5 years. Totally unimmunized children constituted 82% of cases and 18% partially immunized children. The portal of entry was otogenic in 58% of cases and injury in30% of cases. The common complications observed included thrombophlebitis, aspiration pneumonia, laryngospasm and autonomic system involvement. There were no complications specific to intrathecal administration of TIG. The mortality due to tetanus was 9%. DISCUSSION: Mortality and morbidity due to tetanus was less in the present study compared to other centers where TIG is given intramuscularly. CONCLUSION: Intrathecal TIG is effective in the treatment of mild and moderate tetanus. Randomized controlled clinical trials are needed to evaluate the efficacy of intrathecal TIG in the management of severe tetanus.

Clinical profile of depressive disorder in children.

The aim of this retrospective study was to evaluate the risk factors, clinical features and co-morbid disorders of depressive disorder in children below the age of 12 years. Children who attended the child guidance clinic between January 2000 and December 2003 formed the subjects for the study. The diagnosis of depressive disorder was based on DSMIV diagnostic criteria for Major Depressive Disorder, Single episode. There were 26 boys and 19 girls. Stress at school and in the family was significantly associated with depressive disorder. Children with depressive disorder had significantly more family members affected with mental illnesses. The clinical features included diminished interest in play and activities, excessive tiredness, low self- esteem, problems with concentration, multiple somatic complaints, behavior symptoms like anger and aggression, recent deterioration in school performance and suicidal behavior. Majority of children had other associated psychiatric disorders which included dysthymic disorder, anxiety disorders, conduct disorder and conversion disorder.

Effectiveness of individualized education program for slow learners.

OBJECTIVE: To evaluate the effectiveness of an individualized education program for children with scholastic backwardness. METHODS: Among the children attending a Child Guidance Clinic for scholastic backwardness, 12 of them who were diagnosed as slow learners based on current level of academic functioning and IQ and 6 children having mild mental retardation were given individualized education for a period of two months. Independent assessors evaluated the academic functioning at the beginning of the training and at the end. RESULTS: The results showed that the children had significant improvement in their academic functioning and self esteem after the training. CONCLUSION: The present experiment can be a model to set up a resource room in normal schools to provide individualized education to children who are slow learners.

Deliberate self-poisoning in children.

This prospective study was aimed to analyze the nature of and the factors associated with deliberate self-poisoning in children below the age of 12 years. Children referred to the Child Guidance Clinic for evaluation after recovery from the effects of poisoning during the five-year period between 1999 and 2003 formed the subjects of the study. The children were evaluated for stress factors, psychiatric disorders and the nature and mode of deliberate self-poisoning. Deliberate self-poisoning constituted 0.9% of total admissions due to poisoning. There were 10 boys and 2 girls between the ages of 9 and 12 years. Both acute and chronic stress in the family and school were associated with deliberate self-poisoning. Majority of them had psychiatric disorders. Rat poison (zinc phosphide) was the commonest poison used. Two children got the idea from watching TV serials.