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Rodieux F, Ivanyuk A, Besson M, Desmeules J, Samer CF. Hydromorphone Prescription for Pain in Children-What Place in Clinical Practice? Front Pediatr 2022; 10:842454. [PMID: 35547539 PMCID: PMC9083226 DOI: 10.3389/fped.2022.842454] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
While morphine is the gold standard treatment for severe nociceptive pain in children, hydromorphone is increasingly prescribed in this population. This review aims to assess available knowledge about hydromorphone and explore the evidence for its safe and effective prescription in children. Hydromorphone is an opioid analgesic similar to morphine structurally and in its pharmacokinetic and pharmacodynamic properties but 5-7 times more potent. Pediatric pharmacokinetic and pharmacodynamic data on hydromorphone are sorely lacking; they are non-existent in children younger than 6 months of age and for oral administration. The current data do not support any advantage of hydromorphone over morphine, both in terms of efficacy and safety in children. Morphine should remain the treatment of choice for moderate and severe nociceptive pain in children and hydromorphone should be reserved as alternative treatment. Because of the important difference in potency, all strategies should be taken to avoid inadvertent administration of hydromorphone when morphine is intended.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Anton Ivanyuk
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Marie Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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2
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Keskin G, Akın M, Şenaylı Y, Öztorun Cİ, Bahçecitapar M. Effects of 5 µg/kg intrathecal morphine for postoperative analgesia in pediatric patients undergoing major surgery. Anaesthesist 2021; 71:212-218. [PMID: 34549311 DOI: 10.1007/s00101-021-01040-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 07/12/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effects and analgesic adequacy of intrathecal morphine (ITM) administration have been studied less frequently than other regional analgesia techniques in pediatric surgical procedures. OBJECTIVE To evaluate the efficacy and adverse event rate of 5 µg/kg ITM administration for postoperative analgesia according to age group. METHODS We retrospectively evaluated the medical records of patients who underwent major pediatric surgery and were administered ITM for postoperative analgesia. Patients were divided into three age groups: ≤ 5 years (group I), 5.1-13 years (group II) and > 13 years (group III). All patients received ITM 5 µg/kg (max 300 μg) through the L4-5 or L5-S1 interspace. Postoperative pain (modified pediatric objective pain score > 4), need for rescue analgesics, sleep interruption due to pain, sedation (Ramsay sedation scale score > 3), opioid-related postoperative adverse events (at 0, 4, 8, 12, and 24 h after intervention), hemodynamic data and nurse satisfaction with the analgesic method were compared between groups. RESULTS The analysis included 100 children (47 girls, 9 ± 5.4 years). Groups were similar regarding postoperative rescue analgesia consumption and sleep interruption (p = 0.238, p = 0.958), 96% of the children did not require rescue analgesia, and sleep interruption was not observed in 97%. Postoperative adverse events were pruritus in 14 and nausea/vomiting in 9 patients (p = 0.052). Overall, nurses were satisfied or very satisfied in 99% of the cases. CONCLUSION Administration of 5 µg/kg ITM can be used for postoperative analgesia in pediatric surgery in all age groups, with no severe adverse events and high nurse satisfaction with analgesic management.
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Affiliation(s)
- Gülsen Keskin
- Clinic of Anesthesiology and Reanimation, Health Sciences University Dışkapı Yıldırım Beyazıt Training and Research Hospital, Üniversiteler mah. 1598 sok. Kümeevleri 17/22, 06800, Ankara, Turkey.
| | - Mine Akın
- Clinic of Anesthesiology and Reanimation, Ankara City Hospital, Ankara, Turkey
| | - Yeşim Şenaylı
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Can İhsan Öztorun
- Department of Pediatric Surgery, Yıldırım Beyazıt University, School of Medicine, Ankara, Turkey
| | - Melike Bahçecitapar
- Department of Statistics, Faculty of Sciences, Hacettepe University, Ankara, Turkey
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3
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Hush SE, Brady C, Soldanska M, Williams JK. Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty. Cleft Palate Craniofac J 2020; 57:1190-1196. [PMID: 32567352 DOI: 10.1177/1055665620932000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We have previously shown the efficacy of an enhanced recovery after surgery (ERAS) protocol in pediatric cleft palatoplasty for proof of concept (POC). We sought to validate the efficacy of ERAS when expanded to patients of variable age and complexity undergoing primary palatoplasty. MAIN OUTCOME MEASURE(S) Between April 2017 and December 2018, 100 patients were collected prospectively for the expanded assessment (ERAS2) and POC (ERAS1) and compared to historical controls both independently and in aggregate (ERAS(T)). We compared patient demographics, perioperative narcotic administration, length of stay (LOS), and rates of return to service (RTS). RESULTS Despite increased complexity, total narcotic usage (morphine equivalents normalized per weight) during each phase of care was significantly greater in controls when compared to ERAS1, ERAS2, or ERAST, respectively (intraoperative: 0.44 mg/kg vs 0.013 mg/kg vs 0.016 mg/kg vs 0.014 mg/kg; postanesthesia care unit: 0.061 mg/kg vs 0.006 mg/kg vs 0.007 mg/kg vs 0.007 mg/kg; postoperative: 0.389 mg/kg vs 0.009 mg/kg vs 0.026 mg/kg vs 0.017 mg/kg). ERAS1 and ERAS2 groups each demonstrated a decrease in LOS (-36.6%, -26.3%) when compared to controls. Overall, application of ERAS led to a 95.7% reduction in narcotic administration and a 31.7% decrease in LOS when compared to controls. The incidence of RTS was higher in ERAS2 (13.0%) when compared to ERAS1 (2.1%) or controls (2.4%), with the strongest independent predictor being a positive perioperative respiratory viral panel (PRVP). CONCLUSIONS Application of ERAS to palatoplasty patients of advanced age and complexity evidenced consistency with respect to decreased perioperative narcotic administration and shortened LOS. A positive PRVP was found to be an independent predictor of RTS even when ERAS was applied.
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Affiliation(s)
- Stefanie E Hush
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Colin Brady
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Magdalena Soldanska
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Joseph K Williams
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
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Shah P, Siu A. Considerations for neonatal and pediatric pain management. Am J Health Syst Pharm 2020; 76:1511-1520. [PMID: 31504147 DOI: 10.1093/ajhp/zxz166] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Current literature and clinical practice guidelines on pediatric pain management are reviewed. SUMMARY Acute pain is commonly present in neonatal and pediatric patients due to underlying disease states or procedures. Especially in institutions with limited pediatric pain services, it is imperative to describe the appropriate management of pain and pharmacotherapy options that are effective and safe in pediatric patients. Despite the knowledge of pain being an important aspect in the management of children, barriers exist, leading to suboptimal treatment. Addressing these barriers through education of healthcare practitioners, families, and patients will lead to optimizing the patient pain experience. Tools for pain assessment vary depending on the type of pain, the child's age and understanding of pain, and the clinical situation. Pharmacotherapy options for pain management in neonates and pediatric patients include opioid and nonopioid agents. Efficacy and safety data on the use of medications for the treatment of pain in pediatric patients is described. The delivery of medication encompasses patient-specific factors and preferences. Strategies for opioid stewardship and management of iatrogenic withdrawal pose a unique challenge in pediatric patients. CONCLUSION The management of acute pain in neonates and pediatric patients should be a priority for all practitioners caring for these patients. Use of age-appropriate pain assessment tools and understanding of the mechanisms of action and roles in therapy of various nonopioid and opioid therapies can help optimize treatment of pain in neonatal and pediatric patients.
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Affiliation(s)
- Pooja Shah
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers University, the State University of New Jersey, Piscataway, NJ, and Department of Clinical Pharmacy Services, Hackensack University Medical Center, Hackensack, NJ
| | - Anita Siu
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers University, the State University of New Jersey, Piscataway, NJ, and Department of Clinical Pharmacy Services, Jersey Shore University Medical Center, Neptune, NJ
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Abstract
Anesthetic management of pediatric orthopedic patients is uniquely challenging. Approach to the pediatric patient must consider heightened preoperative anxiety and its postoperative behavioral and pain effects. Frequent respiratory infections can complicate timing of surgery and anesthetic care. Perioperative pain management usually involves a multimodal pharmacologic approach with the goal of minimizing opioid requirements. Regional anesthesia is valuable for postoperative pain control. Safety of its use in the pediatric population has been confirmed in recent studies. Included for discussion are fractures, slipped capital femoral epiphysis, club foot, and scoliosis.
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Affiliation(s)
- Jeffrey P Wu
- Department of Anesthesiology, Jersey Shore University Medical Center, 1945 Route 33, Neptune, NJ 07753, USA.
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Implementation of a Modified Enhanced Recovery Protocol in Cleft Palate Repairs. J Craniofac Surg 2019; 30:2154-2158. [DOI: 10.1097/scs.0000000000005718] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Synthesis and anti-inflammatory activity evaluation of novel 3-alkyl-6-(4H-1,2,4-triazol-4-yl)-3,4-dihydro-2H-benzo[e][1,3]oxazine derivatives. Med Chem Res 2016. [DOI: 10.1007/s00044-016-1679-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Liu DC, Gong GH, Wei CX, Jin XJ, Quan ZS. Synthesis and anti-inflammatory activity evaluation of a novel series of 6-phenoxy-[1,2,4]triazolo[3,4- a ]phthalazine-3-carboxamide derivatives. Bioorg Med Chem Lett 2016; 26:1576-1579. [DOI: 10.1016/j.bmcl.2016.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 02/01/2016] [Accepted: 02/04/2016] [Indexed: 11/25/2022]
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Hildenbrand AK, Nicholls EG, Daly BP, Marsac ML, Tarazi R, Raybagkar D. Psychosocial and Pharmacological Management of Pain in Pediatric Sickle Cell Disease. Postgrad Med 2015; 126:123-33. [DOI: 10.3810/pgm.2014.03.2748] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Kocum AI, Sener M, Caliskan E, Bozdogan N, Micozkadioglu D, Yilmaz I, Aribogan A. Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study. Braz J Otorhinolaryngol 2013; 79:89-94. [PMID: 23503913 PMCID: PMC9450869 DOI: 10.5935/1808-8694.20130015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 10/15/2012] [Indexed: 11/20/2022] Open
Abstract
Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. Objective In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. Method 120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/ or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. Results No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. Conclusion Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.
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Affiliation(s)
- Aysu Inan Kocum
- Departamento de Anestesiologia e Reanimação, Universidade Baskent, Turkey
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Addition of Clonidine in Caudal Anesthesia in Children Increases Duration of Post-Operative Analgesia. Trauma Mon 2012. [DOI: 10.5812/traumamon.3393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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13
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Affiliation(s)
- Marcia L Buck
- Department of Pharmacy Services, University of Virginia Children's Hospital, Charlottesville, Virginia, and Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia
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Sohn VY, Zenger D, Steele SR. Pain Management in the Pediatric Surgical Patient. Surg Clin North Am 2012; 92:471-85, vii. [DOI: 10.1016/j.suc.2012.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lak M, Araghizadeh H, Shayeghi S, Khatibi B. Addition of clonidine in caudal anesthesia in children increases duration of post-operative analgesia. Trauma Mon 2012; 16:170-4. [PMID: 24749095 PMCID: PMC3989567 DOI: 10.5812/kowsar.22517464.3393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Revised: 11/20/2011] [Accepted: 11/25/2011] [Indexed: 11/20/2022] Open
Abstract
Background: Pain in infancy is a developmental process. Due to the underdeveloped pain pathways in the spinal cord, the threshold of stimulation and sensation of pain is low at birth and has potential impacts on increasing the central effects of pain. Primary trauma during infancy can cause long term changes in structure and function of pain pathways that continue until adulthood. Lack of pain management in children can result in morbidity and mortality. Objectives: In this study we examined the duration of post-operative analgesia in children when clonidine is added to bupivacaine in caudal anesthesia. Materials and Methods: In this clinical trial, 40 children aged 1-8 years who were candidates for elective inguinal hernia repair were studied. Induction and maintenance of anesthesia were achieved using sodium thiopenthal, halothane and nitrous oxide. Children were randomly divided into 2 groups in a double-blind fashion, and were given caudal anesthesia with 0.125% bupivacaine (1ml/kg) alone or b bupivacaine plus 2 μg/kg clonidine. Blood pressure and heart rate were recorded peri-operatively. Analgesia was evaluated using objective pain scale (OPS) and sedation was assessed using Ramsay sedation scale (RSS). Acetaminophen was administered rectally for cases with OPS score greater than five. Results: Duration of analgesia was found to be significantly longer in the group given bupivacaine plus clonidine (mean 417.50 min vs. 162.00 min). Peri-operative hypotension or bradycardia, post-operative respiratory depression, nausea or vomiting were not recorded in any patient. Conclusions: We concluded that addition of clonidine to bupivacaine prolongs the duration of post-operative analgesia without any respiratory or hemodynamic side-effects.
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Affiliation(s)
- Marzieh Lak
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Marzieh Lak, Trauma Research Center, Baqiyatallah University of Medical Sciences Tehran, IR Iran, Tel: +98-9125262585, Fax: +98-88053766, E-mail:
| | - Hasan Araghizadeh
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Shahnas Shayeghi
- Department of Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Behroz Khatibi
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Breast Milk Hydrocodone and Hydromorphone Levels in Mothers Using Hydrocodone for Postpartum Pain. Obstet Gynecol 2011; 117:611-617. [DOI: 10.1097/aog.0b013e31820ca504] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
Pediatric neurologists frequently treat acute pain in children. A broad range of medication options is available including nonsteroidal anti-inflammatory drugs, opioids, and other analgesic adjuvants, such as antidepressants and antiepileptics. This article reviews the physiology underlying the experience of pain and compares the pharmacologic mechanisms and properties of these medications, providing a framework for developing effective multimodal medical treatment approaches to pain in children.
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Affiliation(s)
- F Wickham Kraemer
- Department of Anesthesiology and Critical Care, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA.
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Synthesis and anti-inflammatory activity evaluation of some novel 6-alkoxy(phenoxy)-[1,2,4]triazolo[3,4-a]phthalazine-3-amine derivatives. Eur J Med Chem 2010; 45:4807-12. [DOI: 10.1016/j.ejmech.2010.07.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 07/24/2010] [Accepted: 07/28/2010] [Indexed: 11/17/2022]
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Paediatric investigation plans for pain: painfully slow! Eur J Clin Pharmacol 2010; 66:1091-7. [DOI: 10.1007/s00228-010-0886-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 08/11/2010] [Indexed: 10/19/2022]
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