Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery

A bibliometric analysis of research on pediatric preoperative anxiety (2007-2022)

Objective

This study aimed to analyze the current state of research on preoperative anxiety in children through CiteSpace, VOSviewer, and the identification of hot spots and frontiers.

Method

Relevant data were retrieved from the Web of Science Core Collection using the search terms children and preoperative anxiety. Data were analyzed using VOSviewer (version 1.6.18), CiteSpace (5.7. R5) software, and Scimago Graphica.

Results

A total of 622 articles were published between 2007 and 2022, with an increasing trend over time. Kain, Zeev N. (13; 2.09%) and Dalhousie University (15; 2.41%) were the most influential authors and most prolific institutions, respectively. The United States (121; 19.45%) was the country with the most publications. Pediatric anesthesia (55; 8.84%) had the most publications. High-frequency keywords were categorized into three themes, including nonpharmacologic interventions for preoperative anxiety in children, preoperative medications, and risk factors for anxiety; of these, "predictor" (38; 2016) and "sedative premedication" (20; 2016) were the most studied keywords over the past 6 years. "Distraction" (67; 2019) and "dexmedetomidine" (65; 2019) have been the main areas of interest in recent years.

Conclusion

Research on preoperative anxiety in children has been the focus of increasing attention over the past fifteen years, with the majority of publications from high-income countries. This review provides a useful perspective for understanding research trends, hot topics, and research gaps in this expanding field.

The effects of primary and recurrent pediatric urological surgeries on parental anxiety levels

INTRODUCTION

Invasive diagnostic and therapeutic procedures in pediatric urology may generally cause distress and pain in children. As a result, it may have a negative effect on adult and child behaviors. The anxiety, depression levels or distress and fear status caused by recurrent diseases or repetitive medical interventions in adult patients or the parents of pediatric patients have been investigated previously.

OBJECTIVE

To the best of our knowledge, we have not found a study evaluating the effects of primary or recurrent pediatric urological operations on parental anxiety. Our main aim was to compare the effects of primary and repetitive pediatric urological surgeries on the anxiety levels of both mothers and fathers. We also aimed to investigate the effects of other factors related to parents and children on parental anxiety.

DESIGN

A total of 163 patients under 14 years old who had undergone primary or recurrent pediatric urological operations and also their parents were included in a prospective, cross-sectional study. Demographic and clinical data of the patients and their parents were recorded. Before the surgeries, the Children's Fear Scale was applied to all patients over 3 years old and the State-Trait Anxiety Inventory was applied to all parents. The participants were divided into two main groups: primary surgery group (n:84) and recurrent surgery group (n:79). A subgroup analysis was performed according to surgery type (day surgery, minor surgery and major surgery).

RESULTS

We found that repetitive surgeries, higher fear scores of children, parents' being younger, having low education level, not having enough information about the surgeries and presence of someone in the immediate vicinity who previously experienced the same surgery increased parental anxiety levels. Day surgeries did not affect fathers' state anxiety levels as much as minor and major surgeries, whereas mothers' state anxiety levels were higher than fathers' regardless of the surgery type. Children's fear level was not affected by child age, gender, surgery type or previous history of surgery.

DISCUSSION

The majority of studies in the literature show no significant difference in terms of pain and fear levels in pediatric patients undergoing repeated diagnostic interventions but there are contradictory results about parental anxiety levels. There is also a lack of studies on the effects of recurrent surgeries.

CONCLUSION

According to our findings, repetitive surgeries and presence of someone who previously experienced the same surgery are the most significant predictive factors increasing parental anxiety levels.

Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children

BACKGROUND

Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications.

OBJECTIVES

To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications.

SEARCH METHODS

We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates.

MAIN RESULTS

We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence).

AUTHORS' CONCLUSIONS

For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.

Influence of preoperative information support on anxiety, pain and satisfaction with postoperative analgesia in children and adolescents after thoracic surgery: A randomized double blind study

AIMS/BACKGROUND

The proportion of patients who experience anxiety prior to planned surgery, even a minimally invasive one, is estimated at 50-70%. Thoracic surgery, causes significant preoperative anxiety, especially in children. The aim of this study was to determine the effect of an important component of psychological preparation for a surgery as information support on levels of anxiety, pain and satisfaction with postoperative analgesia.

METHODS

The randomized double blind study including patients aged 9-18 years qualified for lateral thoracotomy or Ravitch procedure. The subjects were randomized to the control group (n=56) provided with a routine preoperative information by a nurse, and the experimental group (n=56) offered additional psychological consultation. Data were collected via the State-Trait Anxiety Inventory.

RESULTS

In the experimental group, the level of state anxiety at 48 h post-surgery was significantly lower than prior to the procedure, but only in subjects with preoperative trait anxiety Conclusion: Information support from a psychologist offered prior to a thoracic surgery decrease the level of postoperative state anxiety solely in children with lower levels of trait anxiety. Higher level of postoperative state anxiety negatively affect patients' satisfaction with post-surgical analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov; Influence of Preoperative Support on Anxiety, Pain and Satisfaction With Postoperative Analgesia; NCT03488459, https://clinicaltrials.gov/ct2/show/record/NCT03488459?cntry=PL&city=Rabka-Zdr%C3%B3j&rank=1.

Cold Dissection Tonsillectomy and Radiofrequency Tonsil Ablation: A Prospective Comparative Study

<b><i>Background:</i></b> Over the last few years, various techniques have been proposed for performing tonsillectomy in an attempt to lower the morbidity of this surgery. However, controversy still exists regarding the optimal technique involving the least postoperative morbidity. More recently, temperature-controlled radiofrequency has been introduced as a much more effective and safe device for tonsil reduction. <b><i>Objective:</i></b> To compare the effectiveness of conventional tonsillectomy versus radiofrequency tonsil ablation with respect to duration of surgery, amount of intraoperative bleeding, recovery time, and postsurgical pain. <b><i>Materials and Methods:</i></b> 60 patients were randomly divided into two groups. One group underwent conventional cold ablation tonsillectomy while radiofrequency tonsillectomy was performed in the second group. Duration of surgery, amount of intraoperative bleeding, recovery time, and postsurgical pain (using the Wong-Baker FACES Pain Rating Scale®) were measured. All patients were followed for 24 months. <b><i>Results:</i></b> Comparing the radiofrequency tonsillectomy group to the cold dissection tonsillectomy group, the mean duration of surgery was 6.92 versus 18 min, the amount of intraoperative bleeding was 2.75 versus 39.88 mL, and the difference on the postoperative pain scale between the two groups was statistically significant (<i>p</i> &#x3c; 0.005). There was no recurrence of tonsillitis episodes in either of the 2 groups during the 2-year follow-up period. <b><i>Conclusion:</i></b> After adequate training, the radiofrequency technique is beneficial to both the surgeon and the patient, including the possibility to excise tissue and coagulate bleeding vessels with the same device. Postoperative morbidity and complications are lower as compared to the conventional cold dissection technique.

Comparing Cold/Liquid Diet vs Regular Diet on Posttonsillectomy Pain and Bleeding

Objective Tonsillectomy is a common operation; however, there are controversial opinions regarding the posttonsillectomy diet. The aim of this study was to compare the effects of cold/liquid diet vs regular diet on posttonsillectomy pain and bleeding. Study Design Prospective randomized controlled trial. Setting Tertiary referral center. Subjects and Methods In total, 194 children who underwent tonsillectomy (with or without adenoidectomy) were randomly allocated into 2 groups. A total of 100 patients were allocated in the cold/liquid diet, and 94 patients were allocated in the regular diet group. Pain score was recorded for the first 7 days, and rate of hemorrhage was recorded for 10 days after surgery. Results The participants' age range was 3 to 17 years. The mean pain score level in the regular diet group after breakfast, lunch, and dinner was not statistically significant in comparison with the cold/liquid diet group. One patient in the regular diet group was admitted to the hospital due to secondary bleeding, but it stopped without any intervention. Conclusion Most otolaryngologists believe in dietary restrictions following tonsillectomy. However, there is much controversy regarding posttonsillectomy dietary advice in the literature. In addition, only a few randomized clinical trials have focused on this subject. We found that there was no difference between regular diet and cold/liquid diet in terms of posttonsillectomy pain and bleeding. Hence, we do not recommend a limited posttonsillectomy diet.

Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing

BACKGROUND

Recent evidence has challenged the practice of tonsillectomy in children with sleep-disordered breathing. Tonsillotomy (subtotal/partial/intracapsular tonsillectomy) has been proposed as an alternative with equivalent effectiveness and decreased post-operative morbidity, thus improving cost-effectiveness.

OBJECTIVE

To systematically review the literature comparing clinical efficacy, post-operative morbidity, and cost-effectiveness of tonsillotomy and tonsillectomy in paediatric (<16yo) patients with sleep-disordered breathing.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, and CENTRAL (1984-July 2014) was conducted. Papers in English directly comparing post-operative outcomes in tonsillectomy and tonsillotomy in children undergoing surgery for sleep-disordered breathing were included.

REVIEW METHODS

Two authors independently assessed abstracts for relevance, with disagreements resolved by a third author. Selected studies were independently assessed regarding inclusion and exclusion criteria.

RESULTS

Thirty-two studies satisfied inclusion and exclusion criteria (19 randomised, 13 non-randomised). Patient satisfaction, quality-of-life, and polysomnographic improvement post-surgery did not vary between tonsillotomy and tonsillectomy. Tonsillotomy reduced the odds of a secondary haemorrhage by 79% (OR 0.21, 95% CI 0.17-0.27, p < 0.01), decreased post-operative pain and reduced return to normal oral intake by 2.8 days (95% CI 1.08-4.52, p < 0.01). The odds of readmission were decreased by 62% (OR 0.38, 95% CI 0.23-0.60, p < 0.01). Tonsillotomy had a slightly higher rate of symptom recurrence (4.51%) than tonsillectomy (2.55%), the long-term impact of which was unclear.

CONCLUSION

Current evidence supports tonsillotomy in children with obstructive surgical indications. It is likely to reduce post-operative haemorrhage, pain, and facilitate a faster return to normal diet and activity. Healthcare burden is decreased due to fewer post-operative complications and reduced need for medical re-contact. More research is necessary to assess the risk of recurrence, and further classification of secondary haemorrhage severity is required to fully clarify the clinical benefit of tonsillotomy.

Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-2016

The objective of this study was to describe factors affecting pain after pediatric tonsil surgery, using patient reported pain-related outcome measures (pain-PROMs) from the National Tonsil Surgery Register in Sweden. In total, 32,225 tonsil surgeries on children (1 to <18 years) during 2009-2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE ± A), and 18,321 tonsillotomies with or without adenoidectomy (TT ± A). Adjustments were made for variables included in the register to compensate for contributable factors in the analysis. When compared to TE ± A for surgical indication obstruction, TT ± A resulted in lower pain-PROMs, shorter use of postoperative analgesics, earlier return to regular food intake, and lower risk for contact with health care services due to pain. Children who underwent TE ± A because of obstruction problems stopped taking painkillers and returned to normal eating habits sooner, compared to children who underwent TE ± A for infectious indications. In both indication groups, TE ± A performed with hot rather than cold technique (dissection and haemostasis) generally resulted in higher pain-PROMs. Older children reported more days on analgesics and a later return to regular food intake after TE ± A than younger ones. No clinically relevant difference between sexes was found. Between 2012 and 2016 (pre-and post-implementation of Swedish national guidelines for pain treatment), the mean duration of postoperative analgesic use had increased. In conclusion, TE ± A caused considerably higher ratings of pain-related outcome measures, compared to TT ± A. For TE ± A, cold surgical techniques (dissection and haemostasis) were superior to hot techniques in terms of pain-PROMs. Older children reported higher pain-PROMs after TE ± A than younger ones.

Self-reported postoperative recovery in children after tonsillectomy compared to tonsillotomy

OBJECTIVES

Tonsil surgery is associated with significant morbidity during recovery. Patient-reported outcome measures (PROM) are the golden standard for the planning and follow-up of delivered care, which should also be an axiom for children. The current aims were to describe self-reported postoperative recovery in children after tonsil surgery, and to compare tonsillotomy and tonsillectomy in this respect.

METHODS

In total, 238 children (4-12 years old) with a history of obstructive problems and/or recurrent tonsillitis, and undergoing tonsil surgery were included. Forty-eight per cent were operated with partial tonsil resection/tonsillotomy (TT) and 52% with total tonsillectomy (TE), all in day surgery. Postoperative recovery was assessed on days 1, 4 and 10 using the validated self-rating instrument PRiC, Postoperative Recovery in Children. This includes 23 items covering different aspects of recovery after tonsil surgery. A higher score indicates worse status in the respective items.

RESULTS

Daily life activities (sleeping, eating and playing), physical symptoms (e.g., headache, stomach ache, sore throat, otalgia, dizziness, nausea, defecation, urination), and emotional aspects (sadness, frightening dreams) were affected during the recovery period. The TE-girls showed higher scores than the boys regarding stomach ache, defecation and dizziness. Children above 6 years of age reported higher values for the physical comfort variables, while the younger group showed worse emotional states. Postoperative recovery improved from day 1-10 in all surgical groups. The TE-group showed lower recovery compared to the TT-group (p < 0.01-0.001) in most items.

CONCLUSION

The goal of postoperative management is to minimize or eliminate discomfort, facilitating the recovery process and avoiding complications. Children are able to describe their recovery, and thus, PRiC seems to be able to serve as a PROM to obtain patient-centered data after tonsil surgery. The recovery process after TT causes less postoperative morbidity and a quicker return to normal activity compared to TE.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Comparative Effectiveness of Partial versus Total Tonsillectomy in Children

Objective To assess the effectiveness of partial versus total tonsillectomy in children. Data Sources MEDLINE, EMBASE, and Cochrane Library from January 1980 to June 2016. Review Methods Two investigators independently screened studies and extracted data. Investigators independently assessed risk of bias and strength of evidence of the literature. Heterogeneity precluded quantitative analysis. Results In 16 eligible randomized controlled trials (RCTs), definitions of "partial" tonsillectomy varied. In addition to comparing partial with total tonsil removal, 11 studies compared surgical techniques (eg, coblation). In studies comparing the same technique, return to normal diet or activity was faster with partial removal (more favorable outcomes in 4 of 4 RCTs). In studies with differing surgical techniques, return to normal diet and activity was faster with partial versus total tonsillectomy (more favorable outcomes in 5 of 6 studies). In 3 of 4 RCTs, partial tonsillectomy was associated with more throat infections than total tonsillectomy. Differences between groups were generally not statistically significant for obstructive symptom persistence, quality of life, or behavioral outcomes. Across all studies, 10 (6%) of roughly 166 children had tonsillar regrowth after partial tonsillectomy. Conclusions Data do not allow firm conclusions regarding the comparative benefit of partial versus total removal; however, neither surgical technique nor extent of surgery appears to affect outcomes markedly. Partial tonsillectomy conferred moderate advantages in return to normal diet/activity but was also associated with tonsillar regrowth and symptom recurrence. Effects may be due to confounding given differences in populations and surgical approaches/techniques. Heterogeneity and differences in the operationalization of "partial" tonsillectomy limited comparative analyses.

Indications for tonsillectomy stratified by the level of evidence

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children

OBJECTIVE

To conduct a systematic review of the factors predicting anticipatory distress to painful medical procedures in children.

METHODS

A systematic search was conducted to identify studies with factors related to anticipatory distress to painful medical procedures in children aged 0-18 years. The search retrieved 7,088 articles to review against inclusion criteria. A total of 77 studies were included in the review.

RESULTS

31 factors were found to predict anticipatory distress to painful medical procedures in children. A narrative synthesis of the evidence was conducted, and a summary figure is presented.

CONCLUSIONS

Many factors were elucidated that contribute to the occurrence of anticipatory distress to painful medical procedures. The factors that appear to increase anticipatory distress are child psychopathology, difficult child temperament, parent distress promoting behaviors, parent situational distress, previous pain events, parent anticipation of distress, and parent anxious predisposition. Longitudinal and experimental research is needed to further elucidate these factors.

Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children Undergoing Elective Circumcision: A Prospective Cohort Study

BACKGROUND

Although circumcision for phimosis in children is a minor surgical procedure, it is followed by pain and carries the risk of increased postoperative anxiety. This study examined predictive factors of postoperative pain and anxiety in children undergoing circumcision.

METHODS

We conducted a prospective cohort study of children scheduled for elective circumcision. Circumcision was performed applying one of the following surgical techniques: sutureless prepuceplasty (SP), preputial plasty technique (PP), and conventional circumcision (CC). Demographics and base-line clinical characteristics were collected, and assessment of the level of preoperative anxiety was performed. Subsequently, a statistical model was designed in order to examine predictive factors of postoperative pain and postoperative anxiety. Assessment of postoperative pain was performed using the Faces Pain Scale (FPS). The Post Hospitalization Behavior Questionnaire study was used to assess negative behavioral manifestations.

RESULTS

A total of 301 children with a mean age of 7.56 ± 2.61 years were included in the study. Predictive factors of postoperative pain measured with the FPS included a) the type of surgical technique, b) the absence of siblings, and c) the presence of postoperative complications. Predictive factors of postoperative anxiety included a) the type of surgical technique, b) the level of education of mothers, c) the presence of preoperative anxiety, and d) a history of previous surgery.

CONCLUSIONS

Although our study was not without its limitations, it expands current knowledge by adding new predictive factors of postoperative pain and postoperative anxiety. Clearly, further randomized controlled studies are needed to confirm its results.

WITHDRAWN: Diclofenac for acute pain in children

At December 2014, this review has been withdrawn from the Cochrane Library. This review is out of date, although it is correct at the date of publication. The review may be misleading as new studies could alter the original conclusions. All previous versions of the review can be found in the ‘Other versions’ tab. We are seeking additional authors to support the updating of this review. For further information, please contact PaPaS Managing Editor, Anna Hobson [Contact Person].

The editorial group responsible for this previously published document have withdrawn it from publication.

Tonsillectomy versus tonsillotomy for sleep-disordered breathing in children: a meta analysis

Objectives

Tonsillotomy has gained popular acceptance as an alternative to the traditional tonsillectomy in the management of sleep-disordered breathing in children. Many studies have evaluated the outcomes of the two techniques, but uncertainty remains with regard to the efficacy and complications of tonsillotomy versus a traditional tonsillectomy. This study was designed to investigate the efficacy and complications of tonsillotomy versus tonsillectomy, in terms of the short- and long-term results.

Methods

We collected data from electronic databases including MEDLINE, EMBASE, and the Cochrane Library. The following inclusion criteria were applied: English language, children, and prospective studies that directly compared tonsillotomy and tonsillectomy in the management of sleep disordered breathing. Subgroup analysis was then performed.

Results

In total, 10 eligible studies with 1029 participants were included. Tonsillotomy was shown to be advantageous over tonsillectomy in short-term measures, such as a lower hemorrhage rate, shorter operation time, and faster pain relief. In long-term follow-up, there was no significant difference in resolution of upper-airway obstructive symptoms, the quality of life, or postoperative immune function between the tonsillotomy and tonsillectomy groups. The risk ratio of SDB recurrence was 3.33 (95% confidence interval = 1.62 6.82, P = 0.001), favoring tonsillectomy at an average follow-up of 31 months.

Conclusions

Tonsillotomy may be advantageous over tonsillectomy in the short term measures and there are no significant difference of resolving obstructive symptoms, quality of life and postoperative immune function. For the long run, the dominance of tonsillotomy may be less than tonsillectomy with regard to the rate of sleep-disordered breathing recurrence.

Perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures: a quantitative systematic review

AIMS

To examine the relationship between perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures and the differences in children's perioperative anxiety and postoperative pain among subgroups of demographics.

BACKGROUND

While anxiety and pain are regarded as two common problems experienced by children and adolescents perioperatively and the relationship between them has been reported in previous studies, there has been no review paper examining this phenomenon.

DESIGN

A quantitative systematic review.

DATA SOURCES

Nine electronic databases were searched for studies published in English from the inception date of the databases to December 2010, using various combinations of search terms of 'adolescents', 'anxiety', 'child', 'pain', 'surgery' and 'correlation/relationship'.

REVIEW METHODS

Using the Joanna Briggs Institute's comprehensive systematic review strategies, relevant studies were independently appraised and extracted by two reviewers using the standardized critical appraisal instruments and data extraction tool from Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument.

RESULTS

Ten studies were included in this review from 943 studies initially retrieved. Children and adolescents who had higher level of perioperative anxiety experienced a higher level of postoperative pain. Inconclusive evidence was found regarding differences of perioperative anxiety and postoperative pain between demographic subgroups of gender, age and past surgical experience.

CONCLUSION

Results of this review inform healthcare providers of the role perioperative anxiety plays on children's and adolescents' postoperative pain and indicate the need to use interventions to reduce perioperative anxiety and, therefore, optimize their postoperative pain management during the perioperative period.

Exploring influencing factors of postoperative pain in school-age children undergoing elective surgery

PURPOSE

The purpose of this study was to examine the influencing factors of postoperative pain among children undergoing elective surgery.

DESIGN AND METHODS

A survey was conducted in 2011 with a convenience sample of 66 children, 6 to 14 years old, in a tertiary hospital in Singapore.

RESULTS

Children experienced moderate preoperative anxiety and postoperative pain. Gender, preoperative anxiety, and negative emotional behaviors were significant influencing factors for postoperative pain. Boys reported less postoperative pain than girls.

PRACTICE IMPLICATIONS

Effective strategies for assessing and managing children's preoperative anxiety are needed to achieve an optimal postoperative pain management outcome.

Radiofrequency tonsillotomy versus bipolar scissors tonsillectomy for the treatment of OSAS in children: a prospective study

INTRODUCTION

Tonsillotomy is an effective treatment for the management of obstructive sleep apnoea syndrome (OSAS) in children with tonsillar hypertrophy and appears to be associated with less pain and postoperative morbidity.

OBJECTIVE

To compare postoperative morbidity and short-term and intermediate-term efficacy of radiofrequency tonsillotomy (TT) and bipolar scissors tonsillectomy (TE) in children.

PATIENTS AND METHODS

Children with OSAS due to tonsillar hypertrophy were included in a prospective, non-randomized study between February 4, 2008 and March 20, 2010. Exclusion criteria were recurrent tonsillitis (≥ 3 episodes per year), clotting disorders and age less than 2 years. Postoperative complications, efficacy on OSAS, and operating times were evaluated. Pain was evaluated by the Postoperative Pain Measure for Parents score on D0, D1, D7 and D30.

RESULTS

One hundred and ninety-three children were included: 105 in the TE group (age: 4.75 ± 2.37 years) and 88 in the TT group (age: 4.88 ± 2.6 years). The pain score was significantly lower in the TT group than in the TE group during the first postoperative week (P<0.05). A significant difference was observed for the secondary postoperative bleeding rate (1 after TT versus 8 after TE). No significant difference was observed between the two techniques in terms of the efficacy on OSAS. At 1 year, the tonsil regrowth rate in the TT group was 4.5%.

CONCLUSION

Radiofrequency tonsillotomy is a safe technique for the treatment of obstructive tonsillar hypertrophy in children with good results on OSAS and a reduction of postoperative pain.

Tonsillectomy care for the pediatrician

Pediatricians play an important role in the perioperative care of hospitalized children after tonsillectomy and are often called upon to manage posttonsillectomy problems in the outpatient setting. The tonsillectomy operation has changed in recent years. More children are operated upon for sleep disordered breathing and fewer for recurrent pharyngitis. New instruments now permit less invasive surgery. Systematic reviews by the Cochrane Collaboration and others have helped define best practices for preoperative assessment and postoperative care. This article will outline these practices as defined in the 2011 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline "Tonsillectomy in Children." It will describe the different tonsillectomy operations, discuss patterns of normal healing, and review management of pain and posttonsillectomy hemorrhage to form a foundation for improved pediatric care.

Anxiety and pain in children undergoing elective surgical procedures: a systematic review

BACKGROUND

Anxiety and pain are two significant problems experienced by children undergoing elective surgical procedures, which may lead to suboptimal postoperative outcomes. Previous studies have shown a correlation between perioperative anxiety and pain in children.

OBJECTIVES

This review aimed to present the best available evidence on the correlation between perioperative anxiety and pain in children undergoing elective surgical procedures, and to determine the relationship between children's demographics, their anxiety and pain level in the perioperative period.

INCLUSION CRITERIA

Participants were children aged between five to 18 years old who were scheduled for an elective surgical procedure in the hospital setting.No specific intervention was of interest. So long as the primary studies examined correlation of children's anxiety and pain in the perioperative period, they were considered for inclusion.This review focused on children's preoperative level of anxiety; children's postoperative level of anxiety; children's postoperative pain intensity; and/or children's postoperative behavioural changes.This review included quantitative research studies, such as randomised-controlled trials, cohort studies, and descriptive studies which addressed the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. The following databases were searched for articles published in English from the inception date of databases to December 2010: CINAHL, PubMed, Scopus, PsycINFO, Mednar, Trip Database, ProQuest Dissertations and Theses, Scirus ETD and Web of Science.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed independently by two reviewers for methodological quality prior to inclusion in the review using standardised critical appraisal tools from Joanna Briggs Institute. There were no disagreements between the two reviewers, so the third reviewer was not required.

DATA EXTRACTION

Data were extracted using the standardised data extraction tools: the Joanna Briggs Institute Meta-Analysis Statistics Assessment and Review Instrument (JBI-MAStARI) for randomised-controlled trials, cohort studies, and descriptive/case series.

DATA SYNTHESIS

Since the ten included studies used various study designs and outcome measures for the levels of anxiety and pain, this made meta-analysis impossible and therefore the findings were summarised and presented in narrative form.

RESULTS

This review included two randomised-controlled trials, two cohort studies, five observational descriptive studies and one descriptive survey study. Eight studies revealed that children who had higher levels of pre- and post-operative anxiety experienced a higher level of post-operative pain. Pearson correlation coefficients of these eight studies were reported in the findings, with coefficients ranging between r = 0.29 (p < 0.05) to r = 0.57 (p < 0.001). There is no conclusive evidence supporting the relationships of children's demographics characteristics (i.e. gender, age and past surgical experience) and their perioperative anxiety and pain.

CONCLUSION

Children who had higher levels of pre- and post-operative anxiety experienced a higher level of post-operative pain. The review results inform healthcare providers of the role perioperative anxiety plays on paediatric postoperative pain.This evidence serves to generate implications for clinical practice and future studies in order to better manage children's perioperative anxiety and eventually improve their postoperative pain management. However, this review revealed insufficient evidence supporting the correlation between children's demographic data, namely gender, age and past surgical experience and their perioperative anxiety and pain.

IMPLICATIONS FOR PRACTICE

Children's perioperative anxiety should be routinely assessed prior to procedures in the clinical setting. This review also recommends that interventions be developed and implemented so as to reduce pain and anxiety for children during the perioperative period.

IMPLICATIONS FOR RESEARCH

Future studies are needed to examine the effectiveness of different interventions in reducing children's perioperative anxiety and pain, and to examine the relationship between anxiety and pain in other settings and countries. Future research should also be directed towards developing a reliable, shorter and practical anxiety assessment tool.

Are randomised controlled trials involving adenotonsillectomy well reported?

INTRODUCTION

Evidence-based medicine guides clinical practice. Currently, the evidence base on adenotonsillectomy is under scrutiny to establish clinical guidelines. It is therefore important that reports of clinical trials are of high quality. Guidance on reporting of randomised controlled trials (RCTs) are available in the Consolidated Standards for Reporting Trials (CONSORT) statement first published in 1996 and revised in 2001 and 2010.

METHODS

A review of randomised controlled trials on adenotonsillectomy published after 2001 was undertaken. Each report was systematically assessed using the checklist of items from the CONSORT statement.

RESULTS

Twenty-five trials were identified. All trials, except one, were identified as a randomised controlled trial by title or abstract. Twenty percent of trials reported a sample size calculation. A third of trials reported their method of generating a random allocation sequence. Similarly, a third stated the method of implementing the random allocation. A fifth of trials reported a clear flow of trial participants, with only a single trial reporting this with the aid of a diagram.

CONCLUSION

This review shows the quality of reporting needs to be improved. Critical appraisal of poorly reported trials may result in erroneous conclusions, even though these trials may have been carried out with rigorous adherence to a protocol of high standard. Authors of clinical trial reports should be encouraged to consult the CONSORT statement.

The use of nonpharmacological methods for children's postoperative pain relief: Singapore nurses' perspectives

PURPOSE

The purpose of this study was to examine nurses' use of nonpharmacological methods for school-age children's postoperative pain relief.

DESIGN AND METHODS

A survey was conducted in 2008 with a convenience sample of 134 registered nurses from 7 pediatric wards in Singapore.

RESULTS

Nurses who were younger, had less education, lower designation, less working experience, and no children of their own used nonpharmacological methods less frequently.

PRACTICE IMPLICATIONS

Nurses need training and education on nonpharmacological pain relief methods, particularly on methods that have been shown to be effective in prior research but that were less often used by nurses in this study: massage, thermal regulation, imagery, and positive reinforcement.

Psychometric assessment of the Emotional Reactions Instrument-Korean (ERI-K) to measure Korean children's emotional reaction to hospitalization

The purpose of this study was to test psychometric properties of the Emotional Reactions Instrument-Korean (ERI-K). A convenience sample of 170 hospitalized Korean children was recruited. Each child was asked to describe how she or he felt during hospitalization, through the ERI-K and the Facial Affective Scale. Surprisingly, children reported lower levels of negative emotions and physical discomfort and a moderate level of positive emotion (Happy, Good). Internal consistency reliability of .88 for the 14-item scale provides strong support for reliability. Construct validity was supported by item-to-total correlations ranging between .42 and .65. Exploratory factor analysis identified two factors that explained 54% of the variance. Further testing of the ERI-K is recommended to provide additional evidence of psychometric adequacy across Korean populations.

Therapeutic acetaminophen is not associated with liver injury in children: a systematic review

BACKGROUND

Concern exists about the potential for liver injury with therapeutic dosing of acetaminophen in children.

OBJECTIVE

We systematically reviewed the medical literature to determine the rate at which liver injury has been reported for children prescribed therapeutic doses of acetaminophen (≤75 mg/kg per day orally or intravenously or ≤100 mg/kg per day rectally).

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials to locate all studies in which acetaminophen was administered to a defined pediatric population for ≥24 hours and for all case reports of liver injury after therapeutic acetaminophen dosing. Trained reviewers extracted data from each report. Major and minor hepatic adverse events (AEs) were defined prospectively. Causality was assessed by using the Naranjo algorithm.

RESULTS

A total of 62 studies that enrolled 32,414 children were included. No child (0% [95% confidence interval: 0.000-0.009]) was reported to have exhibited signs or symptoms of liver disease, to have received an antidote or transplantation, or to have died. Major or minor hepatic AEs were reported for 10 children (0.031% [95% confidence interval: 0.015-0.057]). The highest transaminase value reported was 600 IU/L. Naranjo scores (2-3) suggested "possible" causation. Twenty-two case reports were identified. In 9 cases, the Naranjo score suggested "probable" causation (5-6).

CONCLUSIONS

Hepatoxicity after therapeutic dosing of acetaminophen in children is rarely reported in defined-population studies. Case reports suggest that this phenomenon may occur, but few reports contain sufficient data to support a probable causal relationship.

A systematic review of faces scales for the self-report of pain intensity in children

CONTEXT

Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.

OBJECTIVES

To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility.

METHODS

Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori.

RESULTS

From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS.

CONCLUSIONS

For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.

Children's tonsillectomy experiences: influencing factors

The aim of this study was to explore factors influencing children's (7-13 years) tonsillectomy experiences and outcomes. A prospective, repeated measures, design was used to investigate the effect of age, gender, ethnicity, time, and previous pain, hospitalization and surgery on children's (N = 60) perceptions of anxiety, pain intensity, quality of pain and sleep, and oral intake. The relationship between postoperative pain and anxiety was also examined. Using a diary, three days of data were collected. Descriptive statistics, Pearson correlation coefficient, and a mixed linear regression model were used for analysis. Children's tonsillectomy experiences and outcomes were affected by time, previous experience, age, and anxiety. Moderate correlations were found between level of anxiety and pain intensity. These findings provide clinicians with additional knowledge to guide their perioperative practice and care of children.

Making sense out of the tonsillectomy literature

BACKGROUND

With the increase in new technology and changing indications for tonsillectomy, the literature has exploded during the last 20 years with scores of publications reporting the relative effectiveness of many different techniques. Despite this "wealth of information," no single technique has been adopted by most surgeons.

OBJECTIVES

To systematically analyze the usefulness of this literature of the past 20 years concerning tonsillectomy technique in children. To propose the use of specific study parameters that could optimize clinical decision-making and future research.

METHODS

Detailed review of the methodologies and findings in articles which compared one or more tonsillectomy techniques in clinical trials of children, ages 1-23 years from 1987 through 2007.

RESULTS

The Medline search revealed 255 papers of which 89 studies were suitable for inclusion in our review. In these 89 studies (found in 87 papers), 9 dissection techniques, 3 planes of dissection, 8 methods of hemostasis, and 41 different outcome measures were reported. Forty-four (49%) were described as randomized, 63 (71%) prospective, 25 retrospective (28%), 1 case report, 1 matched pair, and 9 case series papers. Sixteen (18%) trials were non-blind, 23 (26%) were single blind, 17 (19%) were double blind, and 7 (8%) were not stated. Seventy-five (84%) were comparative and 14 (16%) non-comparative. Eight (9%) studies reported power analyses. Twelve (13%) had no follow-up; 67 (75%) of the studies performed had short-term follow-up in the peri-operative period; 10 (11%) had follow-up for greater than 1 year. Eleven (12%) mentioned outcomes related to the effectiveness of the procedure itself in relieving symptoms for which the surgery was done.

CONCLUSIONS

Tonsillectomy technique research is of obvious interest to the otolaryngologist. We found deficits in: the precise reporting of surgical techniques, adequate study design and useful outcome measures, all of which make the literature less useful than it could be. Guidelines for study design parameters which could lead to more valuable information for the clinician are suggested.

Diclofenac for acute pain in children

BACKGROUND

Diclofenac is commonly used for acute pain in children, but is not licensed for this indication in all age groups.

OBJECTIVES

1) Assess the efficacy of diclofenac for acute pain in children. 2) Assess the safety of diclofenac for short-term use in children. 3) Identify gaps in the evidence to direct future research.

SEARCH STRATEGY

Seventeen databases indexing clinical trial reports were searched in February 2005 (with an update search as part of this first review in May 2008). A hand search of Paediatric Anaesthesia was undertaken and summaries obtained of adverse reaction reports from the UK Yellow Card Scheme and World Health Organization (WHO) Monitoring Centre. The reference lists of included studies were also searched.

SELECTION CRITERIA

Any published report, in any language, involving the administration of diclofenac to a patient aged 18 years or younger for acute pain and detailing either monitoring of efficacy or safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted the data. Authors were contacted where necessary. Review Manager version 5 was used for analysis.

MAIN RESULTS

1) EFFICACY: randomised controlled trials (RCTs) comparing diclofenac with placebo/any other treatment by using pain scores (assessed or reported), or need for rescue analgesia.2) SAFETY: any type of study seeking adverse events (regardless of cause). An adverse event was defined as any reported adverse or untoward happening to a patient being treated with diclofenac for acute pain.Seven publications on diclofenac efficacy and 79 on safety (74 studies plus five case reports) were included in the final analysis. Compared with placebo/no treatment, diclofenac significantly reduced need for post-operative rescue analgesia (relative risk [RR] 0.6; number needed to treat to benefit [NNT] 3.6; 95% confidence interval [CI] 2.5 to 6.3).Compared with any other non-NSAID, patients receiving diclofenac suffered less nausea or vomiting, or both (RR 0.6; NNT 7.7 [5.3 to 14.3]). There appeared to be no increase in bleeding requiring surgical intervention in patients receiving diclofenac in the peri-operative period. Serious diclofenac adverse reactions occurred in fewer than 0.24% of children treated for acute pain. The types of serious adverse reactions were similar to those reported in adults.

AUTHORS' CONCLUSIONS

Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required.

Child behavior and quality of life before and after tonsillotomy versus tonsillectomy

OBJECTIVES

Compare two techniques for pediatric tonsil surgery with respect to postoperative pain and morbidity and changes in sleep behavior, health related quality of life (HRQL) and benefits due to surgery.

METHODS

67 children (4.5-5.5 years) with tonsillar hypertrophy and obstructive sleep-disordered breathing with or without recurrent tonsillitis were randomized to either regular tonsillectomy (TE) (n=32) or intracapsular tonsillectomy/tonsillotomy (TT) (n=35) with Radiofrequency surgical technique (ellman Int.). Before TT/TE, the parents completed a validated Quality of Life survey of pediatric obstructive sleep apnea, the OSA-18 (Obstructive Sleep Apnea-18) and a standardized assessment of their children's behavior with the Child Behavior Checklist (CBCL). Six months after surgery, the parents repeated these measurements, and assessed the health related benefits of the surgery using the Glasgow Children's Benefit Inventory (GCBI).

RESULTS

In the TT group, the children recorded less pain from the first day after surgery onwards, used fewer doses of painkillers and were pain-free 3 days earlier than the children in the TE group. Six months after surgery, there were no significant difference between TT and TE with regard to snoring and ENT-infections. The differences in the total scores and in all the individual domains between the initial OSA-18 and post-surgery scores were all significant (P<0.0001). The improvement in the total problem score measured with CBCL was also significant (P<0.01) and there was no difference between the TT and TE children. The improvements in all subscores of the GCBI indicated a significant health benefit of both TT and TE.

CONCLUSIONS

TT with RF-surgery causes less pain and postoperative morbidity than regular TE and has an equal effect on snoring and recurrent infections. Pre-school children with tonsillar hypertrophy and obstructive sleep-disordered breathing all show an impact on HRQL and behavior before surgery and improve dramatically just as much after TT as after TE. Therefore TT would be considered for treatment of small children.

Perioperative management of children with obstructive sleep apnea

Obstructive sleep apnea syndrome (OSA) affects 1%-3% of children. Children with OSA can present for all types of surgical and diagnostic procedures requiring anesthesia, with adenotonsillectomy being the most common surgical treatment for OSA in the pediatric age group. Thus, it is imperative that the anesthesiologist be familiar with the potential anesthetic complications and immediate postoperative problems associated with OSA. The significant implications that the presence of OSA imposes on perioperative care have been recognized by national medical professional societies. The American Academy of Pediatrics published a clinical practice guideline for pediatric OSA in 2002, and cited an increased risk of anesthetic complications, though specific anesthetic issues were not addressed. In 2006, the American Society of Anesthesiologists published a practice guideline for perioperative management of patients with OSA that noted the pediatric-related risk factor of obesity, and the increased perioperative risk associated with adenotonsillectomy in children younger than 3 yr. However, management of OSA in children younger than 1 yr-of-age was excluded from the guideline, as were other issues related specifically to the pediatric patient. Hence, many questions remain regarding the perioperative care of the child with OSA. In this review, we examine the literature on pediatric OSA, discuss its pathophysiology, current treatment options, and recognized approaches to perioperative management of these young and potentially high-risk patients.

The effect of preoperative fasting on postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy

OBJECTIVE

The aim of this prospective randomized study was to examine whether active counseling and more liberal oral fluid intake decrease postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy.

METHODS

Families, whose child was admitted for ambulatory tonsillectomy or adenotonsillectomy, were randomly assigned to the study groups (n=116; 58 families in each group). The intervention group received the fasting instructions with face-to-face counseling for the child's active preoperative nutrition, and the control group the fasting instructions according to the hospital's standard procedure. The level of postoperative pain and nausea was scored in the postanesthesia care unit (PACU) during the first postoperative hour, as well as at 2, 4, 8 and 24h postoperatively. The first scoring in PACU was performed by the attending nurse with a 0-10 scale. The rest of the estimations were made independently and simultaneously by the children using a VAS scale, and by the parents using a 0-10 scale.

RESULTS

The children in the control group were in more pain in the PACU than the children in the intervention group, and the difference between the groups was statistically significant (p=0.0002). All pain scores, according to the children and the parents, increased after the surgery. In both groups the highest score values were found at home 8h after surgery, and no significant difference was found between the study groups. On the first postoperative morning, the children in the control group were in pain (p=0.047). The children did not have significant nausea in the PACU, but the nausea increased postoperatively. Four hours after surgery the children were most nauseous according to all estimations (60%, n=116). More than half of the children vomited and most vomited clotted blood. Nausea and vomiting decreased during the evening of the surgery, but six children vomited the next morning, four of them vomited blood. The incidence and intensity of postoperative nausea and vomiting between the intervention and control groups were not statistically significant. However, preoperative nutritional counseling and more liberal per oral fluid intake appeared to have a positive effect on the children's well-being and helped them to better tolerate postoperative nausea and vomiting.

CONCLUSIONS

The preoperative counseling about active preoperative nutrition significantly reduces the child's pain during the first posttonsillectomy hours and might prepare the child to better tolerate the stress of potential postoperative nausea and vomiting.

Children's pre-operative tonsillectomy pain education: clinical outcomes

OBJECTIVE

To examine the effects of pre-operative tonsillectomy pain education on children's (7-13 years) self-reported pre-operative anxiety and post-operative clinical outcomes (i.e., anxiety, pain intensity, quality of pain and sleep, oral intake, perceptions of pre-operative education, and pain expectation).

METHOD

A prospective, repeated measures, quasi-experimental design using an age appropriate pain education booklet (n = 30) and a standard care comparison group (n = 30) was employed to investigate children's pre- and post-education anxiety and post-operative tonsillectomy with or without adenoidectomy subjective experiences in the hospital and home settings. Group comparisons were performed using the Wilcoxon test, Fisher's exact test, repeated measures analysis of variance, and mixed model regression.

RESULTS

There were no significant differences between groups for measures of anxiety, pain intensity, quality of pain and sleep, oral intake, or expected pain. There was no change in anxiety before or after pre-operative education (P = 0.85). Ninety-six percent (n = 25) of the children in the intervention group reported that pre-operative pain education helped with their post-operative pain and 72% (n = 16) in the control group stated that it would be helpful to learn about pain before surgery. The majority of children in both the intervention and control groups (96%, 91%, respectively) stated learning about the 0-10 numeric pain intensity scale helped or would be helpful to learn pre-operatively.

CONCLUSION

Pre-operative pain education did not affect anxiety. Children valued pre-operative pain education. Pre-operative pain education may influence children's perceptions of medical care.

Tonsillectomy versus tonsillotomy performed with scissors in children with tonsillar hypertrophy

OBJECTIVE

We sought to determine the morbidity and the short and long-term effectiveness of tonsillotomy (partial tonsillectomy) performed with scissors compared with conventional cold knife (total) tonsillectomy.

METHODS

We conducted a 2-year prospective non-randomized study at a tertiary children's hospital. One thousand and twenty-three children were recruited (243 in the tonsillotomy and 780 in the tonsillectomy group). Age, sex, weight, and time of operation, immediately post-operative complications and pain were recorded. Eighteen months after the operation data on weight, parents' satisfaction and recurrence of obstructed symptoms was obtained in 60 randomly selected children of each group.

RESULTS

Post-operative complications rates were very low in both groups and their differences did not reach statistical significance. However, tonsillotomies were significantly better than tonsillectomies in relation to post-operative pain the 1st (P<0.001) and the 7th (P<0.001) post-operative day, and lasted an average of 2.5 min less. Concerning long-term effects, both methods resulted in an increase of patients' weight without the difference in weight increase be statistically significant. In addition, parents' satisfaction as well as oral malodour do not seem to differ significantly. Finally, although twice as many children in the tonsillotomy group had a recurrence of snoring compared to tonsillectomy group, only in about half of them was the problem regarded significant enough by their parents to require medical consultation or reoperation. At the end, an estimated 3.5% of the tonsillotomy group was offered a tonsillectomy in the long term.

CONCLUSION

This trial shows that scissors tonsillotomy in combination with an adenoidectomy is a viable therapeutic option with less immediate post-operative morbidity than tonsillectomy in young children whose sleep disorder breathing is due to a combination of tonsilar and adenoid hypertrophy. However, parents should be informed of the possibility of regrowth and reoperation.

Long-Term Improvement of Quality of Life as a Result of Tonsillotomy (With Radiofrequency Technique) and Tonsillectomy in Youths

OBJECTIVE

This is a 1 year follow-up to compare the effects of partial tonsil resection using the radiofrequency technique (RF) tonsillotomy (TT) with total tonsillectomy (TE) (blunt dissection). Obstructive symptoms, tendency for infections, and health-related quality of life (HRQL) were studied and compared with the HRQL data from a normal population.

METHOD

The study group consisted of 74 patients (16-25 yr old) randomized to TT (n = 31) or TE (n = 43) with obstructive throat problems with or without recurrent tonsillitis. The Short Form 36 (SF-36) and EuroQul Visual Analogue Scale were used to evaluate HRQL. A questionnaire investigated the degree of obstruction and history of infections.

RESULTS

Preoperatively, both groups reported significantly lower HRQL in all dimensions of the SF-36 compared with the normal population (P < .05-P < .001). After 1 year, a large improvement (P < .01-P < .001) in both groups in HRQL was found. No differences were found when these groups were compared with the normal population or between the study groups. The effect on snoring was the same for both groups, and the rate of recurrence of infections was low and not any higher in the TT group.

CONCLUSION

Preoperative obstructive problems in combination with recurrent tonsillitis have a negative impact on HRQL. Both the TT and TE groups demonstrated large improvements on HRQL, infections, and obstructive problems 1 year after surgery, indicating that the surgical methods are equally effective. With its reduced postoperative complications, less pain, shorter recovery time, and cost reduction, TT with RF should be considered the method of choice.

The development of snoring and sleep related breathing distress from 4 to 6 years in a cohort of Swedish children

BACKGROUND

Snoring is common among both children and adults and a sign of sleep disordered breathing (SDB). Adenotonsillectomy is often the solution offered, although the effect is uncertain. There are also some who say that young children who snore will outgrow it even without treatment. The present investigation compares snoring and co-founding symptoms in parental reports for a cohort of children at age 4 and at age 6 years.

METHOD

A cohort of 4 year old chidren (615) was investigated with respect to SDB [B. Löfstrand-Tideström, B. Thilander, J. Ahlqvist-Rastad, O. Jakobsson, E. Hultcrantz, Breathing obstruction in relation to craniofacial and dental arch morphology in 4 year old children, Eur. J. Orthod. 21 (1999) 323-332]. Each child was given a questionnaire. Those reporting significant symptoms also received a clinical and an orthodontic examination. Forty-eight children were diagnosed with SDB; of these 28 were operated with adenoidectomy and/or tonsillectomy. After 2 years, the same questionnaire was administered and the same children as before were further examined as well as those newly reporting significant symptoms. The results from the two occasions were compared.

RESULTS

Eighty-three percent (509) of the original cohort participated. The frequency of snoring had changed from 53 to 46% for the group as a whole (p<0.05). Significant gender differences in co-founding symptoms were seen. Severity of snoring had changed on an individual basis in half of the cases; some recovered, others got worse. Of the children with SDB at 4 years who were operated, 14/28, did not snore at all, compared to 3/18 of the non-operated (p<0.05).

CONCLUSION

Children who snore at the age 4 seldom "grow out of it" by age 6 and still show other signs of sleep related distress as well. Surgery does not always cure the snoring, thus postoperative follow-up is important. Since new cases develop during this age period, early intervention is not enough.

Tonsil Surgery in Youths: Good Results With A Less Invasive Method

OBJECTIVE

Comparison of two types of tonsil surgery for 16- to 25-year-old patients, with respect to primary morbidity, snoring, and recurrent infections after 1 year. Teenagers and young adults are a significant proportion (26%) of the population that receive tonsil surgery each year and appear to suffer more pain than younger children. Recurrent tonsillitis, in combination with obstructive problems, is the main indication for surgery.

METHOD

One hundred fourteen patients 16 to 25 years of age were randomized to tonsillotomy (TT) with radiosurgery (RF) (Ellman International) or to cold tonsillectomy (TE). Pain and analgesics were logged until patients were pain free.

RESULTS

Thirty-two patients were operated on with TT and 44 with TE. The TT group had less blood loss during surgery and no postoperative bleedings, compared with the TE group (2 primary and 4 late hemorrhages). The TT group recorded significantly less pain from the first day, had less need of analgesics (diclofenac and paracetamol), and were pain free and in school/at work 4 days earlier than the TE group. After 7 days, the TE patients had lost a mean of 1.8 kg compared with TT, with no significant weight loss. After 1 year, both groups were satisfied. The positive effect on snoring was the same for both groups. There were few throat infections in both groups.

CONCLUSION

TT with RF is an effective method for tonsil surgery for many teenagers and young adults, with much less postoperative morbidity than regular TE. Long-term follow-up is necessary.