Pain In Children Research Articles

Neuroparalytic Snake Bite Masquerading as Acute Abdominal Pain in Children

Background: Neurotoxic snakebite (usually by the krait) presents with abdominal colic and chest pain as a common premonitory sign of envenomation. Being a nocturnal snake, the time of unprovoked painless biting is usually at night and the victims are individuals sleeping on the ground. Thus, history is usually not forthcoming. Snakebite causes morbidity (neuroparalytic, myopathic, vasculopathic, venom-induced consumption coagulopathy, cardiotoxic, nephrotoxic, etc.), and mortality if not given timely treatment with anti-snake venom (ASV), the only specific treatment. Clinical Description: We present four children from a rural background who were admitted successively over a month during the last rainy season. They initially became symptomatic with acute abdominal pain from midnight to early morning time and developed neuroparalytic manifestations within a few hours. On exclusion of other causes by clinical evaluation, we suspected snakebite envenomation though there was no witnessing of the event or evidence of fang bites. Investigations to rule out commonly associated organ dysfunction were ordered. Management: All children were given supportive therapy. Three cases required mechanical ventilation. The first two received ASV relatively late as the suspicion of snakebite was not considered initially. In the third case, the administration of ASV was early and the hospital stay was shorter. The fourth case received ASV at a peripheral health center and was referred in case he required ventilator support. However, his neuroparalysis did not progress to respiratory failure and he was discharged the earliest. Conclusions: Clinicians should consider snakebite in children belonging to rural areas who present with acute abdominal pain during the rainy season, and monitor for signs of neurotoxicity and other clinical manifestations of snake envenomation. A high index of suspicion should be kept, as definitive treatment with ASV results in early recovery without any sequelae, and reduces mortality.

Effect of Deep Breathing Exercise using Smartwatch on Behaviour, Anxiety and Pain in Children during Buccal Infiltration Anaesthesia-A Randomised Clinical Trial

Introduction: Despite the newer innovation and recent technological advances in modern dentistry, fear and anxiety constitute an important theme in dentistry. They are a usual reaction to stressful conditions that help children while staying alert in situations of an impending threat. Aim: To evaluate the effect of deep breathing exercise in reducing dental anxiety, behaviour and pain using smartwatch during maxillary buccal infiltration in children aged 7-11 years. Materials and Methods: A prospective interventional and single-blinded randomised clinical trial conducted in the Department of Paediatric and Preventive Dentistry, NDCH, Nellore, Andhra pradesh, India, from November 2019 to October 2020. A total of 70 children of age between 7-11 years. They were randomly allocated into two groups, 35 in each. Children in group I were trained for deep breathing exercise using smartwatch and group II (control group) was traditional tell show do technique. The reaction of children during maxillary buccal infiltration anaesthesia was recorded in terms of behaviour (Frankl behaviour rating scale), anxiety {Facial Image Scale (FIS) and pulse rate}, and pain perception (Wong-Baker FACES pain rating scale and face, leg, activity, cry and consolability scale). Data was tabulated using Kolmogorov-Smirnov test and Kruskal-Wallis for data distribution. Independent Student’s t-test or Mann-Whitney test (Quantitative variables) and Chisquare test or Mann-Whitney test (Qualitative variables) were used to test statistical significance using Statistical Package for Social Sciences (SPSS) version 25.0. Results: The mean age of children in smartwatch group was 8.9±1.4 years and in control group was 8.9±1.6 years with no statistical significant difference. Statistically significant decrease in pulse rate was observed in smartwatch group (p=0.003), subjective anxiety and pain was lowered in intervention group. Objective pain was decreased significantly in smartwatch group (p=0.007). Conclusion: Children performing deep breathing exercise using smartwatch had efficiency to reduce dental anxiety and pain perceived during maxillary buccal infiltration anaesthesia.

Saphenous Nerve Schwannoma: A Rare Differential Diagnosis of Knee Pain in Children

Schwannomas are uncommon benign tumors of the peripheral nerves with a low risk of malignant transformation. They rarely affect children, can affect any part of the body but rarely occur in the lower extremity and typically present with a palpable mass, pain or neurological signs. Imaging helps to orient the diagnosis and anatomopathological examination helps to confirm it. We report a case of a 12-year-old girl who presented with left knee pain with subcutaneous mass overlying the tibial tuberosity medially. Clinical examination revealed a positive Tinel's sign. Magnetic resonance imaging (MRI) of the knee was performed, which revealed an encapsulated subcutaneous soft tissue mass overlying the tibial tuberosity medially, eccentric to the course of the infrapatellar branch of the saphenous nerve. The patient was operated with total intracapsular excision of the lesion and the anatomopathological study of the surgical specimen came back in favor of a schwannoma. Postoperatively, the patient showed a good recovery with disappearance of pain and swelling.

Evaluation of Paste and Aqueous Lubricants on the Incidence of File Breakage, Quality of Obturation and Postoperative Pain in Children after Pulpectomy in Primary Teeth: A Randomised Clinical Trial

Introduction: Pulpectomy in primary teeth involves various steps, including tooth isolation, access opening, canal instrumentation, and obturation. Lubricants are commonly used in the biomechanical preparation of root canals to suspend and emulsify debris generated by the mechanical action of hand and rotary files. While paste-type lubricants (Prime Dental RC Help) and aqueous lubricants (17% aqueous Ethylenediaminetetraacetic acid [EDTA]) are available for use, there is a lack of studies in the literature documenting the effects of these lubricants on file fracture, obturation quality, and postoperative pain. Aim: To compare the effects of paste-type lubricants with aqueous lubricants on file breakage, quality of obturation, and postoperative pain in children treated with pulpectomy in primary teeth. Materials and Methods: This randomised clinical trial involved 40 primary teeth, evenly distributed for instrumentation using Kedo-S Plus pediatric rotary files. In Group 1 (n=20), paste-type lubricant was used during canal preparation, while in Group 2 (n=20), aqueous lubricant was used. The clinician recorded data on file fractures, evaluated the quality of obturation using immediate postoperative radiographs, and measured postoperative pain using the Four-point facial pain intensity rating scale. Descriptive statistics were performed once the data was tabulated. Results: Total of 40 primary teeth were included, participants aged 4-9 years, 22 girls and 18 boys. There was no incidence of file fracture in the group-2 treated with aqueous lubricants. Regarding the quality of obturation, the group-1 treated with paste-type lubricant had a higher number of under-fill and over-fill cases (p=0.002, 0.001), while no statistically significant difference was observed between the groups in terms of optimal fill (p=0.661). At 6, 12, 24, and 48 hours, there was no difference in pain experienced by the participants in both groups (p>0.05). Conclusion: During rotary instrumentation in primary teeth, aqueous lubricants were found to be more effective than pastetype lubricants in preventing file breakage, providing optimal obturation quality, and reducing postoperative pain.

Etiological Evaluation in Children Referred to the Pediatric Cardiology Outpatient Clinic with Chest Pain.

One of the most common reasons for pediatric cardiology referrals is chest pain in childhood. Although it is mostly innocent in character, it is rarely associated with life-threatening pathologies. In this study, it was aimed to evaluate the etiological causes in children with chest pain. Our study included 1000 children who were referred to the pediatric cardiology clinic with the complaint of chest pain between January 2019 and June 2022. Demographic characteristics, accompanying complaints, echocardiographies, electrocardiographies, 24-h rhythm holters, treadmill exercise test, computed tomography angiography, and non-cardiac findings related to etiology were analyzed retrospectively from the file archives of the patients. Five hundred and nine (50.9%) of the patients were female and 491 (49.1%) were male. The mean age of the patients was 11.3 y (range: 3-18 years). Cardiological pathology associated with chest pain was detected in only 6.8% of the patients. Among the etiologies of chest pain, mitral valve prolapse (MVP) was the most common cardiological pathology with a rate of 2.1%. In the non-cardiac etiological evaluation of chest pain, idiopathic causes with a frequency of 48%, musculoskeletal pathologies with a frequency of 22.6%, respiratory pathologies with a frequency of 7.9%, psychiatric pathologies with a frequency of 7.3%, gastrointestinal pathologies with a frequency of 4.1%, and familial Mediterranean fever with a frequency of 2.4%, miscellaneous with a frequency of 1.1% were found, respectively. In the study, it was determined that non-cardiac causes were more common among the etiological causes of chest pain in the pediatric age group. In addition, MVP was the most common cause of cardiac chest pain.

ЖУРНАЛ «КРАПИВА»: НЕЗАВИСИМОЕ ТВОРЧЕСКОЕ СООБЩЕСТВО НАЧИНАЮЩИХ АВТОРОВ

The characteristic of the children’s literary and journalistic periodical “Krapiva” (Nettle) is offered. The journal has been published in Yekaterinburg since 2017 at the Sverdlovsk Regional Library for Children and Youth named after Vladislav P. Krapivin, curated by the young playwright Anna Baturina. The periodicity of issues is once a year; to date, six issues of the journal have been published. The editorial board consists of children, they also select texts for publication, prepare the original layout of the issue and its design (drawings, photographs). An analysis of editorial statements in the journal and interviews with the curator allow us to conclude that the publication is unique: the authors are absolutely free in their work; the tactic and position of the curators are extremely democratic. From the very beginning, “Krapiva” (Nettle) declared itself not only as a journal, but, above all, as a platform for weekly communication, discussion of the problems that concern today’s teenagers. At community meetings, new works of participants are discussed, meetings with writers are held, questions of the theory and poetics of literature are studied. The choice of the name (apart from the reference to Krapivin, whose name the library bears) is motivated by the desire of aspiring authors to share traumatic experiences like stinging nettles. The epigraph to the magazine is the words of one of the participants: “Nettle is the pain of childhood”. The article characterizes the headings of the journal, identifies the dominant themes, and makes observations on the genre composition of the published works.

Parental oral health literacy influences preschool children's utilization of dental services.

Parental behavior towards their children's oral health is strongly influenced by parent's Oral Health Literacy (OHL) level. This study evaluated the impact of parental OHL on preschool children's utilization of dental services. A cross-sectional study was conducted with parents of 419 children aged 3 to 5 years who answered a self-administered questionnaire about their perception of their children's oral health and whether their children had already been to a dental visit. Parental OHL level was assessed by the validated version of the Oral Health Literacy Adult Questionnaire (OHL-AQ) translated into Brazilian Portuguese. Univariate and multivariate Poisson regression analyses with robust variance were used for the data analysis (α = 0.05). Most children had already been to a dental visit (73%). Overall, 31.7% of the parents or guardians reported that their children had experienced dental pain or dental caries. Parental OHL level was classified by tercile as low, medium, and high. The final model showed independent associations between children who had already been to a dental visit and higher parental OHL level (PR = 1.16; 95%CI = 1.00-1.35) when compared to the lowest OHL level, higher parental educational level (PR = 1.39; 95%CI = 1.03-1.87) when compared to lower educational level, the report of children's pain and dental caries (PR = 1.22; 95%CI = 1.09-1.36) and married parents or parents in a common-law marriage (PR = 1.17; 95%CI = 1.03-1.93). The prevalence of children who had already been to a dental visit was higher among those parents with a higher OHL level when compared to those with a lower OHL level.

Exploring the needs of children and caregivers to inform design of an artificial intelligence-enhanced social robot in the pediatric emergency department.

Socially assistive robots (SARs) are a promising tool to manage children's pain and distress related to medical procedures, but current options lack autonomous adaptability. The aim of this study was to understand children's and caregivers' perceptions surrounding the use of an artificial intelligence (AI)-enhanced SAR to provide personalized procedural support to children during intravenous insertion (IVI) to inform the design of such a system following a user-centric approach. This study presents a descriptive qualitative needs assessment of children and caregivers. Data were collected via semi-structured individual interviews and focus groups. Participants were recruited from two Canadian pediatric emergency departments (EDs) between April 2021 and January 2022. Eleven caregivers and 19 children completed 27 individual interviews and one focus group. Three main themes were identified: A. Experience in the clinical setting, B. Acceptance of and concerns surrounding SARs, and C. Features that support child engagement with SARs. Most participants expressed comfort with robot technology, however, concerns were raised about sharing personal information, photographing/videotaping, and the possibility of technical failure. Suggestions for feature enhancements included increasing movement to engage a child's attention and tailoring language to developmental age. To enhance the overall ED experience, participants also identified a role for the SAR in the waiting room. Artificial intelligence-enhanced SARs were perceived by children and caregivers as a promising tool for distraction during IVIs and to enhance the overall ED experience. Insights collected will be used to inform the design of an AI-enhanced SAR.

Effects of eyeshades in sleep quality and pain after surgery in school-age children with supracondylar humeral fractures.

This study aimed to explore the effects of eye masks on the sleep quality and pain of children over 5 years old with humeral supracondylar fracture after surgery. Fifty children with humeral supracondylar fracture who underwent closed reduction and percutaneous pinning (CRPP) in the Pediatric orthopaedic Department of a provincial hospital in China from February 2020 to December 2021 were selected. The children were randomly divided into the experimental group (n = 25) and the control group (n = 25). Children in the control group were given routine sleep care, and the children in the experimental group were given a sleep intervention with eye masks for three nights after surgery. The Pittsburgh Sleep Quality Index was used to evaluate the sleep quality of the children. The Children's Pain Behaviour Scale was used to evaluate the pain of the children. After three nights of receiving the eye mask intervention, the children in the experimental group had significantly lower sleep quality scores than those in the control group; the difference was statistically significant (p < 0.05), and the children in the experimental group had higher sleep quality. The experimental group's pain scores were significantly lower than the control group's, and the difference was statistically significant (p < 0.05), and the children in the experimental group experienced less post-operative pain. Eye masks are a simple, safe and economical intervention, that is beneficial for improving the sleep quality and reducing pain in children over 5 years old with humeral supracondylar fracture after closed reduction and percutaneous pinning. It can be used as a reference and basis for clinical pain relief and sleep quality after surgery for supracondylar fractures of the humerus in children.

Advances in the Cognitive Management of Chronic Pain in Children through the Use of Virtual Reality Combined with Binaural Beats: A Pilot Study

Chronic pain affects the quality of life of those affected. The need to investigate alternative and complementary methods to the pharmacological one to alleviate chronic pain is evident, so virtual reality and binaural tones have become a topic of interest in this field in recent years. This study aims to analyze the contributions of the combination of these two techniques in pediatric patients with chronic pain. For this, data on psychophysiological responses (heart rate and galvanic skin response) and pain perception are collected during and after interaction with this technology using a mixed pre- and posttest experimental methodology. The physiological data and answers in the Pediatric Pain Questionnaire (PPQ) have been collected in a sample of n = 13 healthy participants and n = 9 pediatric patients with chronic pain. The results show a significant difference between baseline and after applying virtual reality and binaural beats, md = 1.205 (t = 3.32; p &lt; 0.05 ). There are great effects on the perception of chronic pain if virtual reality and binaural beats are combined, even greater than with virtual reality alone, making this combination of technologies a very useful tool to be exploited for the management of chronic pain in pediatric patients with rheumatic diseases.

Chronic Pain and High Impact Chronic Pain in Children and Adolescents: A Cross-Sectional Study

The aims of this study were to: 1) estimate the prevalence of chronic pain (CP) and high impact chronic pain (HICP) in a community sample of children and adolescents; and 2) compare groups (those without CP, those with CP but no HICP, and those with HICP) with respect to demographic variables, pain variables, and physical, psychological, and school-related function. One thousand one hundred and fifteen children and adolescents participated (56% girls; age: ߂ = 11.67; SD = 2.47; range = 8–18 years). The prevalence of CP and HICP was 46% and 5%, respectively, and was higher in girls and increased with age. Participants with HICP reported greater pain intensity and higher pain frequency than those with CP but no HICP. In addition, participants with HICP reported lower mobility, greater fatigue, worst sleep quality, more anxiety and depression symptoms, worst cognitive function, missing more school days, and worse perceived school performance. HICP is a prevalent condition in children and adolescents and is associated with many negative consequences. Stakeholders must be aware of this and ensure that treatment programs are available to reduce the individual and societal impact of HICP in young individuals. PerspectiveThis article provides information on CP and HICP prevalence and impact in children and adolescents. By better understanding the nature and score of these conditions, we will be able to develop more effective early interventions to help this population and thereby reduce their long-term negative impact.

641 A CONTROVERSIAL CASE OF FABRY DISEASE: ADDING ANOTHER PIECE TO THE INTERPRETATION PUZZLE OF C.376A&amp;gt;G MISSENSE MUTATION, A PATHOGENIC VARIANT

Abstract Background The association between chronic neuropathic pain in childhood, left ventricular hypertrophy(LVH), early ischemic stroke and unexplained renal failure is suggestive of FD. However, because of the heterogeneity of the genetic substrate, different and more subtle phenotypic manifestations are possible as well as single organ involvement. Diagnostic criteria require an initial measurement of both alpha-galactosidase A (α-Gal-A) activity levels in leukocytes and globotriaosylsphingosine (LysoGb3, a glycosphingolipid derivative) concentration. Genetic testing is needed to confirm the diagnosis if α-Gal-A is decreased or absent and Lyso-Gb3 is increased. Case report A 35-year-old man was referred to our outpatient cardiology clinic at the beginning of summer 2022. He had a family history of sudden death, he had no cardiovascular risk factors and a history of severe acral pain during childhood. On medical background, he had undergone renal transplantation after two years of hemodialysis therapy due to nephroangiosclerosis and tubulointerstitial nephritis, identified in renal biopsy. On physical examination were visible neither angiokeratomas nor ocular manifestations. ECG showed LV hypertrophy and a transthoracic ECO confirmed LV concentric hypertrophy, a preserved LV ejection fraction and the presence of unexplained subtle LV systolic dysfunction due to an abnormal LV global longitudinal strain. Laboratory tests revealed normal serum creatinine and elevated NT-ProBNP levels. Unfortunately, a CMR examination was not performed because of the patient's claustrophobia. Genetic and enzymatic analyses were performed on the high suspicion of a cardiac storage disorder. The enzymatic activity of α-Gal-A and lyso-Gb3 concentration was within normal values, whereas genetic analysis detected a missense mutation (c.376A&amp;gt;G) in exon 3 causing an amino acid substitution (p.S126G). The suspicion of FD was confirmed. Discussion This is an interesting case with a diagnosis of FD that is controversial for several reasons. The c.376A&amp;gt;G is a rare mutation, found mainly in female patients with normal α-Gal-A and LysoGb3 levels ​​and associated with isolated renal failure. In addition, this variant is typically responsible for the late onset of the disease, occurring after 40 years of age2,8–11. Our patient is young and presents early cardiac and severe nephrological involvement, both typical clinical features of FD. A normal activity of α-Gal-A is consistent with the missense gene mutation: enzyme activity appears to be normal up to at least 90-95% reduction of function. To date, there is little evidence in the scientific literature of similar cases and the clinical presentations associated with this mutation are contradictory. Since 2002, c.376A&amp;gt;G has been known to be a pathogenetic variant of FD12, in 2010 it was associated to late-onset disease13. However, in the International Fabry Disease Genotype-Phenotype Database, it is considered a likely benign variant of FD2. Conclusion In this case report, we emphasize that high clinical suspicion should lead to more diagnostic evaluations, including genetic testing in the daily routine. Additional studies are needed to better understand the role of the c.376 A&amp;gt;G mutation in the FD.

Care of suspected long bone fractures in the emergency department: Families' perspectives and priorities

ObjectiveDespite growing interests in patient-reported outcomes, youth and families are rarely involved in designing quality improvement measures. Few quality indicators exist for the care of children with injuries in the Emergency Department (ED) and extremity fractures are among the most common injuries in children. This study's aim was to identify both parents' and youth's perspectives about ED care in the context of a suspected long-bone fracture. MethodsYouth (10–18 years old) and their parents were surveyed prospectively during their ED visit. Participants were asked: 1) to identify their main concerns, 2) to identify quality measures that were most important to them, and 3) to evaluate the ED care they received. Descriptive analyses present participants' responses. Continuous data was analyzed using a Student t-test and categorical data using a Chi-square test. ResultsOver 15 months, 350 families met eligibility criteria and were approached to participate, of which 300 participants consented and 249 surveys were completed (71% response rate): 148 parents and 101 youth (median age: 12) completed their respective surveys. Participants placed a high importance on several themes: pain management, short length of stay, and quality interactions with ED clinicians. Youth as a group prioritized their overall wellbeing and the ED environment (e.g., waiting room comfort, signage), while parents focused on accurate diagnoses and treatments. The following items were less prioritized: that radiology be close to the ED, to see the radiograph, to have access to a wheelchair, to know the identities of clinicians on the team, and to have access to entertainment. Parents and youth within the same family often did not share the same priorities. Ninety-two percent of parents reported their child's pain was treated, while 81% and 63% of youth reported their pain was treated sufficiently and quickly, respectively. ConclusionsParents and youth can identify their priorities for ED care and should be engaged in efforts to improve and report on the quality of care in the ED. Youths' and parents' perspectives are complimentary and may not align, even within families. The priorities identified in this study can help inform quality improvement initiatives and personalized patient care.

Characterizing the Pain Experience of Children With Acute Gastroenteritis Based on Identified Pathogens.

Pain is common with acute gastroenteritis (AGE) yet little is known about the severity associated with specific enteropathogens. We sought to explore the correlation of pain severity with specific enteropathogens in children with AGE. Participants were prospectively recruited by the Alberta Provincial Pediatric EnTeric Infection TEam at 2 pediatric emergency departments (EDs) (December 2014-August 2018). Pain was measured (by child and/or caregiver) using the 11-point Verbal Numerical Rating Scale. We recruited 2686 participants; 46.8% (n = 1256) females, with median age 20.1 months (interquartile range 10.3, 45.3). The mean highest pain scores were 5.5 [standard deviation (SD) 3.0] and 4.2 (SD 2.9) in the 24 hours preceding the ED visit, and in the ED, respectively. Prior to ED visit, the mean highest pain scores with bacterial detection were 6.6 (SD 2.5), compared to 5.5 (SD 2.9) for single virus and 5.5 (SD 3.1) for negative stool tests. In the ED, the mean highest pain scores with bacterial detection were 5.5 (SD 2.7), compared to 4.1 (SD 2.9) for single virus and 4.2 (SD 3.0) for negative stool tests. Using multivariable modeling, factors associated with greater pain severity prior to ED visit included older age, fever, illness duration, number of diarrheal or vomiting episodes in the preceding 24 hours, and respiratory symptoms, but not enteropathogen type. Children with AGE experience significant pain, particularly when the episode is associated with the presence of a bacterial enteric pathogen. However, older age and fever appear to influence children's pain experiences more than etiologic pathogens.

Efficacy of Hyoscine Butylbromide Versus Drotaverine in Relieving Acute Nonspecific Abdominal Pain in Children- A Non - Randomized Trial

Introduction: Acute abdominal pain is a very common complaint for children presenting to the emergency department (ED). The purpose of this study was to compare efficacy of hyoscine and drotaverine for relieving acute nonspecific abdominal pain in children presenting to ED. Methods: Total of 52 children aged six years to 16 years were enrolled in a non-randomized trial at Paediatric ED of TUTH from Dec 2017 to June 2018, and randomly allocated to drotaverine or hyoscine groups; 26 in each group. Face pain score-revised tool was used to measure the efficacy of the drug. The primary outcome was to measure the reduction of face pain score (Self-reported) by at least 2 / 10 at 60 minutes after ingestion of study intervention. Other outcomes were requirement of rescue analgesia and adverse effects of drugs. Results: A total of 20 (77%) in hyoscine and 21 (81%) in drotaverine group responded to oral medication at the end of 60 minutes of oral administration and the difference was not statistically significant (p=0.808). Vomiting was only adverse event present in five (19%) in drotaverine and two (8%) in hyoscine groups, respectively. Conclusions: In this single center randomized controlled trial, both hyoscine and drotaverine were found to be equally efficacious for relieving acute non-specific abdominal pain in children.

Culture, religion, language and the assessment and management of children's pain by expatriate nurses in Saudi Arabia: A qualitative study.

Unrelieved pain among hospitalized children is a common problemthat affects all aspects of children's health and their quality of life. Cultural and language differences between nurses and patients have been shown to impact the quality and safety of nursing care and management for children with pain. The aim of this study was to identify the cultural factors, barriers, and facilitators impacting the assessment and management of children's pain by expatriate nurses in Saudi Arabia. A qualitative descriptive design was employed in this study. A sample of 16 nurses was conveniently recruited and interviewed through face-to-face semistructured interviews. Each interview lasted between 30 and 60 min and was audio-recorded. Content analysis was used to analyze the transcripts. Transcripts were carefully read, significant statements were highlighted, coded, categorized, and clustered thematically. Three main themes were identified, namely, (I) low priority of children's pain, (II) culture and religious challenges, and (III) communication challenges. Cultural and language differences described by expatriate nurses hindered their care of children with pain. A systematic education for expatriate nurses, children, and families is urgently needed to enhance inter/cross-cultural understandings and improve childcare in Saudi Arabia. This study identifies the unique challenges faced by expatriate nurses in Saudi Arabia. The findings reveal how a lack of knowledge about cultural values and beliefs can lead to misunderstandings and conflicts between nurses, children, and familiesand can have animpact on childcare and pain. It also highlights the need to improve pain management practices in multicultural healthcare settings, similar to those of Saudi Arabia and neighboring Arab nations, and across the globe.

No associations between C-reactive protein and spinal pain trajectories in children and adolescents (CHAMPS study-DK)

Preliminary evidence points to a link between C-reactive protein (CRP) and spinal pain in adults. However, there is a paucity of research in younger populations. Therefore, we aimed to determine associations between CRP and spinal pain in childhood and adolescence. We identified trajectories of spinal pain from childhood to adolescence and investigated the associations between CRP and trajectory subgroups. Six- to 11-year-old children from 13 primary schools, were followed from October 2008 and until 2014. High-sensitivity CRP collected at baseline (2008) was measured using serum samples. The outcome was the number of weeks with non-traumatic spinal pain between November 2008 and June 2014. We constructed a trajectory model to identify different spinal pain trajectory subgroups. The associations between CRP and spinal pain trajectory subgroups were modelled using mixed-effects multinominal logistic regression. Data from 1556 participants (52% female), with a mean age of 8.4 years at baseline, identified five spinal pain trajectory subgroups: “no pain” (55.3%), “rare” (23.7%), “rare, increasing” (13.6%), “moderate, increasing” (6.1%), and “early onset, decreasing” (1.3%). There were no differences in baseline high-sensitivity CRP levels between spinal pain trajectory subgroups. Thus, the heterogeneous courses of spinal pain experienced were not defined by differences in CRP at baseline.

Effectiveness of the "pain-free dental injection" (PaFein) teaching model in reducing children's pain: A randomized, controlled study.

This study explores the effectiveness of a comprehensive structured teaching model - the "PaFein" - for instructing postgraduate pediatric dental residents in the provision of pain-free local anesthesia to children. Ten postgraduate pediatric dental residents and 172 children between the ages 5 and 13 participated in the study following ethical approval. The previously measured baselines guided the randomization of study and control groups. The study group (five residents) attended the PaFein course (9hours). Based on power calculations, residents performed dental injections (8 mandibular block, 8 palatal/lingual and 14 buccal infiltrations) in randomly assigned child patients. Demographic data of residents/children, parental and self-report anxiety scores and Visual Analogue Scale (VAS) pain scores were noted to examine children's anxiety and pain during dental injections. Children's mean anxiety score did not differ significantly between groups; however, VAS pain reports during dental injections (a, b, c, d) were found lower in the PaFein study group than the control group (p<0.05). VAS pain reports for (a) buccal injections were 1.08 and 1.9 (p=0.02); (b) inferior alveolar nerve blocks were 1.58 and 3.37 (p=0.0002); (c) palatal/lingual injections were 1.34 and 3.02 (p<0.0001); (d) total means were 1.28 and 2.59, respectively (p=0.0001). VAS pain reports of anxious and non-anxious children in the PaFein study group (1.63 and 1.17) were also lower than the control group (3.33 and 2.39) (p<0.0001 and p=0.005). The "PaFein" teaching model was found to be effective in training dental residents to reduce dental injection pain in children, including the anxious ones.

No Specific Factors Associated with Risk of Readmission for Rebound Pain in Children with Sickle Cell Disease and Asthma Treated with Systemic Corticosteroids

Introduction: Asthma occurs in up to 28% of patients with sickle cell disease (SCD) and is associated with increased incidence of vaso-occlusive pain, acute chest syndrome (ACS), and mortality. Systemic steroids are the standard treatment for acute asthma and are often used in patients with SCD, especially as clinical symptoms of acute asthma exacerbations may often overlap with those of ACS. The risk of rebound pain following treatment with corticosteroids has been reported in other studies. However, the temporal association and the factors associated with the risk of rebound vaso-occlusive pain, specifically in those with co-morbid asthma diagnosis, have not been well described. Objective: To evaluate the temporal association between the use of systemic corticosteroids in patients with SCD and asthma and the factors associated with the risk of rebound vaso-occlusive pain. Methods: Patients with confirmed SCD and asthma, between ages 4-18 years of age, and admitted between 2006 and 2009, were eligible. Based on their associations with SCD and asthma, the co-variables of interest evaluated included hydroxyurea (HU) usage, age, sex, atopy, indication for hospitalization, and length of hospital admission. Participants were included if they received systemic glucocorticoids (dexamethasone, methylprednisolone, prednisone, prednisolone) during admission. Participants were excluded if they were receiving chronic blood transfusion therapies or participating in clinical trials involving blood transfusions. Our primary end-point was readmission for rebound vaso-occlusive pain within 14 days of the index admission. Continuous variables were analyzed with the mean (std. deviation) or median (inter-quartile range), based on the distribution, and compared by group with a t test or Somers'd statistic. Categorical variables were analyzed with counts (percent) and compared with a Chi-square statistic. All tests were adjusted for clustering by patients. Results: Fifteen distinct patients, 9 (60%) females, with a total of seventy-six admissions with administration of corticosteroids were included in the analysis (Table). Fifty-seven (75%) of admissions occurred in female patients with a median length of hospitalization of 3.0 days (IQR 2.0 - 4.8). Of the 76 episodes of corticosteroid use, 65 (85.5%) were due to a primary respiratory illness. There were twenty-eight (36.8%) readmissions for rebound vaso-occlusive pain with a median time to readmission of 3.0 (IQR 2.0 - 6.0) days. Amongst all patients, neither sex, history of atopy (>=2 positive skin sensitization tests), indication for hospitalization, or length of hospitalization were associated with the risk of readmission for rebound pain (p=0.425, p=0.540, p=0.721 respectively). Only 2 patients with 5 admissions were documented to be on HU and so we could not assess the relationship to rebound with HU usage. There was a trend for an association of history of early ACS and risk of rebound vaso-occlusive pain. Patients with ACS before the age of 4 were less likely to experience rebound vaso-occlusive pain compared to those without early ACS (P=0.051). Discussion: Our data shows that patients with sickle cell disease and asthma treated with corticosteroids are at risk for readmission due to rebound vaso-occlusive pain in more than one third of episodes (36.8%) following initial corticosteroid exposure. Our study did not identify any specific factors associated with risk of readmission for rebound pain following corticosteroid use. While corticosteroids are life-saving in status asthmaticus, the risk for rebound pain is significant and clinicians should work to optimize chronic asthma therapy to prevent the need for systemic corticosteroids in asthma exacerbations in patients with SCD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Ketamine Use for Management of Vaso-Occlusive Pain in Children with Sickle Cell Disease

Introduction: Sickle cell disease (SCD) vaso-occlusive pain episode (VOE) management often includes non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, which can be inadequate and associated with significant side effects. Ketamine, a dissociative anesthetic, produces potent analgesic effects by blocking N-methyl-D-aspartate (NMDA) receptors, which impairs sensitization of spinal neurons to nociceptive stimuli. This mechanism allows ketamine to mitigate neuropathic pain and modulate opioid tolerance and opioid-induced hyperalgesias. Although only FDA-approved for use as an anesthetic agent, limited data suggest that low-dose ketamine is a safe and potentially effective adjunctive treatment for VOE pain. Objectives: This study aimed to characterize ketamine use for VOE management in children with SCD. Method: This retrospective cohort study summarizes a single-center experience regarding the use of ketamine for inpatient management of VOE in 156 admissions from 2014 to 2020 in which 44 unique children received ketamine. Results: Continuous low-dose ketamine infusion was most commonly prescribed to adolescents as an adjunct to opioids (median starting dose 2.0 mcg/kg/min; median maximum dose 3.0 mcg/kg/min). Ketamine was started a median of 13.7 hours after admission. Median ketamine infusion duration was 3 days (IQR 1.8-4.3). For admissions in which opioid was decreased during ketamine infusion, the median time from start of ketamine infusion to first opioid dose adjustment was 12.5 hours (IQR 3.25-36.6). In most encounters (n=119, 76.3%), ketamine infusion was discontinued prior to opioid PCA discontinuation. In 33 (21.2%) of encounters, the ketamine dose was decreased within 6 hours prior to discontinuation. The majority of encounters (79.3%) had a reduction in either PCA dose, continuous opioid infusion, or both while receiving ketamine. Low-dose ketamine infusion was well-tolerated overall, with side effects noted in 21.8% (n=34) of encounters. The most common side effects included dizziness (5.6%), hallucinations (5.1%), dissociation (2.6%), and sedation (1.9%). Nearly all side effects were reversible, resolving within 24 hours of dose reduction (n=11, 78.6%) or infusion discontinuation (n=21, 95.5%). There was no significant difference in patient sex or age at admission between groups with reported side effects compared to those without. There was a significant difference in hemoglobin genotype between groups (p=0.005). In both groups, most patients had hemoglobin SS. However, a higher percentage of encounters with side effects included patients with hemoglobin SC. Further, a higher percentage of patients in the no side effect group received hydroxyurea before admission (p=0.032) (Table 2). There were no reports of ketamine withdrawal. In 11 (7.1%) encounters, benzodiazepines were administered during ketamine infusion; 7 intravenously and 4 enterally. In most cases (n=5, 45.5%) the benzodiazepine was given for anxiety, in 2 cases (18.2%) for spasticity, 2 (18.2%) for spasm, 1 (9.1%) for agitation and 1 (9.1%) for pain. Benzodiazepines were administered within 12 hours after ketamine initiation in only 3 cases. Most patients who received ketamine went on to receive it again during a subsequent admission (72.1%, n=98). Conclusion: Ketamine infusion should be considered when developing individualized pain plans for children with SCD, and it may be particularly beneficial for those who have a history of inadequate pain relief from opioids or dose-limiting opioid side effects. The variability of ketamine administration highlights the need for standardized protocols for ketamine use in VOE management. Further prospective study is needed to establish the efficacy of ketamine infusion and to determine optimal dosing, which may be patient-specific. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal