Opioids for Pediatric Pain Management

OBJECTIVES

To study the efficacy and adverse effects of opioids in management of pain in children.

METHODS

A descriptive study was conducted in children aged below 15 years with moderate to severe pain, and response to opioids and adverse effects were assessed at 24, 48 and 72 hours after administration.

RESULTS

100 children (68% males) with median (IQR) age of 6.5 (3.5,10) years were studied. 81% (n=81) children with moderate pain and 78.9% (n=15) with severe pain responded to opioids in 72 hours. Among children with severe pain of non-malignant origin, 80% (n=8) responded in 48 hours compared to 11.1% (n=1) with malignancy and this difference was statistically significant at 24 hours (P=0.005). Of children with severe pain 73.7% (n=14) developed adverse reactions compared to 30.9% (n=25) with moderate pain.

CONCLUSIONS

Children with moderate-severe pain, either of malignant or non-malignant origin could be managed effectively with opioids without severe adverse effects.

Cutaneous manifestations of chikungunya during a recent epidemic in Calicut, north Kerala, south India

BACKGROUND

There was a recent epidemic of chikungunya (CKG) in Calicut and other northern districts of Kerala, South India, affecting thousands of people.

AIMS

To study the cutaneous manifestations of CKG and to have a serological and histopathological correlation.

METHODS

A total of 162 patients (63 males and 99 females) with cutaneous manifestations of CKG were enrolled in the study and serological confirmation was done with capture IgM ELISA for CKG. Skin biopsy was done in all representative cases.

RESULTS

Cutaneous manifestations were found more in females. There were 23 children, the youngest being 39 days old. Generalized erythematous macular rash was the most common finding. Vesicles and bullae were also common especially in infants. Localized erythema of the nose and pinnae, erythema and swelling of the pre existing scars and striae and toxic epidermal necrolysis-like lesions sparing mucosae were the other interesting findings. Different types of pigmentation were observed with a striking nose pigmentation in a large number of patients, by looking at which even a retrospective diagnosis of CKG could be made. Hence we suggest this peculiar pigmentation may be called "chik sign". There was flare up of existing dermatoses like psoriasis, lichen planus and unmasking of Hansen's disease with type 1 reaction. Serological tests were positive in 97%. Some hitherto unreported histopathologic findings like melanophages in the erythematous rashes were observed.

CONCLUSION

A spectrum of cutaneous manifestations of CKG with a wide variety of unusual presentations with confirmed serological and histopathological evidence was encountered.

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

OBJECTIVE

To assess the effectiveness of a structured communication skills training workshop on the perceptions and practice of pediatric residents.

METHODS

The perceptions and practice of pediatric residents with regard to doctor- patient (parent) communication were evaluated before and 6 weeks after a communication skills training workshop, using a structured questionnaire.

RESULTS

Twenty pediatric residents participated in the study. They included nine residents who had completed 1 year of pediatric training and 11 residents who had completed 2 years or more of pediatric training. 9 were female residents and 11 were males. Before the intervention, majority of the residents rated themselves poorly on assessment of their perceptions and practice of communication skills. After the workshop there was overall improvement in the communication skills of the residents.

CONCLUSIONS

Communication skills of pediatric residents are generally inadequate. Structured training programs will help to improve their communication skills. There is a need to incorporate communication skills training in the pediatric postgraduate curriculum.

Acute disseminated encephalomyelitis presenting as acute psychotic disorder

A 5 year old boy and a 10 year old girl presented with acute onset of psychotic disorder, which occurred one week after an upper respiratory infection. MRI images of brain were consistent with the diagnosis of acute disseminated encephalomyelitis (ADEM) in both cases. ADEM is one of the differential diagnoses to be considered when acute psychotic disorder occurs during childhood.

Revesz syndrome

A 5-year-old girl was admitted with pallor, hypopigmented sparse hair, tongue ulcers, atrophic nail changes, hypoplastic anemia and bilateral exudative retinopathy. A diagnosis of Revesz syndrome was made. She had the additional features of retinal detachment and retinitis pigmentosa, which are hitherto unreported in this syndrome.

Poland syndrome (anomaly) with congenital hemangioma: A new association

Unilateral defect of pectoral muscle and ipsilateral syndactyly constitute Poland syndrome. Absence or hypoplasia of the breast and nipple, axillary hair loss and dermatoglyphic abnormalities have also been reported in this syndrome. The primary defect could be in the development of the proximal subclavian artery with early deficit of blood flow to the distal limb and the pectoral region, resulting in partial loss of tissue in those regions. However, the association of congenital hemangioma with Poland sequence has not been observed so far. Such an association is being reported here in a 1-year-old infant, second-born of nonconsanguineous parents, who also had polydactyly instead of the documented syndactyly.

Focal dermal hypoplasia (Goltz syndrome)

A 7-year-old girl born of non-consanguineous marriage was evaluated for facial dysmorphism. She had multiple skeletal anomalies like hypoplasia of the right mandible, narrow nasal bridge with broad tip and unilateral notching of the right ala nasi, concomitant squint and low set ears. She also had generalized hypopigmented, atrophic linear macules, multiple papillomas, fat herniations, umbilical hernia, hypoplastic nails, cicatricial alopecia, mild mental retardation, 'lobster-claw' hand and osteopathia striata of long bones, pointing to a diagnosis of Goltz syndrome. The unusual features noted were absence of the left first rib and aortic regurgitation.

Hemihypertrophy and primary small intestinal lymphangiectasia in incontinentia pigmenti achromians

A rare occurrence of primary small intestinal lymphangiectasia in an 8-year-old girl with incontinentia pigmenti achromians is reported. In addition, she had right sided hemihypertrophy. Though intestinal lymphangiectasia is known to have a few syndromic associations, its co-existence in a child with incontinentia pigmenti achromians has not yet been reported in the literature. Hemihypertrophy is also extremely rare in the latter and only very few instances of an association between the two have been documented previously.

Hemihypertrophy and primary small intestinal lymphangiectasia in incontinentia pigmenti achromians

A rare occurrence of primary small intestinal lymphangiectasia in an 8-year-old girl with incontinentia pigmenti achromians is reported. In addition, she had right sided hemihypertrophy. Though intestinal lymphangiectasia is known to have a few syndromic associations, its co-existence in a child with incontinentia pigmenti achromians has not yet been reported in the literature. Hemihypertrophy is also extremely rare in the latter and only very few instances of an association between the two have been documented previously.

De sanctis cacchione syndrome

A case of de Sanctis Cacchine syndrome in a female infant is presented.

Goldenhar syndrome with unusual features

We report two cases of Goldenhar syndrome in whom bilateral ocular and auricular changes were observed. One patient also had hypertelorism, macrophthalmia and bulbous nose.

Nalidixic acid induced pseudotumour cerebri in children

Nalidixic acid, the quinolone frequently used in the treatment of acute dysentery, is now emerging as an important cause of pseudotumour cerebri in infants and young children. A study of 20 such cases showed that all the patients had received a higher than recommended dose of nalidixic acid and that 85% of them were given the drug unnecessarily (i.e., for acute watery diarrhoea). A high concentration of the drug in the commercial preparations as well as the lack of awareness about this among doctors, especially the general practitioners, is the possible contributory factor leading to this situation. A simple measure of bringing down the concentration of nalidixic acid in the available preparations and sticking to oral rehydration solution alone in the treatment of acute watery diarrhoea, can bring down the incidence of this condition.