Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Current pediatric pain practice in Nigeria, South Africa, Uganda, and Zambia: A prospective survey of anesthetists

BACKGROUND

Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub-Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub-Saharan African countries.

METHODS

A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices.

RESULTS

One hundred and sixty-six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient-controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty-eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting.

CONCLUSION

This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non-pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques.

Postoperative Morbidity after Dental Treatment under General Anesthesia in Children with and without Disabilities

Background and Objectives: General anesthesia induces reversible unconsciousness, eliminating sensation and enabling painless medical procedures. Vital for dental care, it addresses patients with medical conditions, those needing extensive procedures, and those unable to cooperate due to fear. Dental care for patients with disabilities is a significant unmet need, with studies showing increased oral disease prevalence. This research aims to analyze postoperative morbidity both in healthy and disabled children undergoing dental procedures under general anesthesia. Materials and Methods: This study involved 96 children aged 3 to 15 with dental caries. Two groups were formed: the control group (CTL) (52.94%) included healthy patients requiring general anesthesia due to unsatisfactory cooperation, and the other group included children with physical or intellectual disabilities (CD) (47.96%). Postoperative complications were monitored 1 h after the procedure and 1, 3, 7, and 14 days after the procedure by contacting parents/caregivers by phone. The intensity of postoperative pain was assessed using the Wong-Baker faces pain rating scale. General anesthesia was conducted following a standardized protocol for dental procedures. Results: CTL patients complained more often about postoperative pain 1 h after the procedure (p = 0.03). One day after the procedure, oral bleeding (p = 0.04), fever (p = 0.009), and diarrhea (p = 0.037) occurred more often in CD. In the same period, sore throat appeared more often in CTL (p = 0.036). Three days after the dental treatment, there were statistically significant increases in the occurrence of agitation (p = 0.043) and constipation (p = 0.043) in CD. Seven days later, CD demonstrated a higher occurrence of agitation (p = 0.037). According to the Wong-Baker faces pain rating scale, CTL experienced more frequent and intense pain. Conclusions: CD more frequently reported complications like oral bleeding, fever, and diarrhea. In contrast, the CTL group more often reported pain-related symptoms. The conclusion underscores the need for a pain control protocol for CD and emphasizes the importance of frequent monitoring to prevent unwanted consequences during tooth restoration under general anesthesia.

Clinical case report of intractable paroxysmal sympathetic hyperactivity in TANGO2 deficiency disorder

TANGO2 deficiency disorder (TDD) is a neurodegenerative disease characterized by a broad and variable spectrum of clinical manifestations, even among individuals sharing the same pathogenic variants. Here, we report a severely affected individual with TDD presenting with intractable paroxysmal sympathetic hyperactivity (PSH). While progressive brain atrophy has been observed in TDD, PSH has not been reported. Despite comprehensive workup for an acute trigger, no definite cause was identified, and pharmacological interventions were ineffective to treat PSH. Ultimately care was redirected to comfort measures. This article expands the clinical phenotype of patients with TDD, highlights the possibility of PSH in these patients, and the need for continued research for better treatments of TDD.

The management of paediatric acute pain in Spain in 2021: Results of a national survey among paediatric anaesthesiologists

OBJECTIVE

To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain.

METHODS

A telematic survey was conducted via the Internet on a representative sample of healthcare professionals involved in the management of paediatric acute pain (specifically anaesthesiologists) in Spain. The survey included 28 questions about their usual clinical practice in the assessment and treatment of acute pain, and also training and organisational aspects in paediatric acute pain.

RESULTS

The survey was completed during March 2021 by 150 specialists in anaesthesiology. The respondents widely experienced in the management of acute paediatric pain (mean years of experience: 14.3: SD: 7.8), essentially in acute postoperative pain (97% of cases). Although 80% routinely used validated paediatric acute pain assessment scales, only 2.6% used specific scales adapted for patients with cognitive impairment. Most of the respondents routinely used analgesic drugs such as paracetamol (99%) or metamizole (92%), but only 84% complemented these drugs with a loco-regional blocking technique or other non-steroidal anti-inflammatory drugs (62%). Furthermore, only 62.7% acknowledged having received specific training in paediatric acute pain, only 45% followed hospital institutional protocols, and a scant 28% did so through paediatric pain units.

CONCLUSIONS

The survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients.

Timeline of diagnosed pain causes in children with severe neurological impairment

Objective

Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children.

Methods

We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0-24 months), preschool children (3-5 years), schoolchildren (6-12 years), and adolescents (13-17 years).

Results

Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001).

Conclusions

Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.

A systematic review of self and observer assessment of pain and related functioning in youth with brain-based developmental disabilities

ABSTRACT

Pain experiences of youth with brain-based developmental disabilities are often overlooked and/or misinterpreted, increasing the risk for poor or inadequate pain assessment and management. Ample measures exist to assess acute and chronic pain, yet their utility and frequency of use in youth with brain-based developmental disabilities is unclear and available measures do not have strong measurement properties for this diverse group. This systematic review identified the scope of self-reported and observer-reported pain assessment in studies of youth (aged 3-24 years) with brain-based developmental disabilities (phase 1) and summarized other measures of pain-related functioning for acute and chronic pain (ie, physical, emotional, social, sleep, and quality of life, within the subset of quantitative studies focused primarily on pain, phase 2). A comprehensive search for English-language studies was conducted in August 2022 in Web of Science, CINAHL, MEDLINE, Cochrane CENTRAL, EMBASE, and APA PsychINFO (PROSPERO registration: CRD42021237444). A total of 17,029 unique records were screened. Of the 707 articles included in phase 1, most assessed chronic pain (n = 314; 62.0%) and primarily used observer-report (n = 155; 31%) over self-report (n = 67; 13%). Of the 137 articles included in phase 2, other outcomes assessed alongside pain intensity included motor ability (16.8%), adaptive functioning (11%), quality of life (8%), pain interference (6.6%), mental health (5.8%), and communication ability (2.9%). Cerebral palsy was the most common population in both phase 1 (n = 343; 48.5%) and phase 2 (n = 83; 59.7%). This review provides a foundational understanding of pain assessment in brain-based developmental disabilities and highlights continued inequities in holistic pain assessment for this population.

Challenging Case: A Multidisciplinary Approach to Demystifying Chronic Sleep Impairment in an Infant with a Complex Medical and Behavioral Profile

CASE

X is a 22-month-old White male infant with a complex medical history, including diagnoses of FBXO11 mutation, hypotonia, restrictive lung disease and mild intermittent asthma, laryngotracheomalacia, obstructive sleep apnea (OSA), feeding difficulties with a history of aspiration, gastroesophageal reflux disease (GERD), and developmental delays. X's medical presentation has resulted in multiple prior medical admissions for respiratory failure due to acute illnesses, procedures and treatments including gastrojejunostomy (GJ) tube dependence, supraglottoplasty to reshape tissues of the upper larynx, and the use of biphasic positive airway pressure (BiPAP) at night and room air during the day when he is at baseline. In addition, he has nocturnal events characterized by significant agitation, screaming, crying, body stiffening and limb movements with pauses in breathing, mouth breathing, restless sleep, and difficulty waking in the morning with concomitant daytime fatigue despite above treatments for OSA. There is no history of congenital heart disease or sudden unexplained death. Family history is noncontributory because parents are negative for the FBXO11 variant.X's sleep disruption has led to significant sleep deficits for both X and his caregivers, who spend much of the night strategizing on how to console him. X has undergone several sleep studies, starting when X was aged 4 months, at several children's hospitals across the nation to determine the cause of his chronic sleep disturbance, which yielded limited information and treatment success. As an infant, X received a medical workup and was subsequently treated with a proton pump inhibitor (PPI) for reflux. At 12 months, he was diagnosed with disordered sleep with myoclonic jerks and started on melatonin and gabapentin for involuntary movements. At 13 months, gabapentin was weaned back because of intolerance, and at 15 months, nortriptyline and clonidine were started because of worsening symptoms to target potential neuropathic pain. While most of his symptoms were at night, he had occasional daytime screaming episodes, particularly when experiencing illness. Gabapentin and clonidine were stopped because nortriptyline seemed most effective.At 17 months, the results from a sleep study led to a diagnosis of night terrors, and several clinicians agreed that X's sleep disruption was behavioral in nature. At this time, an infant mental health consultant met with a sleep psychologist on the family's behalf to support family in considering systematic desensitization therapy to increase tolerance to wearing his BiPAP mask, as well as other behavioral and sleep hygiene strategies, which were tried on several occasions and again, resulted in limited improvement in functioning.At 19 months, X's multidisciplinary team reconsidered a night terror diagnosis after a failed trial of clonazepam and pursued a differential diagnosis of periodic limb movement disorder (PLMD). X trialed gabapentin again, but this time only a nighttime dose, per sleep medicine and psychiatry recommendation. While this brought some temporary relief from nighttime distress, despite increasing to the highest dose for age and weight (15 mg/kg/dose), this became less effective, and he was weaned off at 22 months. He had been on iron supplementation since age 6 months and received an iron infusion at 22 months because of persistently low ferritin levels and PLMD in sleep.At 24 months, X was briefly trialed on levetiracetam. While no evidence for seizures on EEG was present, this medication was chosen for involuntary movements and genetic risk for seizures. However, this medication was not useful. At 25 months, an evaluation with a movement disorder physiatrist resulted in a diagnosis of nocturnal paroxysmal dystonia, and he was started on baclofen, which has provided some, but not complete relief to nighttime symptoms. Parents are reporting he has more "good nights" than "bad nights," but "bad nights" come in stretches of a few days in length with no known trigger or relief.Most recently, X was evaluated by general genetics. Whole exome sequencing (WES) was pursued which revealed a pathogenic de novo variant in FBXO11 and provides a likely cause for his neurodevelopmental phenotype. However, he has some features not explained by FBX011; thus, reanalysis of his WES was performed and revealed a de novo variant of uncertain significance in RAF1. Because pathogenic variants in RAF1 have been associated with dilated cardiomyopathy and Noonan spectrum disorder, it was recommended that X be followed periodically in a cardiac genetics clinic. Family is well connected into the FBXO11 community, including supportive Facebook groups. Parents have shared that they do not feel X's breathing issues and pain fit with the phenotype of other children with FBXO11 mutations.X is also enrolled in a medical child care program to facilitate development and social-emotional functioning and receives learning, speech, occupational, physical, and feeding therapy while in attendance. Despite periods of absence due to contracting numerous viral illnesses over the past several months, X continues to make progress across developmental therapies and happily engages when at the program.What additional diagnostic tests and treatment should be considered to better understand X's medical and behavioral presentation? What are the implications of chronic sleep deprivation and stress on the behavior and development of infant with X's profile? What are important psychosocial considerations because it relates to children with medical complexity (CMC), particularly for X and his family to support caregiver, family, and X's quality of life and overall well-being?

"I have to obey my pain" - children's experiences of pain burden in cerebral palsy

PURPOSE

To explore pain experiences of children with cerebral palsy, and how it influences their everyday life.

METHOD

Fourteen children with CP between eight and seventeen years old were included, using a purposeful sampling strategy. They had different experiences of pain, and different degrees of physical and cognitive impairments. Sixteen individual semi-structured interviews were carried out, and analyzed using inductive thematic analysis.

RESULTS

Data analysis resulted in the main theme "I have to obey my pain" and four themes were identified. Experiences regarding pain varied ("My pain is mine alone"). Both pain itself and the use of cognitive strategies to cope with pain involved a mental struggle ("Pain brings me down"). The children had to make adjustments to manage their pain ("I want to participate, but I have to rest"). The most important help was to be understood, but adults also provided valuable help with interventions like stretching, medication and adjustment of activity levels ("Others can help me").

CONCLUSION

Pain was a determining feature in the lives of these children with CP. The wide variety of experiences and challenges emphasized the need for tailored management strategies developed together with each child and their parents.IMPLICATIONS FOR REHABILITATIONChildren with cerebral palsy had varied experiences of pain, and health professionals need to tailor their pain management approaches to the individual child.Health services should offer pain education to expand children's repertoire of pain management strategies.When a child's pain influences their daily activities, health services must ensure that the school is informed of the child's situation, and able to make necessary adjustments.Health professionals should strive to include children's own descriptions whenever possible to make sure children feel heard and believed.Even children with communicative and cognitive impairments were able to self-report when necessary adjustments in the communication situation were made.

Fifteen-minute consultation: Assessment of pain in a non-verbal child

In both inpatient and outpatient settings, clinicians will encounter patients with pain. This consultation is further complicated if the child is non-verbal. This article aims to equip the clinician with tools to assess these patients comprehensively and develop an appropriate management plan. It will take the clinician through the important aspects of a comprehensive history from the caregiver, thorough examination, importance of understanding how the child communicates and pain assessment tools to consider.

Intractable Feeding Intolerance in Children With Severe Neurological Impairment: A Retrospective Case Review of Nine Children Known to a Pediatric Palliative Care Service

BACKGROUND

Intractable feeding intolerance in children with severe neurological impairment (SNI) is poorly defined and understood.

OBJECTIVES

(1) To describe 9 children with SNI, where intractable feeding intolerance was thought to be a contributor to their deterioration or death. (2) To consider terminology to describe the severe end of the spectrum of feeding difficulties in children with SNI.

RESULTS

Mean age at death was 10.3 years (range: 5 - 15.6), and median time from palliative care referral to death was 3.1 months. Location of death was home (n = 3), hospice (n = 1), and hospital (n = 5) with 1 death in intensive care. Gastrointestinal "failure" or "dysfunction" were documented for 7 children, (median time between documentation and death was 3.9 months (range: .1 to 13.1)). All children were fed via a gastrostomy tube during their life (median age of insertion 2.5 years (range: 1.2 to 6.8 years)), and 7 via the jejunal route (median age of insertion 9.2 years (range 2.4 to 14.7 years)). Children lived a median of 9 percent of their lives after jejunal tube feeding was commenced. No child had home-based parenteral nutrition. Multiple symptom management medications were required.

CONCLUSION

'Intractable feeding intolerance' describes a clinical crossroads in a child's life where there is an opportunity to consider the appropriateness of further interventions. Further work should explore predictors of intractable feeding intolerance and the delicate balance between cause or contributor to death. The importance of clinician-family prognostic conversations and goal-concordant care both during life and in the terminal phase is highlighted.

Measuring pain intensity through physical interaction in an experimental model of cold-induced pain: A method comparison study

OBJECTIVES

Assessment of pain is challenging given its subjective nature. Standard pain assessment tools have limitations. We aimed to compare the verbal numeric rating scale (NRS) and Grasp, a novel handheld electronic device that reports pain by squeezing.

METHODS

To compare Grasp and NRS, healthy adult volunteers were invited to undergo two subsequent standardised tests of cold-triggered pain using a cold pressor test (CPT) at a temperature of 3°C. Pain intensity was in a randomised manner reported by NRS (scale 0-10) or by squeezing Grasp (0-3 V) during the two CPTs. A third CPT was performed 1 to 14 days later where subjects reported pain by Grasp a second time in order to study the association of repeated Grasp measurements. Acceptable association was a priori considered as mean Kendall's τ-b coefficient (τ-b) ≥ 0.7. The subjects reported their experience of using Grasp in a purpose-made questionnaire.

RESULTS

In total, 102 subjects were included, and 96 subjects (56 females) completed all three tests. The association of pain intensity reported by Grasp and NRS was moderate with a mean τ-b of 0.53 (95% confidence interval [CI] 0.47-0.58). The association between the repeated Grasp measurements was weak with a mean τ-b of 0.43 (95% CI 0.37-0.48). Most subjects reported that Grasp was intuitive and easy to use.

CONCLUSIONS

Pain intensity reported by squeezing Grasp did not show acceptable association with pain intensity reported by NRS during CPTs. The association between pain intensity reported by Grasp during two CPTs on separate days was weak. Further improvements of the Grasp ball are needed before use in clinical settings.

The Pharmacological Treatment of Neuropathic Pain in Children

The International Association for the Study of Pain (IASP) defines neuropathic pain as pain caused by a lesion or disease of the somatosensory nervous system. It is characterized as a clinical condition in which diagnostic studies reveal an underlying cause of an abnormality in the peripheral or central nervous system. Many common causes of neuropathic pain in adults are rare in children. The purpose of this focused narrative review is, to 1) provide an overview of neuropathic pain in children, 2) highlight unique considerations related to the diagnosis and mechanisms of neuropathic pain in children, and 3) perform a comprehensive analysis of the pharmacological treatments available. We emphasize that data for routine use of pharmacological agents in children with neuropathic pain are largely inferred from adult literature with little research performed on pediatric populations, yet have clear evidence of harms to pediatric patients. Based on these findings, we propose risk mitigation strategies such as utilizing topical treatments whenever possible, assessing pain phenotyping to guide drug class choice, and considering pharmaceuticals in the broader context of the multidisciplinary treatment of pediatric pain. Furthermore, we highlight important directions for future research on pediatric neuropathic pain treatment.

Management of neurological problems in children on home invasive mechanical ventilation

INTRODUCTION

Home invasive mechanical ventilation (HIMV) has become a crucial long-term respiratory support for children with neurological disorders, but requires advanced technological skills and 24-h care. The increasing global population of children on HIMV is attributed to advancements in intensive care and improved survival rates.

METHOD

The manuscript will review the most common neurological problems encountered in children on HIMV.

CONCLUSION

The manuscript emphasizes the multidisciplinary nature of managing these patients, involving pediatric pulmonologists, pediatric neurologists, pediatric intensivists, nurses, therapists, dietitians, psychologists, and caregivers. The manuscript outlines the challenges posed by neurological disorders, such as spinal muscular atrophy, muscular dystrophy, cerebral palsy, spinal cord injuries, and neurodegenerative disorders, which may result in respiratory muscle weakness and impaired ventilation. The importance of individualized assessments, appropriate ventilator mode and equipment selection, training of caregivers, airway clearance techniques, nutritional support, regular follow-up visits, psychological and educational support, and addressing specific neurological issues such as involuntary movement disorders, prolonged seizures, sleep disorders, pain, sialorrhea, and immobilization-related complications are discussed. The treatment options for these specific challenges are outlined. This review highlights the complex nature of managing children with neurological disorders on HIMV and the importance of a collaborative approach among healthcare professionals and caregivers to optimize care and improve the quality of life for these children.

Multicenter study. Nursing professionals' perception of training needs in pain assessment in pediatric patients with cognitive dysfunction

INTRODUCTION

Pediatric patients with cognitive dysfunction are at greater risk of pain than typically developing children. Pain assessment in these patients is complex and could generate uncertainty in health professionals about what the key aspects are.

AIM

To determine the training needs perceived by nursing professionals regarding acute pain assessment in pediatric patients with cognitive dysfunction.

METHODS

A descriptive, cross-sectional, and multicenter study was performed using a survey addressed to nursing professionals who work in pediatrics during the months of August and September 2022.

RESULTS

163 responses were obtained. Most of the professionals who responded were female (92.6%, n = 151), with a mean age of 38.98 ± 10.40 years. The most frequent work unit was the pediatric intensive care unit (PICU), in 36% (n = 58). Most of the participants reported not having previously received training on pain assessment in pediatric patients with cognitive disabilities (85.9%, n = 139). However, 70.4% (n = 114) considered it "very necessary" for the development of their work to receive specific training on this topic. Knowing how to assess acute pain in this population (85.3%, n = 139) and knowing the clinical and behavioral manifestations of pain in this type of patient (84.7%, n = 138) were the aspects that obtained higher scores.

CONCLUSION

This research notes more than 90% of participants consider "quite necessary" and "strong necessary" to be training in pediatric cognitive dysfunction patients pain assessment. Furthermore, work experience, academic education and to be pediatric specialist obtain statistical significance data.

Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study

INTRODUCTION

Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention.

METHODS

Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability.

RESULTS

Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730).

CONCLUSIONS

The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.

Effect of virtual reality combined with repetitive transcranial magnetic stimulation on musculoskeletal pain and motor development in children with spastic cerebral palsy: a protocol for a randomized controlled clinical trial

PURPOSE

This trial aims to investigate the efficacy and safety of virtual reality (VR) combined with repetitive transcranial magnetic stimulation (rTMS) for improving musculoskeletal pain and motor development in children with unilateral spastic cerebral palsy (CP).

METHODS

This study protocol is for a randomized controlled trial consisting of 2 treatment sessions (3 days/week for 4 weeks in each session, with a 1-week interval between sessions). We will recruit children aged 3-10 years with unilateral spastic CP (Gross Motor Function Classification System level I or II). Participants will be randomly divided into 3 groups: the VR + rTMS group (immersive VR intervention, rTMS and routine rehabilitation therapy), rTMS group (rTMS and routine rehabilitation therapy), and control group (sham rTMS and routine rehabilitation therapy). VR therapy will involve a daily 40-minute movement training session in a fully immersive environment. rTMS will be applied at 1 Hz over the primary motor cortex for 20 min on the contralateral side. The stimulation intensity will be set at 90% of the resting motor threshold, with 1200 pulses applied. A daily 60-minute routine rehabilitation therapy session including motor training and training in activities of daily living will be administered to all participants. The primary outcome will be pain intensity, assessed by the Revised Face, Legs, Activity, Cry, and Consolability Scale (R-FLACC). The secondary outcomes will include motor development, evaluated by the 66-item version of the Gross Motor Function Measure (GMFM-66) and Fine Motor Function Measure (FMFM); balance capacity, measured by the interactive balance system; activities of daily living; and quality of life, measured by the Barthel index and the Chinese version of the Cerebral Palsy Quality of Life scale for Children (C-CP QOL-Child). Safety will be monitored, and adverse events will be recorded during and after treatment.

DISCUSSION

Combined application of VR therapy and rTMS may reveal additive effects on pain management and motor development in children with spastic CP, but further high-quality research is needed. The results of this trial may indicate whether VR therapy combined with rTMS achieves a better analgesic effect and improves the motor development of children with spastic CP.

TRIAL REGISTRATION

Registration number: ChiCTR230069853. Trial registration date: 28 March 2023. Prospectively registered.

Parental perspectives of episodic irritability in an ultra-rare genetic disorder associated with NACC1

BACKGROUND

A recurrent de novo variant (c.892C>T) in NACC1 causes a neurodevelopmental disorder with epilepsy, cataracts, feeding difficulties, and delayed brain myelination (NECFM). An unusual and consistently reported feature is episodic extreme irritability and inconsolability. We now characterize these episodes, their impact on the family, and ascertain treatments that may be effective. Parents of 14 affected individuals provided narratives describing the irritability episodes, including triggers, behavioral and physiological changes, and treatments. Simultaneously, parents of 15 children completed the Non-communicating Children's Pain Checklist-Revised (NCCPC-R), a measure to assess pain in non-verbal children.

RESULTS

The episodes of extreme irritability include a prodromal, peak, and resolving phase, with normal periods in between. The children were rated to have extreme pain-related behaviors on the NCCPC-R scale, although it is unknown whether the physiologic changes described by parents are caused by pain. Attempted treatments included various classes of medications, with psychotropic and sedative medications being most effective (7/15). Nearly all families (13/14) describe how the episodes have a profound impact on their lives.

CONCLUSIONS

NECFM caused by the recurrent variant c.892C>T is associated with a universal feature of incapacitating episodic irritability of unclear etiology. Further understanding of the pathophysiology can lead to more effective therapeutic strategies.

Study Confirms Safety and Effectiveness of Intra-Articular Glucocorticoids for Painful Hip Dislocation in Children and Young Adults with Neurologic Impairment

BACKGROUND

Hip dislocation is a common source of pain in children with neurologic impairment. When medical interventions fail, orthopedic surgery does not guarantee a definitive result as the displacement may continue postoperatively and a second operation is often required.

METHODS

Retrospective analysis of data regarding the safety and effectiveness of an intra-articular corticosteroid injection (IACI) in 11 patients, aged 15 ± 5 years old, collected through a telephonic questionnaire administered to parents.

RESULTS

21 IACIs were performed, a mean number of 1.9 ± 1.5 times for each patient, at a mean age (of the first IACI) of 13.5 ± 5 years. According to the parents, the IACI significantly lowered the number of participants experiencing pain (82% reduction) and using analgesics (60% reduction). There was also a significant improvement in the children's hip mobility (63% reduction in patients experiencing stiffness), decubitus (90% reduction in obligated positioning), behavior (80% reduction in lamenting or crying patients), sleep quality (87.5% reduction in patients awakening every night), and caregivers' quality of life (91% reduction in worried parents). The mean reported duration of the IACIs' benefit was 5.4 ± 2.4 months (range 1-9), with a positive correlation with the number of IACIs (r = 0.48; p-value = 0.04) and a negative correlation with the age at the first injection (r = -0.71; p-value = 0.02). The only reported adverse event was mild local swelling in one child.

CONCLUSIONS

the IACI could represent a safe and effective intervention for painful hip dislocation, both before and after surgery, with a long-lasting benefit which seems to increase as multiple IACIs are performed.

Pain Management in the Most Vulnerable Intellectual Disability: A Review

This review is made up of two parts; the first part discussing intellectual disability (ID) in general, while the second part covers the pain associated with intellectual disability and the challenges and practical tips for the management of pain associated with (ID). Intellectual disability is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. ID is a disorder with no definite cause but has multiple risk factors, including genetic, medical, and acquired. Vulnerable populations such as individuals with intellectual disability may experience more pain than the general population due to additional comorbidities and secondary conditions, or at least the same frequency of pain as in the general population. Pain in patients with ID remains largely unrecognized and untreated due to barriers to verbal and non-verbal communication. It is important to identify patients at risk to promptly prevent or minimize those risk factors. As pain is multifactorial, thus, a multimodal approach using both pharmacotherapy and non-pharmacological management is often the most beneficial. Parents and caregivers should be oriented to this disorder, given adequate training and education, and be actively involved with the treatment program. Significant work to create new pain assessment tools to improve pain practices for individuals with ID has taken place, including neuroimaging and electrophysiological studies. Recent advances in technology-based interventions such as virtual reality and artificial intelligence are rapidly growing to help give patients with ID promising results to develop pain coping skills with effective reduction of pain and anxiety. Therefore, this narrative review highlights the different aspects regarding the current status of the pain associated with intellectual disability, with more emphasis on the recent pieces of evidence for the assessment and management of pain among populations with intellectual disability.

Predictors of Delayed Diagnosis of Pediatric CNS Tumors in the Emergency Department

OBJECTIVE

Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays.

STUDY DESIGN

We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit.

RESULTS

We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98).

CONCLUSIONS

Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs.

Pain research and children and adolescents with severe intellectual disability: ethical challenges and imperatives

Children with severe intellectual disabilities encounter inequities in pain-related care, yet little pain research involves this population. A considerable issue with pain research in this population is its ethical complexity. This Viewpoint delineates the ethical challenges of pain research involving children (aged 2-12 years) and adolescents (aged 13-21 years) with severe intellectual disabilities. There are two main issues. First, some of the standard methods for assessing pain and pain sensitivity are not suitable for individuals with severe intellectual disability, who are often non-verbal and unable to understand or follow instructions. Second, children and adolescents with severe intellectual disability cannot provide informed consent or assent to participate in pain research, and their dissent is not always recognised. The existing ethical guidelines for pain research by the International Association for the Study of Pain provide helpful, but general, guidance. This Viewpoint supplements these guidelines and uses a well established framework for assessing the ethics of clinical research to highlight points relevant to designing, doing, reviewing, and evaluating research involving children and adolescents with severe intellectual disability, focusing on issues that are unaddressed in existing guidance.

Assessment of postoperative pain in children with computer assisted facial expression analysis

PURPOSE

The present study was conducted to evaluate the use of computer-aided facial expression analysis to assess postoperative pain in children.

DESIGN AND METHODS

This was a methodological observational study. The study population consisted of patients in the age group of 7-18 years who underwent surgery in the pediatric surgery clinic of a university hospital. The study sample consisted of 83 children who agreed to participate and met the sample selection criteria. Data were collected by the researcher using the Wong Baker Faces pain rating scale and Visual Analog Scale. Data were collected from the child, mother, nurse, and one external observer. Facial action units associated with pain were used for machine estimation. OpenFace was used to analyze the child's facial action units and Python was used for machine learning algorithms. The intraclass correlation coefficient was used for statistical analysis of the data.

RESULTS

The pain score predicted by the machine and the pain score assessments of the child, mother, nurse, and observer were compared. The pain assessment closest to the self-reported pain score by the child was in the order of machine prediction, mother, and nurse.

CONCLUSIONS

The machine learning method used in pain assessment in children performed well in estimating pain severity.It can code facial expressions of children's pain and reliably measure pain-related facial action units from video recordings.

APPLICATION TO PRACTICE

The machine learning method for facial expression analysis assessed in this study can potentially be used as a scalable, standard, and valid pain assessment method for nurses in clinical practice.

Addressing Self-Injurious Behavior in the Medically Complex Child: Identifying the Root Cause vs Blocking Resulting Behavior

Gillian is a 7-year-old nonverbal, internationally adopted girl with significant visual impairment (sees shadows and objects with high contrast), moderate-severe hearing loss, autism spectrum disorder, profound intellectual disability, and a seizure disorder. She resided in an orphanage until age 4 years when she was adopted by her mother. She is referred to the multidisciplinary team in developmental-behavioral pediatrics by her gastroenterologist, who is managing her constipation, for evaluation and management of self-injurious behavior that occurs before bowel movements.Gillian's adoptive mother reported that Gillian has a history of repetitive and self-injurious behavior including hitting her head with the palm of her hand and poking her eyes. The head-hitting behavior has resulted in consistent bruising to her forehead and nasal bridge. The eye poking is of significant concern because of the possibility of resultant injury including corneal abrasion or retinal detachment. Eye poking occurs exclusively during the hour before stooling, at home and school, and is accompanied by screaming, pacing, and increased aggression toward her mother/teachers. Mother typically responds by blocking the eye poking, redirecting Gillian to the toilet, providing prompts to use calming strategies (e.g., deep breathing), or providing sensory input by rubbing her arms/back. Teachers respond in a similar way at school. Gillian's mother has tried to place goggles over Gillian's eyes during eye poking, but this resulted in increased aggressive behaviors.Gillian is not fully bowel trained but will sit on the toilet to urinate when prompted. She completes toilet-sits at home/school 5 to 7 times daily. Gillian passes small, soft bowel movements 2 to 4 times daily on a bowel management regimen consisting of polyethylene glycol 3350 17 grams twice daily and liquid senna 8.8 mg daily. Seizures are reportedly well controlled with an antiepileptic medication managed by her neurologist. Previous medical evaluation by otolaryngology, ophthalmology, neurology, and gastroenterology did not identify a source of pain or other cause for the eye poking. Physical examination reveals normal bowel sounds and a mildly distended abdomen but is otherwise unremarkable. What are your next steps for evaluation and treatment?

The clinical features of OSTM1-associated malignant infantile osteopetrosis: A retrospective, single-center experience over one decade

Mutation in OSTM1 give rise to the rarest and most lethal subtype of malignant infantile osteopetrosis (MIOP), and an improved understanding of OSTM1-associated MIOP would help with informed decision-making regarding symptom management and early palliative care referral. This retrospective study describes the clinical and laboratory features of patients with a genetic diagnosis of OSTM1 MIOP made between January 2011 and December 2021 in the Department of Pediatrics, Al-Adan Hospital, Kuwait. Twenty-two children had confirmed homozygous deletion in OSTM1 (13 females, nine males). Consanguinity was reported in almost all parents. 72.7% were diagnosed before the age of two months, most commonly incidentally with a high clinical suspicion. All 22 patients developed upper respiratory symptoms, hepatosplenomegaly, poor feeding, and had severe developmental delay. 80% of patients developed pain and/or irritability, and 40.9% were diagnosed with primary seizures. Bone fractures developed in 27% of patients, most likely iatrogenic, and some patients had hernia and gum abnormalities. The mean survival was 10.9 months. The clinical presentation, symptomatology, and mortality of our cohort were compared with other cases of OSTM1 MIOP identified through a comperhensive search of the PubMed database. The findings conclude that OSTM1 MIOP is a multi-systemic disease with distinct clinical features, of which neurological complications are the most severe and include nociplastic pain and irritability. Although orthopedic complications influence the trajectory of most patients with other forms of osteopetrosis, OSTM1 MIOP is driven by its neurological complications. Hence, OSTM1 should be regarded as a neurodegenerative disease with osteopetrosis as a comorbidity that warrants early palliative care referral.

Clinical characteristics of children with severe neurologic impairment: A scoping review

OBJECTIVE

The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies.

METHODS

Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics.

RESULTS

We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials.

CONCLUSIONS

Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Les pratiques exemplaires pour l’évaluation et le traitement de la douleur chez les enfants

L’évaluation et le traitement de la douleur sont des aspects essentiels des soins pédiatriques. L’évaluation de la douleur adaptée au développement représente une première étape importante pour en optimiser la prise en charge. L’autoévaluation de la douleur est à prioriser. Si c’est impossible, des outils appropriés d’évaluation du comportement, adaptés au développement, doivent être utilisés. Des directives et stratégies de prise en charge et de prévention de la douleur aiguë, qui combinent des approches physiques, psychologiques et pharmacologiques, doivent être accessibles dans tous les milieux de soins. Le meilleur traitement de la douleur chronique fait appel à une combinaison de modalités thérapeutiques et de counseling, dans l’objectif premier d’obtenir une amélioration fonctionnelle. La planification et la mise en œuvre de stratégies de prise en charge de la douleur chez les enfants doivent toujours être personnalisées et axées sur la famille.

Best practices in pain assessment and management for children

Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first step in optimizing pain management. Self-reported pain should be prioritized. Alternatively, developmentally appropriate behavioural tools should be used. Acute pain management and prevention guidelines and strategies that combine physical, psychological, and pharmacological approaches should be accessible in all health care settings. Chronic pain is best managed using combined treatment modalities and counselling, with the primary goal of attaining functional improvement. The planning and implementation of pain management strategies for children should always be personalized and family-centred.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Novel Use of Intranasal Dexmedetomidine for Refractory Irritability in Pediatric Home Care

Background: Dexmedetomidine is a selective alpha-2 agonist with sedative, analgesic, and anxiolytic properties used intravenously for procedural sedation and in the intensive care unit. The reported use of intranasal (IN) dexmedetomidine for symptom management in pediatric palliative care is limited. Case History: A boy with cardiofaciocutaneous syndrome and refractory irritability was supported by pediatric palliative care throughout numerous hospitalizations for goals of care discussions and pain and symptom management. Given functional and multiorgan system deterioration, he was enrolled in home hospice to optimize comfort measures at anticipated end of life. After the addition of scheduled IN dexmedetomidine for management of irritability, the boy demonstrated marked improvement in comfort and sleep. Conclusion: This case report shows the successful use of IN dexmedetomidine for management of refractory irritability with no noted adverse effects. Future studies and use of this medication will need to consider potential indications, optimal dosing, and long-term effects in the pediatric palliative care setting.

Risk of exposure to prescription opioids in children and adolescents with autism spectrum disorder: A nationwide longitudinal study

Whether children and adolescents with autism spectrum disorder (ASD) are more likely to be exposed to prescription opioids than others remains unknown. The Taiwan National Health Insurance Research Database was employed, and 14,849 children and adolescents with ASD and 148,490 age- and sex-matched non-ASD controls were enrolled between 2001 and 2009 and followed up till the end of 2011. Those exposed to prescription opioids during the follow-up period were identified. Patients with ASD were more likely to be exposed to prescription opioids (hazard ratio [HR]: 4.95, 95% confidence interval [CI]: 4.50-5.45), including intravenous or intramuscular opioids (HR: 5.80, 95% CI: 5.23-6.43) and oral or transcutaneous opioids (HR: 2.32, 95% CI: 1.87-2.89), than were non-ASD controls. Furthermore, the ASD cohort had the increased likelihood of cumulative exposure of >14 days (HR: 6.19, 95% CI: 4.91-7.79) and >30 days (HR: 7.17, 95% CI: 5.19-9.90) to prescription opioids compared with the control cohort. ASD was a risk factor for exposure to prescription opioids. Close monitoring of prescription opioid use is necessary for at-risk children and adolescents with ASD, such as those having with or chronic pain. We found that patients with ASD were more likely to be exposed to prescription opioids, including intravenous or intramuscular opioids and oral or transcutaneous opioids, than were non-ASD controls. We suggest that close monitoring of prescription opioid use is necessary for at-risk children and adolescents with ASD, such as those having with or chronic pain.

Sanfilippo syndrome: consensus guidelines for clinical care

Sanfilippo syndrome is a group of rare, complex, and progressive neurodegenerative lysosomal storage disorders that is characterized by childhood dementia. The clinical management of patients with progressive neurological decline and multisystem involvement requires a multidisciplinary team with experience in the management of neurodegenerative disorders. Best practice guidelines for the clinical management of patients with these types of rare disorders are critical to ensure prompt diagnosis and initiation of appropriate care. However, there are no published standard global clinical care guidelines for patients with Sanfilippo syndrome. To address this, a literature review was conducted to evaluate the current evidence base and to identify evidence gaps. The findings were reviewed by an international steering committee composed of clinical experts with extensive experience in managing patients with Sanfilippo syndrome. The goal was to create a consensus set of basic clinical guidelines that will be accessible to and informed by clinicians globally, as well as providing a practical resource for families to share with their local care team who may not have experience with this rare disease. This review distills 178 guideline statements into an easily digestible document that provides evidence-based, expert-led recommendations for how to approach common management challenges and appropriate monitoring schedules in the care of patients with Sanfilippo syndrome.

Evaluation of children with severe neurological impairment admitted to hospital with pain and irritability

BACKGROUND

Pain is the most common symptom reported by caregivers of children with severe neurological impairment (SNI), a descriptive term for children with disorders affecting the neurological system across multiple domains. In SNI, cognition, communication, and motor skills are impaired and other organ systems are impacted. Pain is difficult to identify and treat in children with SNI because of communication impairment. When a clear cause of pain is not determined, the term "Pain and Irritability of Unknown Origin (PIUO)" is used to describe pain-like behaviours. This study explores the clinical care received by children with SNI admitted to hospital after presenting to the emergency department of a tertiary pediatric hospital with pain or irritability. Findings are compared to the approach suggested in the PIUO pathway, an integrated clinical pathway for identifying and treating underlying causes of pain and irritability in children with complex conditions and limited communication.

METHODS

Retrospective chart review of children (age 0 to 18 years inclusive) with diagnoses compatible with SNI presenting with pain, irritability, and/or unexplained crying that required hospitalization between January 1st, 2019 and December 31st, 2019. Descriptive statistics were used to analyze the clinical care received by children in whom a source of pain was identified or not. In children for whom no cause of pain was identified, investigations completed were compared to the PIUO pathway.

RESULTS

Eight hospital admissions of six unique children were included for data analysis. A cause for pain and irritability was identified and resolved in three patients. In children with PIUO, there were gaps in history taking, physical examination, and investigations that might have allowed a cause of pain and irritability to be found. Pain was assessed using the r-FLACC pain scale and varying medications for pain/irritability were given during each hospital admission.

CONCLUSION

Children with SNI admitted to a tertiary pediatric hospital did not undergo a standardized approach to identifying a cause of pain and irritability. Future efforts should explore the effectiveness of the PIUO pathway, a standardized approach to reducing and resolving pain in children with SNI.

Use of Epidural Analgesia in Children With Neuromuscular Conditions Following Hip Reconstruction

BACKGROUND

Neuromuscular conditions, such as cerebral palsy, are the most common motor disabilities in the pediatric population. Children with these conditions frequently have accompanying hip deformities that require pelvic and femur osteotomy to correct the spastic hip dislocations. However, postoperative pain management remains an elusive and challenging problem. The purpose of this study was to determine whether postoperative use of epidural analgesia in patients with neuromuscular conditions provided similar outcomes with regard to pain scores, length of stay, duration of foley placement, duration of pain control, and complications as compared to traditional pain management regimens. To our knowledge, this is the first study comparing the use of epidural analgesia to conventional pain relief modalities following hip reconstruction in patients with neuromuscular conditions.

METHODS

A retrospective cohort study was performed using records of pediatric patients with neuromuscular conditions treated at our tertiary care center between January 2009 and December 2019. Patients with neuromuscular conditions treated with epidural or non-epidural analgesia for pain relief following unilateral or bilateral proximal femoral osteotomies, pelvic osteotomies, or open hip reduction were eligible for study inclusion. Multiple linear regression was used to determine differences in length of stay, pain score, pain modality, duration of Foley placement, and complications between the two cohorts.

RESULTS

Seventy patients met the inclusion criteria for the study. In all, 58 patients underwent unilateral procedures, of which 30 (52%) received epidural analgesia, and 28 (48%) received non-epidural pain control modalities. Demographic and baseline characteristics were similar among the cohort, except for BMI, which varied slightly. Average pain scores and pain control duration were not statistically different between the pain control modalities. After controlling for demographics, procedure, and immobilization type, the epidural group experienced significantly increased length of stay (+3.18 days, P=0.032) and duration of Foley placement (+1.04 days, P=.013). Complication rates between the two groups were not statistically significant.

CONCLUSIONS

The use of epidural analgesia in children with neuromuscular conditions was associated with comparable pain scores, despite the increased length of stay and duration of Foley placement. No statistically significant difference in complication rates was observed between patients receiving epidural anesthesia and those receiving traditional pain modalities.

Postsurgical pain assessment in children and adolescents with cerebral palsy: A scoping review

AIM

To investigate factors that influence the assessment of postoperative pain in children and adolescents with cerebral palsy (CP) and the tools available to determine pain intensity.

METHOD

The search was performed in January 2022 using six databases. Articles focused on paediatric patients with CP; we included instruments for postsurgical pain assessment in this population published in the last 11 years.

RESULTS

Eight of 441 studies were included. Males and females behave differently; their families can be called on to describe their pain responses. Seven instruments for pain assessment were identified: the Non-Communicating Children's Pain Checklist and its Postoperative Version; the Paediatric Pain Profile; the revised Face, Legs, Activity, Cry and Consolability (FLACC) pain scale; the Douleur Enfant San Salvador scale; the Pain Indicator for Communicatively Impaired Children; the University of Wisconsin Children's Hospital Pain Scale; and the Individualized Numeric Rating Scale.

INTERPRETATION

The revised FLACC pain scale is suited to postsurgical units because of its ease of use and the fact that parental collaboration is not required. More studies are needed to demonstrate the clinical utility of these scales in postsurgical units and the factors that influence pain assessment.

WHAT THIS PAPER ADDS

Families should be asked to collaborate when assessing pain in children and adolescents whenever possible. Larger studies that focus on the factors influencing pain assessment in this population are required.

Pediatric Palliative Care in Oncology: Basic Principles

Simple Summary

About 4 million children with an oncological disease worldwide require palliative care due to the nature of their condition. The WHO defines pediatric palliative care (PPC) as the prevention and relief of suffering in patients with life-threatening or life-limiting disease and their families. PPC relies on the comprehensive and multidisciplinary management of the child and the family’s physical, psychological, spiritual, and social needs. Importantly, PPC begins at the diagnosis of incurability, or supposed incurability, and continues regardless of whether the patient receives any oncological treatment. As such, PPC is a general approach continuing over the entire disease trajectory, which includes, but is not limited to, end-of-life care. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology.

Abstract

About 4 million children with an oncological disease worldwide require pediatric palliative care (PPC) due to the nature of their condition. PPC is not limited to end-of-life care; it is a general approach continuing over the entire disease trajectory, regardless of whether the patient receives any oncological treatment. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Moreover, models for PPC implementation in oncology, end-of-life care, and advanced care planning are discussed.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

Understanding disease symptoms and impacts and producing qualitatively-derived severity stages for MPS IIIA: a mixed methods approach

Background

MPS IIIA is a rare, degenerative pediatric genetic disease characterized by symptoms impacting cognition, mobility and behavior; the mean age of death is around 15 years of age. Currently, there are no approved therapies for MPS IIIA.

Methods

A two-year, multi-center, prospective, descriptive cohort study was conducted to document the natural history course of MPS IIIA. In the context of this study, semi-structured interviews were performed with parents of children at study entry and one year later. Interview transcripts were analyzed using thematic analysis methods to identity concepts of interest to children and parents, identify what factors impacted parents’ burden the most, and develop qualitatively-derived disease severity stages. Children were sorted into these stages according to the symptoms their parents described at the entry interview. This sorting was compared quantitatively to the sorting of children at baseline according to the child’s calendar age and their BSID development quotient (DQ).

Results

22 parents in France, Germany, the Netherlands and the UK were interviewed. Children ranged in age from 28 to 105 months (mean 61.4 months). The conceptual models for children’s symptoms and impacts and parents’ impacts provided a detailed and comprehensive picture of what it is like for children of various ages and their parents to live with MPS IIIA. Four factors were identified as mediating the burden perceived by parents: state support, family support, time since diagnosis, and parent coping strategy. Four disease stages were developed, accounting for both the presence and the severity of MPS IIIA symptoms. The comparison of children’s sorting into these stages with the BSID DQ and the child’s calendar age showed strong statistical associations.

Conclusions

The findings of this qualitative research embedded in a natural history study add to the current understanding of MPS IIIA as a complex disease that impacts every aspect of the lives of children and their families. This study demonstrates the unique potential of mixed methods research in rare diseases to address some of the current limitations of more traditional quantitative approaches by providing an individualized, detailed understanding of the patient experience.

The Parental Experience of Caring for a Child With Pain and Irritability of Unknown Origin

BACKGROUND AND OBJECTIVE

Approximately 73% of children with severe neurological impairment (SNI) can experience episodes of pain and irritability often of unknown origin (PIUO). Limited research exists on how these experiences of PIUO may affect parental caregivers and families. The primary objective of this study was to understand the parental caregiver experience of caring for a child with SNI who experiences persistent PIUO.

METHODS

We conducted a qualitative study using semi-structured interviews to explore the experience of parental caregivers of children with SNI. Interview guide questions focused on exploring pain behaviours, the diagnostic process, pharmacological and non-pharmacological management, healthcare-team support, discussion surrounding irritability, and family impact. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed by 2 independent reviewers using thematic analysis.

RESULTS

15 parental caregivers were interviewed, with 93% being mothers and 33% being a visible minority. Interviews revealed 3 major themes: 1) Variations in Clinical Care for PIUO; 2) The Experience and Challenges of Living with PIUO); 3) Managing the Impact of PIUO on Parental Well Being. Interviews demonstrated that parent and child can be viewed as a dyad, in which the child's experience is inherently linked to the parental experience.

CONCLUSION

Parental caregivers described caring for a child with persistent PIUO as physically and emotionally exhausting, and negatively impacting family quality of life. Interviews highlighted avenues of future exploration for clinical care, including both enhanced management pathways for children and supportive resources for education and coping for parents.

Bereaved Parent Perspectives on the Benefits and Burdens of Technology Assistance among Children with Complex Chronic Conditions

Background: Many children with complex chronic conditions (CCCs) are supported by medical technologies. Objective: The aim of this study was to understand bereaved parent perspectives on technology assistance among this unique population. Design: Mixed methods design was used to analyze data from the cross-sectional Survey of Caring for Children with CCCs.Setting/Subjects: Bereaved parents of children with CCCs who received care at a large academic institution in the United States and died between 2006 and 2015. Measurements: Survey items were analyzed descriptively and integrated with thematic analysis of open-response items to identify key themes pertaining to parents' perspectives on technology. Results: 110/211 (52%) parents completed the survey and at least 1 open-response item. More than 60% of parents had children with congenital/chromosomal or central nervous system progressive CCCs, used technology at baseline, and died in the hospital. A subset of parents recalled making decisions either not to initiate (n = 26/101, 26%) or to discontinue (n = 46/104, 44%) technology at end of life. Parents described both the benefits and burdens of technology. Two themes emerged regarding technology's association with the (1) intersection with goals of care and (2) complications and regret. Within goals of care, two subthemes arose: (a) technology was necessary to give time for life extension and/or to say goodbye, and (b) technology greatly impacted the child's quality of life and symptoms. Conclusions: Parents have nuanced perspectives about the benefits and burdens of technology. It is essential to understand parent's most important goals when supporting decisions about technology assistance for children with CCCs.

Research priorities for children with neurological impairment and medical complexity in high-income countries

AIM

To identify the highest-priority clinical research areas related to children with neurological impairment and medical complexity among clinicians and caregivers.

METHOD

A modified, three-stage Delphi study using online surveys and guided by a steering committee was completed. In round 1, clinicians and family caregivers suggested clinical topics and related questions that require research to support this subgroup of children. After refinement of the suggestions by the steering committee, participants contributed to 1 (family caregivers) or 2 (clinicians) subsequent rounds to develop a prioritized list.

RESULTS

A diverse international expert panel consisting of 49 clinicians and 12 family caregivers provided 601 responses. Responses were distilled into 26 clinical topics comprising 126 related questions. The top clinical topics prioritized for research were irritability and pain, child mental health, disorders of tone, polypharmacy, sleep, aspiration, behavior, dysautonomia, and feeding intolerance. The clinician expert panel also prioritized 10 specific research questions.

INTERPRETATION

Study findings support a research agenda for children with neurological impairment and medical complexity focused on addressing clinical questions, prioritized by an international group of clinicians and caregivers.

An observational, prospective, multicenter, natural history study of patients with mucopolysaccharidosis type IIIA

Mucopolysaccharidosis type IIIA (MPS IIIA, also known as Sanfilippo syndrome) is a rare genetic lysosomal storage disease characterized by early and progressive neurodegeneration resulting in a rapid decline in cognitive function affecting speech and language, adaptive behavior, and motor skills. We carried out a prospective observational study to assess the natural history of patients with MPS IIIA, using both standardized tests and patient-centric measures to determine the course of disease progression over a 2-year period. A cohort of 23 patients (7 girls, 16 boys; mean age 28-105 months at baseline) with a confirmed diagnosis of MPS IIIA were assessed and followed up at intervals of 3-6 months; cognitive function was measured using Bayley Scales of Infant and Toddler Development 3rd edition (BSID-III) to derive cognitive development quotients (DQ). Daily living, speech/language development and motor skills were measured using the Vineland Adaptive Behavior Scale (VABS-II). Sleep-wake patterns, behavior and quality-of-life questionnaires were also reported at each visit using parent/caregiver reported outcome tools. All patients had early onset severe MPS IIIA, were diagnosed before 74 months of age, and had cognitive scores below normal developmental levels at baseline. Patients less than 40 months of age at baseline were more likely to continue developing new skills over the first 6-12 months of follow-up. There was a high variability in cognitive developmental age (DA) in patients between 40 and 70 months of age; two-thirds of these patients already had profound cognitive decline, with a DA ≤10 months. The highest cognitive DA achieved in the full study cohort was 34 months. Post hoc, patients were divided into two groups based on baseline cognitive DQ (DQ ≥50 or <50). Cognitive DQ decreased linearly over time, with a decrease from baseline of 30.1 and 9.0 points in patients with cognitive DQ ≥50 at baseline and cognitive DQ <50 at baseline, respectively. Over the 2-year study, VABS-II language scores declined progressively. Motor skills, including walking, declined over time, although significantly later than cognitive decline. No clear pattern of sleep disturbance was observed, but night waking was common in younger patients. Pain scores, as measured on the quality-of-life questionnaire, increased over the study period. The findings of this study strengthen the natural history data on cognitive decline in MPS IIIA and importantly provide additional data on endpoints, validated by the patient community as important to treat, that may form the basis of a multidomain endpoint capturing the disease complexity.

Pain Phenotypes in Adults Living With Cerebral Palsy

Background and Objectives

To identify pain phenotypes among adults living with cerebral palsy (CP) and compare phenotypes of pain intensity, anxiety and depressive symptoms, and self-reported perceived stress.

Methods

Seventy-one adults with CP presented to the University of Michigan (mean age = 39.3 ± 16.2; 43 women, 28 men). The median of 6 on the American College of Rheumatology fibromyalgia survey was used to classify patients for nociplastic pain centralization. The painDETECT Score was used to classify patients for neuropathic pain. These measures were then used to cross-classify each patient into 1 of 4 possible pain categories: neuropathic, nociplastic, mixed neuropathic/noclipastic, or nociceptive pain (-neuropathic/-nociplastic pain).

Results

Twenty-eight adults with CP (39.4%) were classified as nociceptive, 24 (33.8%) as nociplastic, 8 (11.3%) as neuropathic, and 11 (15.5%) as mixed neuropathic/nociplastic. Subgroups differed significantly on average scores on the Brief Pain Inventory pain intensity scale, the Perceived Stress Scale, and on the Patient-Reported Outcomes Measurement Information System measures of anxiety and depression; the nociceptive pain subgroup reported lower pain and emotional distress compared with the other groups.

Discussion

Findings suggest that type of pain is variable among adults with CP and may arise through multiple mechanisms.

A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurologic Impairment

The term “severe neurologic impairment” (SNI) is used to describe a group of disorders of the central nervous system which arise in childhood, resulting in motor impairment, cognitive impairment and medical complexity. As a result, much assistance is required with activities of daily living. Since these patients are often unable to self-report pain, or they may exhibit uncommon behaviors when suffering, pain manifestations may go unrecognized. In this article, the basic principles of how to approach pain in children with SNI are discussed.

Old Drug, New Pain. Roles and Challenges of Methadone Therapy in Pediatric Palliative Care: A Systematic Review

BACKGROUND

Pediatric palliative care (PPC) is defined as the prevention and relief from suffering of families and children with life-limiting (LLDs) or life-threatening diseases (LTDs). These patients often experience pain, with morphine being the most widely used drug to treat it. Few studies investigated the role of methadone in PPC patients, although it is considered among the most effective and underutilized drugs in PPC.

OBJECTIVES

Our aim was to evaluate the efficacy, safety, and dosage of methadone in PPC.

METHODS

Between August and October 2021 PubMed, Scopus and the Cochrane Library were searched for studies on the use of methadone in children with LLDs and LTDs. Articles were included if they met the following criteria: published in the last 10 years, English language, patients aged 0-23 years; children enrolled in a PPC center or receiving declared support from a PPC service; reporting of specific data on methadone in interventional trials, observational studies, or case series on >10 patients. The reporting of the article was guided by the PRISMA guidelines, and a critical appraisal of the included studies was performed using the JBI-tool.

RESULTS

After duplicates removal and full-text assessment, four studies were included and another one was added after checking the references of the retrieved papers. All were retrospective, and the literature is concordant in documenting the lack of evidence. A total of 116 children received methadone in PPC. From our review emerges the poor quality of data collection: in only one study pain was assessed with standardized scales. All studies documented the effectiveness of methadone in treating complex pain, either nociceptive or neuropathic. No serious adverse events were reported, with no cases of cardiac arrhythmias.

CONCLUSION

Our results suggest that methadone could represent a suitable strategy for treating pain in PPC. However, the evidence base is insufficient, and further research is warranted.

CHRONIC PAIN AND PHYSICAL THERAPY IN CHILDREN WITH PARALYTIC SYNDROMES: ARE THERE ANY CHANGES DURING LOCKDOWN?

OBJECTIVE

The aim: To evaluate an influence of physical therapy on chronic pain in children with paralytic's syndrome and to maternal emotional status on lockdown time during the COVID-19 pandemic.

PATIENTS AND METHODS

Materials and methods: Data from 96 children and their mothers (96 persons) were included in the study. On-site services of physical therapists before the pandemic (2018- 2019) were received by 64 children and by 32 children during quarantine measures due to COVID-19 pandemic (2020). The age of the children ranged from 1 to 6 years, the median age was 3 years and 3 months.

RESULTS

Results: We note that there were more boys with paralytic syndromes. Among the leading paralytic syndromes, the most common was spastic tetraparesis. The frequency of children with level III-V motor disorders prevailed.

CONCLUSION

Conclusions: The authors consider that physical rehabilitation in children with paralytic syndromes reduces the incidence of moderate chronic pain and improves the emotional state of parents. But, these changes do not occur during the pandemic.