Face, Legs, Activity, Cry, Consolability Research Articles

The impact of oral melatonin on pain and anxiety reduction during venipuncture in pediatric patients: a double-blind randomized clinical trial

Background: Pain resulting from therapeutic procedures and injections is a prevalent source of stress for children. Immediate side effects of pain in infants include syncope, irritability, sleep disturbances, and nutritional issues. This study aimed to investigate the effects of oral melatonin on alleviating pain and anxiety in pediatric patients undergoing venipuncture. Methods: This double-blind, randomized controlled trial was conducted in the pediatric emergency ward. Patients were randomly assigned to one of two groups; the intervention group received 0.5 mg/kg of oral melatonin (maximum 5 mg) 30 min before venipuncture, while the placebo group received an equivalent amount of a placebo 30 min before the procedure. Using the Face, Legs, Activity, Cry, Consolability (FLACC) scale, postcanulation fear, pain severity, compliance, and potential side effects were evaluated. Results: In total, 202 patients (113 male and 89 female) in the intervention and control groups were included in the analysis. The mean pain score during venipuncture was 1.52±3.04 in the intervention group and 2.04±6.57 in the control group (P<0.001). In the intervention group, only 19 (18.8%) patients reported pain during venipuncture, whereas 79 (78.2%) patients in the control group reported pain (P<0.001). Less than half (44.6%) of the patients in the intervention group experienced anxiety during venipuncture, while the majority (94.1%) of the patients in the control group exhibited anxiety (P<0.001). The venipuncture success rate was 60.4% in the intervention group and 51.5% in the control group (P=0.257). Conclusion: Administering 0.5 mg/kg of oral Melatonin 30 min before venipuncture reduces procedure-related pain and anxiety in pediatric patients and may be associated with higher venipuncture success rates.

Effectiveness of a dental simulation game on reducing pain and anxiety during primary molars pulpotomy compared with tell-show-do technique in pediatric patients: a randomized clinical trial

BackgroundDental simulation games are virtual educational games that help children get familiar with different dental procedures. This study aimed to evaluate the pretreatment exposure to the “Baby Panda Dental Care” game in reducing pain and anxiety in comparison with the tell-show-do (TSD) technique during primary molars pulpotomy for patients aged 6–10 years.Materials and methodsIt was a triple-blinded, two-arm, parallel-group, randomized, active-controlled trial. It was done on 60 patients, who were randomly divided into two groups: the control group, TSD technique (n = 30), and the experimental group, “Baby Panda Dental” Care (n = 30). For the TSD technique, children were provided with a verbal explanation followed by a demonstration of the dental treatment in a non-threatening way. The “do” phase is then initiated during performing treatment. For the “Baby Panda dental care” game, children were asked to play for 5 min before treatment, selecting root canal therapy procedures. Pulse rate and RMS pictorial scale were recorded at four time points: (1) at the baseline (t0). (2) After conditioning the child (t1). (3) During treatment (t2). (4) After finishing the treatment (t3). Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scale was recorded during treatment (t2).ResultsThe pulse rate is higher in the control group at t1 (p = 0.012) and t2 (p = 0.015). There was a statistically significant difference in the mean RMS pictorial scale score at t1 (p < 0.001), t2 (p = 0.006), and t3 (p < 0.001), a statistically significant difference was noticed in FLACC behavioral pain assessment between the two groups (p = 0.033).ConclusionsThe mobile dental game showed better results than the TSD technique, but neither technique did not reduce anxiety and pain effectively during dental treatment.Trial registrationThe trial was registered at the ISRCTN registry (ISRCTN30470866) on 19/04/2024.

Immersive Virtual Reality Versus Video Distraction for the Management of Emergence Delirium in Children: A Randomized Controlled Study

PurposeEmergence delirium (ED) presents challenges for both parents and health care providers in pediatric surgical settings. This study aims to evaluate the effectiveness of immersive virtual reality (VR) distraction and video distraction combined with parental presence in reducing ED in preschool-aged children undergoing elective surgery. DesignA prospective, randomized, controlled clinical trial was conducted with 90 children ages 4 to 7. Participants were randomly assigned to three groups: VR distraction (group V), tablet video distraction with parental presence (group T), and standard care (group C). The primary endpoints were the incidence of ED and Pediatric Anesthesia Emergence Delirium Scale scores, with secondary measures encompassing scores from the Parental Separation Anxiety Scale and the Faces, Legs, Activity, Cry, Consolability (FLACC) scale. MethodsParticipants were assigned to one of the three intervention groups, and relevant scales were used to assess ED, parental separation anxiety, and postoperative pain. The immersive VR distraction and video distraction with parental presence interventions were compared against standard care. FindingsImmersive VR distraction significantly reduced the incidence of ED (6.67% in group V vs 40% in group T and 60% in group C), and the incidence of ED in group V was notably lower than in the other groups (P = .023 vs group T and P = .004 vs group C). Children in group V displayed significantly lower FLACC compared with the other groups as well (P < .05). However, no significant differences between the 3 groups were observed in perioperative anxiety as assessed by the Parental Separation Anxiety Scale scores (P = .27). ConclusionsThis study underscores the potential of immersive VR distraction as an effective intervention for mitigating ED in pediatric surgical patients. The findings suggest that incorporating VR technology during the perioperative period can positively impact postoperative outcomes. Further research in diverse surgical contexts is recommended to validate these findings and explore the broader applicability of VR distraction in pediatric health care settings.

Evaluation of the clinical effects of atropine in combination with remifentanil in children undergoing surgery for acute appendicitis.

Acute appendicitis (AA) is the most common cause of acute abdomen in children. Anesthesia significantly influences the surgical treatment of AA in children, making the scientific and effective selection of anesthetics crucial. To assess the clinical effect of atropine (ATR) in combination with remifentanil (REMI) in children undergoing surgery for AA. In total, 108 cases of pediatric AA treated between May 2020 and May 2023 were selected, 58 of which received ATR + REMI [research group (RG)] and 50 who received REMI [control group (CG)]. Comparative analyses were conducted on the time to loss of eyelash reflex, pain resolution time, recovery time from anesthesia, incidence of adverse events (AEs; respiratory depression, hypoxemia, bradycardia, nausea and vomiting, and hypotension), intraoperative responses (head shaking, limb activity, orientation recovery, safe departure time from the operating room), hemodynamic parameters [oxygen saturation (SPO2), mean arterial pressure, heart rate, and respiratory rate], postoperative sedation score (Ramsay score), and pain level [the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale]. Compared with the CG, the RG showed significantly shorter time to loss of eyelash reflex, pain resolution, recovery from anesthesia, and safe departure from the operating room. Furthermore, the incidence rates of overall AEs (head shaking, limb activity, etc.) were lower, and influences on intraoperative hemodynamic parameters and stress response indexes were fewer. The Ramsay score at 30 min after extubation and the FLACC score at 60 min after extubation were significantly lower in the RG than in the CG. ATR + REMI is superior to REMI alone in children undergoing AA surgery, with a lower incidence of AEs, fewer influences on hemodynamics and stress responses, and better post-anesthesia recovery.

Postsurgical pain intensity in children on the VAS and FLACC scale across various analgesic techniques. Mathematical prediction as a component of justification

Nowadays, in pediatric practice, the Visual Analogue Scale (VAS) and the Face, Legs, Activity, Cry, Consolability (FLACC) scale are effective for assessing postsurgical pain. The modern concept of pain management includes a multimodal approach, including regional analgesia techniques. The aim of the study was to present a mathematical model to assess the efficacy of regional analgesia techniques in managing postsurgical pain intensity on the VAS and FLACC scale up to the fifth day of the study and predict the behaviour of the experimental data function up to day 87 following surgery using the autoregressive probability model. Materials and Methods. 89 patients operated on the anterior abdominal wall were divided into 3 groups depending on the type of anesthesia. The assessment of pain management quality and the presence of acute pain was conducted using the VAS and FLACC scale on days 1, 2, 3, and 5 post-operatively in all children. The ‘predict’ function in РТС MathCad Prime 7.0. software was used to automate calculating predictions based on the Burg method. Results. Studying the efficiency of the proposed treatment using regional analgesia techniques versus conventional analgesia enabled the prediction of varying postsurgical pain intensities on the VAS and FLACC scale based on their mathematical models, with coefficient of determination R2=0.9876, R2= 0, 9827, R2=0.9952 for the FLACC scale and R2=0.9868, R2=0,915, R2=0.9774 for the VAS. Conclusions. The use of regional analgesia techniques in children undergoing anterior abdominal wall surgery has been confirmed to be associated with a significant reduction in postsurgical pain intensity to the fifth day of observation and predicted to remain so up to day 87

Comparison of ultrasound-guided sacral erector spinae plane block and caudal epidural block for analgesia in paediatric patients undergoing hypospadias repair: A double-blind, randomised controlled trial.

Caudal block is more frequently used in children for postoperative analgesia. However, its disadvantage is its short duration. Erector spinae plane block (ESPB) at the sacral level can potentially block the pudendal nerve. It may prove an alternative to caudal block for hypospadias repair regarding time to first rescue analgesia. Fifty children of 2-7 years of age were included. After induction of general anaesthesia, Group I (n = 25) was given ultrasound-guided sacral ESPB with 1 ml/kg of 0.25% bupivacaine and Group II (n = 25) was given caudal block with 0.5 ml/kg of 0.25% bupivacaine. Postoperatively at face, leg, activity, cry, consolability (FLACC) score ≥4, rescue analgesia was given using intravenous 15 mg/kg paracetamol. The primary outcome was to compare time to first rescue analgesia, and secondary outcomes were intraoperative haemodynamic parameters, fentanyl consumption, postoperative FLACC score and analgesic consumption in 24 h. Continuous variables were compared using the independent sample t-test or Mann-Whitney test, and categorical variables were compared using the Chi-square test. The mean time to first rescue analgesia was 21.30 (standard deviation [SD]: 3.06) h in Group I and 9.36 (SD: 1.71) h in Group II (P < 0.001) (mean difference -11.94 [95% CI: -13.39, -10.48]). The FLACC score was significantly higher (P < 0.05) postoperatively at 8, 10, 12 and 18 h in Group II. Mean postoperative analgesic consumption was 310.5 (SD: 72.69) mg in Group I and 615.6 (SD: 137.51) mg in Group II (P < 0.001) (mean difference 30.5 [95% CI: 236.41, 373.78]). Sacral ESPB is better regarding time to first rescue analgesia than caudal block in paediatric patients undergoing hypospadias repair.

Effectiveness of Audiovisual Distraction in Reducing Children's Anxiety for Pain During Medical and Dental Treatments: A Systematic Review and Meta-analysis.

Audiovisual distraction is a potentially good technique to reduce medical treatment procedure-related fear and anxiety among children. However, few studies have assessed its effectiveness. To conduct a systematic review and meta-analysis for evaluating the effectiveness of audiovisual distraction in reducing pain anxiety in pediatrics. Randomized control trials and experimental studies that reported the use of audiovisual distraction during medical/dental treatments among children aged 3-8 years, used the Face, Legs, Activity, Cry, Consolability (FLACC) scale to assess pain, and were published between 2005-2021 and in English were retrieved from PubMed, Scopus, and Web of Science. A random-effects model was used for evidence analysis. A total of four studies were included in the systematic review and meta-analysis: two were from South Asia and one each were from Africa and North America. Three of these studies were randomized control trials. The variability among the studies was high. Three of the four studies found that AV techniques were significantly effective in reducing pain during procedures compared with the control group (P < 0.00001), while one study found no difference; the cumulative evidence in the forest plot was similar. Cumulative evidence suggests that the use of audiovisual distraction is an effective strategy in reducing medical/dental procedures-related pain anxiety among children aged 3-8 years. However, evidence on this is currently limited, and thus further studies are required using various AD techniques and on different populations to substantiate these findings. None. PROSPERO (Ref no.: CRD42021245874).

Suprazygomatic Maxillary Nerve Blocks and Opioid Requirements in Pediatric Adenotonsillectomy

Pain management following pediatric adenotonsillectomies is opioid-inclusive, leading to potential complications. To investigate the use of suprazygomatic maxillary nerve (SZMN) blocks to reduce pain and opioid use after pediatric intracapsular adenotonsillectomy and to measure recovery duration and incidence of complications. This was a randomized, blinded, prospective single-center tertiary pediatric hospital that included 60 pediatric patients (2-14 years old) scheduled for intracapsular adenotonsillectomy from November 2021 to March 2023. Patients were excluded for having combined surgical procedures, developmental delay, coagulopathy, chronic pain history, known or predicted difficult airway, or unrepaired congenital heart disease. Participants were randomized to receive bilateral SZMN blocks (block group) or not (control group). SZMN block administered bilaterally under general anesthesia for intracapsular adenotonsillectomy. Opioid consumption, FLACC (Face, Legs, Activity, Cry, Consolability) scores, and rates of opioid-free postanesthesia care unit (PACU) stay. Secondary outcomes were recovery duration and incidence of adverse effects, ie, nausea, vomiting, block site bleeding, and emergency delirium. The study population included 53 pediatric patients (mean [SD] age, 6.5 [3.6] years; 29 [55%] females; 24 [45%] males); 26 were randomly assigned to the SZMN block group and 27 to the control group. The mean (SD) opioid morphine equivalent consumption during PACU stay was 0.15 (0.14) mg/kg for the 27 patients in the control group compared with 0.07 (0.11) mg/kg for the 26 patients in the block group (mean difference, 0.08; 95% CI, 0.01-0.15; Cohen d, 0.64). The block group had a higher incidence of opioid-free PACU stays (n = 7 patients; 58%) compared with the control group (n = 15 patients; 26%) (mean difference, 32%; 95% CI, 5%-53%). Patients in the block group experienced lower FLACC scores (0.7 vs 1.6; mean difference, 0.9; 95% CI, 0.2-1.6; Cohen d, 0.7). The overall occurrence of adverse events was similar in the 2 groups, with no reported nerve block-related complications. The results of the randomized clinical trial indicate that SZMN blocks are a useful adjunct tool for managing postoperative pain in pediatric intracapsular adenotonsillectomy. Use of these blocks during adenotonsillectomy provided clinically meaningful reductions of postoperative opioid consumption with a low risk of complications. ClinicalTrials.gov Identifier: NCT04797559.

Does heart rate variability using the Newborn Infant Parasympathetic Evaluation index identify postsurgical pain levels and emergence delirium in toddlers? A prospective observational study.

Children recovering from anesthesia commonly experience early postoperative negative behaviour, caused by pain and emergence delirium. Differentiating the two is challenging in young children. Perioperative pain influences the heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) index and may also affect emergence delirium. We sought to investigate whether the perioperative NIPE index can discriminate between mild, moderate, or severe pain levels and can detect emergence delirium. This prospective observational study enrolled children aged three years or younger undergoing elective adenotonsillectomy, tonsillectomy, or adenoidectomy. The NIPE index, the Faces, Legs, Activity, Cry, Consolability (FLACC) score, and the Pediatric Anesthesia Emergence Delirium (PAED) score were recorded in the postanesthesia care unit (PACU). The primary aim was to investigate the relationship between the postoperative NIPE index and postoperative pain severity. The secondary aims were to evaluate the association between the NIPE index and emergence delirium (PAED ≥ 10) and its delirium-specific (ED-I) and pain-specific (ED-II) components. Sixty-nine children were recruited. In the PACU, the mean (standard deviation [SD]) NIPE values in children experiencing moderate and severe pain were 50 (12) and 49 (14), respectively. These values were significantly lower than the mean (SD) value of 64 (13) observed in children with mild pain (mean difference moderate vs no/mild pain, -14; 95% confidence interval [CI], -17 to -11; P < 0.001, and mean difference severe vs no/mild pain, -17; 95% CI, -20 to -14; P < 0.001, respectively). The NIPE index was significantly lower in children experiencing pain-specific ED-II (mean [SD] NIPE instantaneous [NIPEi] for ED-II 49 [10] vs no ED-II 55 [13]; mean difference, -6; 95% CI, -11 to -2; P = 0.009). The NIPE index was unable to detect emergence delirium (mean [SD] NIPEi for ED, 54 [15] vs no ED, 51 [10]; mean difference, 3; 95% CI, -2 to 8; P = 0.23) or the delirium-specific component ED-I (mean [SD] NIPEi for ED-I, 55 [15] vs no ED-I, 51 [11]; mean difference, 4; 95% CI, 0 to 8; P = 0.06). The NIPE index can identify moderate and severe postoperative pain after adenotonsillectomy but not emergence delirium in children aged three years and younger. This discrimination can be valuable in the early postoperative phase when the differentiation between pain and emergence delirium is difficult. ClinicalTrials.gov ( NCT04909060 ); first submitted 26 May 2021.

Comparative Evaluation of New Needleless Local Anesthetic System (INJEX) and Conventional Syringe Needle Technique during Pulpotomy Treatment: A Randomized Clinical Trial.

The dreaded sensation of pain in the dental chair has a significant impact on children's behavior. This study aimed to compare and contrast the perception of pain and patient behavior between the use of INJEX and the conventional syringe needle technique during pulpotomy among children. A randomized clinical trial was designed and conducted among pediatric dentistry patients aged 6-12 years old. Fifty-eight children were divided into two groups, conventional syringe needle and INJEX, using simple randomization method applying the sequentially numbered, opaque, sealed envelope method of allocation concealment. Anesthesia was administered to the groups as local infiltration by a single operator following routine behavior guidance techniques. After 3 min, pulpotomy was performed using the standard protocol. The Face, Legs, Activity, Cry, Consolability (FLACC) scale and Wong-Baker FACES Pain Rating Scale (WBS) were used to assess the intensity of pain, while the Frankl behavior rating scale (FBRS) was used to assess the children's behavior. During anesthesia, most of the participants in the INJEX group (median = 3) had higher FBRS scores compared with the conventional syringe needle group (median = 2), and the difference was very highly significant (p-value < 0.001). Analyzing the FLACC scores during local anesthesia administration revealed a high statistical significance (p-value < 0.01) across the two groups. A very high statistically significant difference (p-values < 0.001) with higher WBS scores for pain intensity was seen in the group using conventional syringe needles. INJEX administration significantly reduced the intensity of pain experienced by the children and helped maintain a positive attitude among them during pulpotomy. It provided a positive and comfortable experience for both the child and the practitioner. Therefore, it can serve as an excellent alternative to conventional needle anesthesia.

Reducing Pain and Anxiety in the Blood Collection Unit: The Impact of the Child-Friendly Design.

Purpose: The study aimed to examine the effect of a child-friendly design on the pain and anxiety levels during blood draw in children aged 1-3 years and the satisfaction levels of their parents toward the environment in which they receive health care services. Methods: The nonrandomized study was conducted with 158 children aged 1-3 years and their parents. Data were obtained with the "Personal Information Form," "Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale," "Visual Analog Scale (VAS) Anxiety Scale," and "Parental Satisfaction Scale-VAS." Data were collected from the control group before the design and from the intervention group after the design. Results: During the blood draw, the VAS Anxiety score of the children in the intervention group was 3.17 ± 1.44 and that of the control group was 7.00 ± 2.51 (t = 246.500, p < .001). The FLACC score was 3.94 ± 1.65 in the intervention group and 7.32 ± 2.51 in the control group (t = 915.000, p < .001). The mean satisfaction scores of the parents in the intervention group for the environment where they received health care were 10.00 ± 0.00, and those of the parents in the control group were 4.85 ± 1.68 (test = -11.561, p < .001). Conclusion: The child-friendly design effectively reduced children's pain and anxiety levels during blood draws and increased parents' satisfaction with the environment in which health care was received. Practical Implications: Implementing a child-friendly design in blood collection units is recommended to alleviate the pain and anxiety associated with children's blood draws, thereby enhancing parental satisfaction with the care provided.

Evaluation of the Efficacy of a Customized Mucosal Vibrator in Alleviating Pain Perception Associated with Local Anesthesia Administration in Children Aged 6-10 Years.

Local anesthetics are used to alleviate pain, but the prick of the injection delivering anesthesia is known to cause anxiety and pain that affect dental treatment. The most difficult aspect of pediatric dentistry is minimizing discomfort while the intraoral local anesthetic is administered. This pain has been treated using physical, psychological, pharmacological, and combinations of these approaches. Recently, the idea of vibration, which is based on the gates control theory, has gained popularity as a way to reduce discomfort while local anesthesia (LA) is being administered. The aim of this trial was to evaluate the efficacy of mucosal vibrators in children aged 6-10 years to alleviate pain associated with LA administration. A total of 60 patients aged 6-10 years requiring inferior alveolar nerve block were enrolled for this randomized, single-blind clinical trial. In group I, before and during LA administration, the customized mucosal vibrator was placed at the injection site. In group II, the topical local anesthetic gel was applied to the injection site prior to the administration of LA. Then, the local anesthetic solution was deposited using a disposable syringe needle on both groups. The pain was evaluated using the physiological scale (pulse rate and oxygen saturation), the subjective scale (Wong-Baker scale), and the objective scale [Face, Legs, Activity, Cry, Consolability (FLACC) scale] by an experienced assistant who was unaware of the procedure. A customized mucosal vibrator along with local anesthetic injections resulted in significantly less pain (p = 0.001*) when compared with the injections with topical anesthetic gel. The results show that the customized mucosal vibrator is an effective and inexpensive means to reduce pain during LA administration. Tatiya N, Singh C, Surana P, et al. Evaluation of the Efficacy of a Customized Mucosal Vibrator in Alleviating Pain Perception Associated with Local Anesthesia Administration in Children Aged 6-10 Years. Int J Clin Pediatr Dent 2024;17(4):404-409.

Evaluating Gabapentin Dosing, Efficacy and Safety in Infants

OBJECTIVE Gabapentin for management of neuropathic pain, irritability, neonatal abstinence syndrome, rescue sedation, feeding intolerance and visceral hyperalgesia in infants has grown over the past decade. There remains little guidance for indications, initiation, titration and maintenance dosing trends and assessment of outcomes. The primary objective was to describe gabapentin dosing, and the secondary objectives were to identify outcomes to assess efficacy and describe weaning practices. METHODS A retrospective single-center study was performed in infants younger than 1 year who received gabapentin at Boston Children’s Hospital between 2015 and 2021. The primary outcome was indication, initiation and maximum gabapentin dose. Secondary outcomes included mortality, adverse reactions and impact on feeding volumes, weight-for-age Z-scores and face, legs, activity, cry, consolability (FLACC) scores. Descriptive statistics were utilized. RESULTS Sixty-six infants received gabapentin at a mean ± SD age of 5.5 ± 2.7 months (range of 0–11 months). The mean ± SD initiation dose of gabapentin was 8.6 ± 5.4 mg/kg/day with a median interval of 24 hours (8–24 hours). The maximum mean dose was 23.2 ± 14.4 mg/kg/day at a median interval of every 8 hours (8 hours). The most common indications for initiation were irritability, rescue sedation, and visceral hyperalgesia. There was a statistical improvement in weight-for-age Z scores from 24 hours prior to gabapentin initiation to 2 weeks after the maximum dose of gabapentin (−2.23 ± 1.78 to −1.66 ± 1.91, p &amp;lt; 0.001) and a reduction in FLACC scores (2.29 ± 1.64 to 1.52 ± 1.76, p = 0.007) from 24 hours prior to gabapentin initiation to 3 days after the maximum dose of gabapentin. Three patients experienced minor adverse events. CONCLUSIONS Gabapentin was well tolerated in infants. Initial gabapentin dosing of 5 mg/kg/dose every 24 hours appears safe and consistent with other published studies in infants. The improvement in outcomes with few adverse events suggests a beneficial role for gabapentin.

Clinical Assessment of Preemptive Analgesia on Success of Pulpal Anesthesia and Postendodontic Pain in Children with Irreversible Pulpitis: A Randomized Comparative Study.

Optimal pain management of symptomatic pulpitis in formative years goes a long way in developing a positive dental attitude. Efforts should be made to increase the success of anesthesia, thus diminishing negative dental experiences. The aim of the study was to assess the efficacy of preemptive analgesia on the success of pulpal anesthesia following inferior alveolar nerve block (IANB) in children with symptomatic irreversible pulpitis and on reducing postendodontic pain. The research design was an in vivo, three-group, parallel, quadruple-blind study. A total of 75 patients were randomly allocated to one of the three groups-group I: ibuprofen, group II: combination of ibuprofen and paracetamol, and group III: multivitamin (placebo). Premedication was given 45 minutes before treatment, and patients received IANB in a standardized manner. Pain during pulpectomy was recorded using the face, legs, activity, cry, consolability (FLACC) scale and postoperatively using Wong-Baker's pain rating scale (WBPRS) at 4, 12, and 24 hours. Success was measured if the pain felt was of no or mild intensity. Success of IANB was 64% for ibuprofen, 72% for the combination group, and 40% for the placebo group, with no statistically significant difference between all groups (p = 0.06) on the FLACC scale. At 4 hours postoperatively, a significant difference (p = 0.02) was found among groups with more children experiencing no or mild pain in groups I and II and the highest number of rescue medications taken by the placebo group. Ibuprofen and a combination of ibuprofen and acetaminophen as preemptive analgesics had no significant effect on the success rate of IANB, although it was effective in reducing pain at 4 hours postoperatively. Gori NA, Patel MC, Bhatt RK, et al. Clinical Assessment of Preemptive Analgesia on Success of Pulpal Anesthesia and Postendodontic Pain in Children with Irreversible Pulpitis: A Randomized Comparative Study. Int J Clin Pediatr Dent 2024;17(1):72-78.

Assessment of Medical Clowning in Influencing the Anxiety and Behavior Scores of Children Undergoing Various Dental Treatments and the Stress Levels of the Operator.

To investigate the potential effectiveness of "medical clowns" on preoperative, intraoperative, and postoperative anxiety of children undergoing various dental treatments and also its effect on the operator's stress levels in a dental setup. A total of 170 pediatric patients, aged 4-8 years, indicated for preventive therapy, extractions, restorative, and endodontics were included and divided into two groups [group I-audiovisual (A-V) aids; group II-medical clowns], group of 85 patients each after recording Modified yale preoperative scale. Both pre- and postoperatively, Frankl's behavior score was recorded for each patient. During treatment, the face, legs, activity, cry, consolability (FLACC) pain scale, and dental operator's stress level were recorded. Intervention of medical clowns positively influenced children during dental treatment by increasing their pain threshold. The majority of children showed positive Frankl rating scales after dental treatment. Also, the operator's stress was significantly reduced, which led to enhanced treatment outcomes. Humor yields the power of healing, distracts pediatric patients, reduces their anxiety, and alleviates their pain, conferring the patients with a sense of laughter, creativity, and care.Therefore, medical clowns in pediatric dentistry can prove to be serviceable and valuable as a nonpharmacological approach to behavior management. Aggarwal P, Mathur S, Chopra R. Assessment of Medical Clowning in Influencing the Anxiety and Behavior Scores of Children Undergoing Various Dental Treatments and the Stress Levels of the Operator. Int J Clin Pediatr Dent 2024;17(1):59-66.

Post-operative Pain Control: A Comparison between Bupivacaine and Tramadol Local Wound Infiltration in Children Undergoing Herniotomy and Orchidopexy.

Post-operative pain control improves patient's satisfaction and affects the period of admission. Local wound infiltration following hernia surgery using xylocaine or bupivacaine has been a common practice. The use of tramadol for such infiltration is relatively new and has not been studied in our environment. This study compared the efficacy of post-operative pain control between Bupivacaine and Tramadol wound infiltration in children who underwent herniotomy and orchidopexy. This was a prospective randomised study involving 104 patients. A simple random method was used to allocate the study group into two equal groups (A, n = 52 and B, n = 52) using sealed envelopes with contents labelled A or B. Pre- and post-operative respiratory rate, heart rate, and C-reactive protein (CRP) were all recorded. Time to first and subsequent analgesia was determined using face, legs, activity, cry, consolability (FLACC) pain score. Fifteen patients in Group A and 18 patients in Group B received each two doses of supplemental analgesia within the first 24 h, ( P = 0.527). Time to first analgesia was significantly different between the two groups, (6.93 ± 0.80 h and 6.11 ± 1.08 h, P = 0.020). The mean FLACC pain score at the time of first analgesia in hours was 4.93 ± 0.59 and 4.72 ± 0.67 for Group A and B, respectively, P = 0.350. The changes in CRP were not different in the two groups, ( P = 0.665). Four patients in Group A, but none in Group B had an episode each of post-operative vomiting. Tramadol showed comparable efficacy with bupivacaine in post-operative pain control by wound infiltration in children who had unilateral herniotomy or orchidopexy. Tramadol, however, achieves a longer duration of action before rescue analgesic is required. Caution is necessary to avoid post-operative vomiting.

Observational Behavioral Coding in the Pediatric Emergency Department: Development of the Emergency Department Child Behavior Coding System

BackgroundDespite improvements over the past decade, children continue to experience significant pain and distress surrounding invasive procedures in the emergency department (ED). To assess the impact of newly developed interventions, we must create more reliable and valid behavioral assessment tools that have been validated for the unique settings of pediatric EDs. ObjectiveThis study aimed to create and test the Emergency Department Child Behavior Coding System (ED-CBCS) for the assessment of child distress and nondistress behaviors surrounding pediatric ED procedures. MethodsVia an iterative process, a multidisciplinary expert panel developed the ED-CBCS, an advanced time-based behavioral coding measure. Inter-rater reliability and concurrent validity were examined using 38 videos of children aged from 2 to 12 years undergoing laceration procedures. Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were used to examine concurrent validity. ResultsThe final ED-CBCS included 27 child distress and nondistress behaviors. Time-unit κ values from 0.64 to 0.98 and event alignment κ values from 0.62 to 1.00 indicated good to excellent inter-rater reliability for all but one of the individual codes. ED-CBCS distress (B = 1.26; p < 0.001) and nondistress behaviors (B = –0.69, p = 0.025) were independently significantly associated with FLACC scores, indicating concurrent validity. ConclusionsWe developed a psychometrically sound tool tailored for pediatric ED procedures. Future work could use this measure to better identify behavioral targets and test the effects of interventions to relieve pediatric ED pain and distress.

The effect of aromatherapy with Lavender-Neroli oil and music in management of pediatric dental anxiety: a randomized control trial

AimThis study aimed to evaluate the efficacy of aromatherapy with Lavender-Neroli essential oil combined with background music in reducing dental anxiety and pain during anesthesia in children.Materials and methodsA total of 56 children aged 6–10 years old who needed dental treatment with inferior alveolar nerve injection (IANB) were randomly divided into two groups: Group 1 (Experimental, n = 28) aromatherapy with music group, and Group 2 (Control, n = 28) the placebo group. Children in the group 1 were asked to inhale the aromatic blend of Lavender-Neroli essential oil using a nasal mask similar to one that is used for nitrous oxide after modifying it by adding a 3D printed box on its circle hole and listening to their favorite music as a background before 5 min and during anesthesia, meanwhile in the placebo group children were asked to wear an empty nasal mask. Anxiety and pain were been assessed before and after anesthesia using the self-report anxiety scale Facial image scale (FIS), Observational pain assessment scale Face-Legs-Activity-Cry-Consolability (FLACC), heart rate, SPO2 saturation, diastolic and systolic blood pressure.ResultsDental anxiety and vital signs except SPO2 saturation were significantly lower in the aromatherapy with music group when compared to the control group (p < 0.05), with no differences in pain perception between groups (p = 0.176).ConclusionsAromatherapy with Lavender-Neroli oil combined with music seems to be a useful and safe non-pharmacologic technique for managing dental anxiety in children.

Low-level Laser Therapy to Alleviate Pain of Local Anesthesia Injection in Children: A Randomized Control Trial.

The aim of our study was to evaluate and compare pain perception following photobiomodulation (PBM), topical anesthesia, precooling of the injection site, and vibration during administration of local anesthesia injection in pediatric patients aged 6-13 years. In this split-mouth study, a total of 120 patients between the age group of 6 and 13 years were selected and randomly divided into three equal groups with 40 subjects in each. Pain was assessed using visual analog scale (VAS) and the Wong-Baker Faces Pain Rating Scale after the administration of local anesthesia. Behavior during the procedure was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale filled by the operator. Pulse rate was recorded before and during the administration of local anesthesia using pulse oximeter. After the procedure, patient compliance was also recorded using validated questionnaire. The level of significance was set at p < 0.05. The study showed PBM exhibited the lowest mean scores of anxiety/pain using VAS, Wong-Baker Faces Pain Rating Scale, FLACC scale and pulse rate as compared to precooling, vibration, and topical anesthesia. The differences in pain scores recorded were found to be statistically significant. Children were not anxious about the PBM method and exhibited good compliance (p < 0.001). Photobiomodulation (PBM) was found to be effective means of reducing injection pain, demonstrating much better efficacy than other tested methods. Photobiomodulation (PBM) can be used effectively to better manage procedures that patients frequently find painful without the need for prescription drugs, which frequently have several side effects. Khan BS, Setty JV, Srinivasan I, et al. Low-level Laser Therapy to Alleviate Pain of Local Anesthesia Injection in Children: A Randomized Control Trial. Int J Clin Pediatr Dent 2023;16(S-3):S283-S287.

Effectiveness of External Precooling and Vibration Induced by BUZZY on Pain and Anxiety During Inferior Alveolar Nerve Block Injection in Children.

Purpose: Children's fear of the injection of local anesthetic agents affects their cooperation in pediatric dentistry. Different techniques are available to decrease the injection pain, including the use of precooling agents or vibrators. The present study investigated the effectiveness of Buzzy (Buzzy MMJ Labs, Atlanta, GA, USA). This device transfers cold and external vibration to the injection site during the inferior alveolar nerve block (IANB) injection. Materials and Methods: The present self-control, randomized, and double-blind clinical trial evaluated 30 children aged 6-12, who had bilateral mandibular permanent or primary carious molar teeth. On one side, the BUZZY was applied before and during the IANB injection, and the other side was considered as control. On both sides, a topical anesthetic gel was applied before injection. The pain severity and children's anxiety were determined using Wong-Baker, face, leg, activity, cry, consolability (FLACC) scales, and the heart rate. Results: The mean age of the participants was 7.18 ± 1.5 years, with 12 girls and 18 boys. The Wong-Baker scale and FLACC scale did not show any statistically significant difference between BUZZY and control (p value = 0.9 and 0.15, respectively). In addition, BUZZY tool did not significantly decrease pain and anxiety during injection, assessed through the heart rate difference (p=0.38). Conclusion: Under the limitations of the present study, a combination of precooling and vibration using the BUZZY device did not decrease pain and anxiety in children during the IANB injection.