Face, Legs, Activity, Cry, Consolability Research Articles

Music Therapy During Basic Daily Care in Critically Ill Children: A Randomized Crossover Clinical Trial

To assess whether music therapy is effective to reduce pain during daily personal hygiene care (DPHC), a procedure performed in all patients in a pediatric intensive care unit. Fifty critically ill children were enrolled in a crossover controlled clinical trial with random ordering of the intervention, i.e., passive music therapy, and standard conditions, and blind assessment of pain on film recordings. Primary outcome was variation of the Face Legs Activity Cry Consolability (FLACC) score (range 0 to 10) comparing before and during DPHC. Secondary outcomes were changes in heart rate, respiratory rate, and mean arterial blood pressure, and administration of analgesic or sedative drugs during DPHC. Mixed-effects linear model analysis was used to assess effect size (95% CI). Median (Q25-Q75) age and weight of the patients were 3.5 (1.0, 7.6) years and 15.0 (10.0, 26.8) kg. Consecutive DPHC were assessed the 3rd (2, 5) and 4th days (3, 7) of hospitalization. In standard conditions, FLACC score was 0.0 (0.0, 3.0) at baseline and 3.0 (1.0, 5.5) during DPHC. With music therapy, these values were, respectively, 0.0 (0.0, 1.0) and 2.0 (0.5, 4.0). Rates of FLACC scores >4 during DPHC, which indicates severe pain, were 42% in standard conditions and 17% with music therapy (p=0.013). Mixed-effects model analysis found smaller increases in FLACC scores (-0.54 [-1.08 to -0.01]; p= 0.04) and heart rate (-9; [-14.53; -3.4]; p=0.001) with music therapy. Music therapy is effective to improve analgesia in critically ill children exposed to DPHC.

The effect of auditory stimuli on the pain and physiological parameters of children on mechanical ventilation during aspiration procedure: A randomized controlled trial.

The study was conducted to determine the effect of mother's voice and music sound on pain and physiological parameters during aspiration procedure in children with mechanical ventilation support in the pediatric intensive care unit. This study was a randomized controlled type experimental study. According to the power analysis result of the sample of the study, 84 children who were treated in the pediatric intensive care unit of two university hospitals in Istanbul were formed. Introductory Information Form, Ramsey Sedation Scale, Physiological Parameter Form and Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale were used to collect data. When the pain results of the children were evaluated, the mean FLACC Pain Scale value of the children in the control group was found to be significantly higher than children in the mother's voice and music voice group (p < 0.05). It was determined that the lowest FLACC Pain Scale value was in the mother's voice group (p < 0.05). When the physical parameter results were evaluated, it was determined that the physiological measurement values of the children in the experimental group were positively affected (p < 0.05), there was a significant difference between the control group (p < 0.05) and the most effective result was in the mother's voice group (p < 0.05). Allowing children to listen mother's voice and music during aspiration procedure reduces pain of the children, positively affects their physical parameter values and enhances quality of nursing care. The results of this study create a scientific basis for nursing practices in the clinical settings and contribute to the clinical practices by shedding a light on future evidence-based studies.

Efficacy of adding nalbuphine to caudal bupivacaine for postoperative analgesia in children undergoing hypospadias repair surgery. Randomized controlled trial

ABSTRACT Background We hypothesized that adding nalbuphine to bupivacaine would prolong the duration of caudal epidural anaesthesia (CEA) in pediatric patients undergoing hypospadias repair surgery. Methods 60 children scheduled for elective hypospadias surgery under general anesthesia combined with CEA were divided into two equal groups: the control group received caudal bupivacaine 0.25% 1 ml/kg plus 2 ml normal saline. The Nalbuphine group received caudal bupivacaine 0.25% 1 ml/kg plus nalbuphine 0.1 mg/kg in 2 ml normal saline. Intraoperative and postoperative rescue analgesia was managed by giving intravenous paracetamol 15 mg/kg and/or 100mcg nalbuphine. The Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, and the Richmond AgitationSedation Scale (RASS) score were measured. Pre-operative and postoperative blood samples were collected for a subgroup of patients for cortisol analysis. Results The duration of postoperative analgesia was significantly longer in the nalbuphine group (p < 0.001). The number of patients who needed postoperative supplemental analgesia was significantly lower in the nalbuphine group (p < 0.001). Total paracetamol consumption was significantly higher in the control group (p < 0.001). The FLACC and RASS were significantly lower in the nalbuphine group. Postoperative cortisol levels were lower in the nalbuphine group compared to the control group. Conclusions Adding caudal nalbuphine 0.1 mg/kg to bupivacaine 0.25% provides better postoperative pain control than bupivacaine alone in children undergoing hypospadias repair.

Effect of photobiomodulation on the efficacy of anesthesia in maxillary permanent molar teeth with molar incisor hypomineralization: A randomized clinical trial.

Difficulty in anesthetizing teeth that have been diagnosed with molar incisor hypomineralization (MIH) is a frequently reported clinical problem. The effects of low-level laser application (photobiomodulation) on the efficacy of anesthesia during the dental treatment of patients with MIH have not yet been studied. To assess the effects of photobiomodulation therapy (PBMT) on the efficacy of anesthesia in maxillary permanent molar teeth with MIH. This prospective, parallel-arm control, randomized, triple-blind clinical trial included children aged 7-12 years. Maxillary permanent first molar teeth with MIH that required pulpotomy treatment were included. Seventy participants were randomly divided into two groups: experimental (with PBMT) and control (placebo). In the experimental group, before the administration of local infiltration anesthesia, PBMT (diode laser: 940 nm; continuous mode; 0.5 W; 78 J/cm2) was applied to the oral mucosa for 60 s each. In the control group, the laser probe was channeled toward the mucosa but was not activated. Pain scores were evaluated during the access cavity preparation of the pulpotomy treatment (when using the dentin cutting handpiece and while entering into the pulp) using the Face, Legs, Activity, Cry, Consolability (FLACC) scale. Additional anesthesia requirements were assessed in both groups. The data obtained were analyzed for statistical significance (p < .05). The chi-squared test was used to determine the effect of PBMT on categorical outcomes. The no-pain scores of the experimental group were higher than those of the control group (29% vs. 20%). Moderate-to-high pain was more frequent in the control group than in the experimental group (43% vs. 20%). While 31% of the experimental group required supplemental anesthesia, 49% of the control group required supplemental anesthesia during pulpotomy of the tooth with MIH. No statistical difference, however, was found between the two groups in terms of pain scores and the need for supplemental anesthesia (p = .235, p = .143). Anesthesia with and without PBMT caused no difference in pain during the treatment of maxillary molar teeth with MIH.

Retrospective Analyses of Sacral Erector Spinae Plane Blocks in Pediatric Patients

Objective: The erector spinae plane block (ESPB) was first described in 2016. Recently the use of ESPB at the sacral levels was defined for adult surgeries, and a modification of the technique for pediatric surgeries, with the claim that it could replace caudal blocks, was described by our clinic. Methods: This retrospective cohort study was approved by the institutional ethical committee of Kocaeli University Hospital (GOKAEK-2021/6.04). The data were obtained from the registry of regional anesthesia saved in the department. Pre- and perioperative data regarding age, height, weight, American Society of Anesthesiologist classification, surgery duration, and anesthesia duration during the perioperative period were collected. US-guided S-ESPB was successfully applied to 16 patients included in the retrospective study. The registry of regional anesthesia data includes detailed information on block performance, postoperative pain severity, and complications in the early postoperative period (for at least 24 h). Results: 16 pediatric patients were included in the retrospective study. The mean age of the patients was 21,5 months. The mean weight of the patients was 13,1kg. In the postoperative 24-hour follow-up, one patient had a The Face, Legs, Activity, Cry, Consolability (FLACC) score greater than 4 in the PACU. None of the patients were observed to have postoperative complications. Conclusions: To our knowledge, this study is the first to retrospectively investigate the efficacy of the S-ESPB in pain management in pediatric patients. The sacral ESPB appears to be an effective option for postoperative pain in pediatric patients undergoing lower abdominal surgery.

Opioid-free Pain Management after Cleft Lip Repair.

Side effects of opioid pain management after surgical repair of cleft lips are numerous and affect postoperative course. We compared opioid versus opioid-free pain management regimens for infants who underwent cleft lip repair to evaluate the impact on postoperative recovery. Cleft lip repairs at our institution from December 2016 to February 2021 were retrospectively reviewed, comparing patients who received opioids to patients receiving a nonopioid pain control regimen. Data collected include length of stay, oral morphine equivalents (OME) received on day of surgery (DOS)/postoperative day (POD) 1, time to and volume of first oral feed, and Face/Legs/Activity/Cry/Consolability (FLACC) scores. Seventy-three infants were included (47 opioid and 26 nonopioid). The opioid group received average 1.75 mg OME on DOS and 1.04 mg OME on POD1. Average DOS FLACC scores were similar between groups [1.57 ± 1.18 nonopioid versus 1.76 ± 0.94 (SD) opioid; P = 0.46]. Average POD1 FLACC scores were significantly lower for the nonopioid group (0.73 ± 1.05 versus 1.35 ± 1.06; P = 0.022). Median time to first PO (min) was similar [178 (interquartile range [IQR] 66-411) opioid versus 147 (IQR 93-351) nonopioid; P = 0.65]. Median volume of first feed (mL) was twice as high for the nonopioid group [90 (IQR 58-120) versus 45 (IQR 30-60); P = 0.003]. Nonopioid postoperative pain management was more effective than opioids for pain management in infants after cleft lip repair, as evidenced by FLACC scores and increased volume of the first oral feed.

Hydrogel burn dressing effectiveness in burn pain

Severe burns are painful and dramatic injuries. Studies show that pain is underestimated and often not adequately treated. This study aims to evaluate the analgesic efficacy of hydrogel burn dressing and silver sulfadiazine, which are two agents commonly used in first-aid dressings for burn patients. This study, designed as a prospective, observational, and cross-sectional study. Study included 64 pediatric patients admitted to our burn center between 01.03.2020 and 01.09.2020 who were examined by our burn service after their first treatment in the emergency dressing room. Two groups of patients were included in the study. Pain level was assessed in the dressing room before and 10 min after the procedure using the Visual Analog Scale and FLACC (Face, Legs, Activity, Cry, Consolability) pain assessment scales.During the study period, Burnaid® was applied to 62.5% of patients (40 patients) and silver sulfadiazine to 37.5% (24 patients). In terms of pain scores, pre-dressing FLACC values were higher in Group B (p = 0.039); post-dressing VAS and FLACC values were significantly lower in group B (p 0.001; p 0.001). In terms of additional analgesia, we found more patients in Group S received analgesics (p 0.001).We believe that its effect on burn wound pain is superior to that of silver sulfadiazine.

Incidence and risk factors for emergence delirium in children undergoing surgery under general anaesthesia - A prospective, observational study.

Emergence delirium (ED) is a common complication after general anaesthesia (GA) in children, with an incidence of 2%-80%. This study evaluated the incidence and risk factors for ED in children undergoing surgery under GA. This observational, prospective study was conducted in 336 children of either gender aged 2-13 years scheduled for surgeries under GA. Preoperative anxiety and demographics were noted. Paediatric Anaesthesia Emergence Delirium (PAED) scale, Watcha scale, and Face, Legs, Activity, Cry, Consolability (FLACC) scale were monitored 30 min postsurgery. A PAED score ≥12 and a Watcha scale score ≥3 were taken as ED. The primary outcome was the incidence of ED. An adjusted multivariate linear regression model explored the association with ED. The incidence of ED was 3.87% (n = 13, 95% confidence interval [CI]: 1.80, 5.94). ED was significantly associated with male sex (β coefficient 0.06, 95% CI: 0.003, 0.11) and severe preoperative anxiety (β coefficient 0.07, 95% CI: 0.01, 0.12) in a multivariate linear regression model adjusted for other confounders. When pain scores were added to the regression model, ED was significantly associated only with pain at 0 and 10 min after surgery (P values 0.005 and 0.002, respectively). Both PAED (AUROC 0.99, 95% CI: 0.98, 1.00) and Watcha (AUROC 0.99, 95% CI: 0.98, 1.00) scores showed an excellent ability to detect ED. The incidence of ED was 3.87% (95% CI: 1.80, 5.94) and was significantly associated with male sex, severe preoperative anxiety and pain.

Playing it down - effectiveness of clay therapy, origami and building blocks in the management of dental anxiety among children aged 6-10 years

Background: Children experience dental anxiety during their first dental visit, which affects the quality of dental treatment and gives rise to behaviour management problems. Clay, origami and building blocks have been effective in alleviating hospitalization anxiety in pediatric patients. These successful techniques in hospitalized pediatric patients have seldom been used in the dental set up. Therefore, the aim of this study is to assess and compare the efficacy of clay therapy, origami and building blocks in the management of dental anxiety in children aged 6-10 years. Methods: Sixty children aged 6-10 years, with no previous dentist exposure, with Frankl’s behaviour rating 2 or 3 having dental caries with international caries detection and assessment system (ICDAS) score 3 requiring restorations without local anesthesia were selected and divided into four groups. Group 1 – clay therapy; group 2 - building blocks; group 3 – origami; and group 4 – tell show do. Pulse rate, facial image scale (FIS) and face, leg, activity, cry, consolability (FLACC) behaviour scales were used to quantify anxious behaviour. Operator compliance and parent acceptance was rated on the Likert scale. Results: The results showed lower mean pulse rates, lower FIS and FLACC scores, and better operator compliance and parental acceptance in clay therapy, origami and building blocks groups than in the conventional tell-show-do group. The most significant reduction in all the parameters was seen in the clay therapy group. Conclusions: Clay therapy, origami and building blocks can be used as an effective means to reduce dental anxiety in children.

Reducing pain and discomfort associated with rubber dam clamp placement in children and adolescents: a systematic review and meta-analysis of effectiveness

BackgroundThe application of rubber dams is a widely accepted method of tooth isolation in dental practice. Placement of the rubber dam clamp might be associated with levels of pain and discomfort, especially in younger patients. The purpose of the present systematic review is to evaluate the efficacy of the methods for reducing pain and discomfort associated with rubber dam clamp placement in children and adolescents.Materials and methodsEnglish-language literature from inception until September 6th, 2022 was searched in MEDLINE (via PubMed), SCOPUS, Web of Science, Cochrane, EMBASE, and ProQuest Dissertations & Theses Database Global for articles. Randomized controlled trials (RCTs) comparing methods of reducing the pain and/or discomfort associated with rubber dam clamp placement in children and adolescents were retrieved. Risk of bias assessment was performed using a Cochrane risk of bias-2 (RoB-2) risk assessment tool and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profile.Studies were summarized and pooled estimates of pain intensity scores and incidence of pain were calculated. The meta-analysis was conducted in the following groups according to type of interventions (LA, audiovisual (AV) distraction, behavior management (BM), electronic dental anesthesia (EDA), mandibular infiltration, inferior alveolar nerve block (IANB), TA), outcome (intensity or incidence of pain), and assessment tool (face – legs – activity – cry – consolability (FLACC), color scale, sounds – motor – ocular changes, and faces pain scale (FPS)):(a) pain intensity using (LA + AV) vs (LA + BM), (b) pain intensity using EDA vs LA (c) presence or absence of pain using EDA vs LA (d) presence or absence of pain using mandibular infiltration vs IANB (e) Comparing pain intensity using TA vs placebo (f) Presence or absence of pain using TA vs placebo.Meta-analysis was conducted using StataMP software, version 17.0 (StataCorp, College Station, Texas). Restricted maximum-likelihood random effect model (REML), Mean difference (MD) with 95% confidence interval, and log odds ratio (OR) with 95% CI were calculated were calculated.ResultsInitially, 1452 articles were retrieved. Sixteen RCTs were finally included for reviewing and summarizing. Nine articles with a total of 867 patients were included for quantitative meta-analysis. The differences in pain intensity scores were not significant in any comparison groups (group a: [MD = -0.04 (95% CI = − 0.56, 0.47), P = 0.87, I2 = 0.00%], group b: [MD = 0.25 (95% CI = -0.08, 0.58), P = 0.14, I2 = 0.00%], group c [MD = -0.48 (95% CI = -1.41, 0.45), P = 0.31, I 2 = 0.00%], group d: [MD = -0.67 (95% CI = -3.17, 1.83), P = 0.60, I 2 = 0.00%], group e: [MD = -0.46 (95% CI = -l.08, 0.15), P = 0.14, I 2 = 90.67%], and group f: [MD = 0.61 (95% CI = -0.01, 1.23), P = 0.06, I 2 = 41.20%]. Eight studies were judged as having some concern for risk of bias and the remaining studies were considered as low risk for bias. The certainty of evidence was considered medium for all comparison groups.DiscussionIn the present meta-analysis, a considerable difference was obtained between the included studies regarding intervention methods and pain assessment tools and the analysis was performed in groups with small numbers of the studies. Owing to the mentioned variabilities and the small number of studies, the results of the analysis should be interpreted with caution. The indistinguishability of the manifestations of pain/discomfort from fear/anxiety, particularly in children, should also be considered while using the results of the present study.Within the limitations of the current study, no significant differences were found between the proposed methods for reducing pain and discomfort associated with rubber dam clamp placement in children and adolescents. A larger number of more homogenous studies regarding intervention methods and pain assessment tools need to be conducted in order to draw stronger conclusions.Trial registrationThis study was registered in PROSPERO (ID number: CRD42021274835) and research deputy of Mashhad University of Medical Sciences with ID number 4000838 (https://research.mums.ac.ir/).

Perioperative Analgesic Modality and Effectiveness in Paediatric Patients Who Have Undergone Common Major Urology Surgery - A Two-Year Retrospective Study

Perioperative paediatric major urology surgery pain management remains challenging. These surgeries require general anaesthesia (GA) combined with either regional analgesia technique or systemic morphine infusion for optimal pain relief. We aimed to compare and evaluate the effectiveness of both analgesic techniques. This single centre retrospective descriptive study involved 88 patients, aged 3 months to 12 years old with American Society of Anaesthesiologists (ASA) I or II status, who underwent major urology surgery under GA. Group A patients received perioperative systemic morphine while Group B received regional anaesthesia blocks (continuous caudal epidural infusion, single-shot caudal blocks or single-shot erector spinae blocks). We measured requirements of perioperative rescue intravenous (IV) fentanyl, pain scores using Face, Leg, Activity, Cry, Consolability (FLACC) scale, perioperative non-opioid IV analgesia usage and associated complications. Intraoperative rescue fentanyl in both groups was comparable. Intraoperative non-opioid analgesia and postoperative rescue fentanyl requirement were significantly higher in Group A compared to Group B (p&lt;0.001). Median FLACC scores in Group A were higher than Group B (p&lt;0.001) for first 12 hours post-surgery. Commonest complications in Group A was vomiting (38.6%) and peri-catheter leak in Group B (6.81%). Regional anaesthesia technique is superior to systemic morphine in providing analgesia in the first 12 hours post paediatric major urology surgery and is devoid of opioid side effects.

Retroperitoneal localized neuroblastoma in children: a comparison of enhanced recovery after surgery versus traditional care.

To investigate the clinical value of enhanced recovery after surgery (ERAS) protocols for children with neuroblastoma (NB). This retrospective review was conducted by using the electronic medical records of 48 children with retroperitoneal localized NB who underwent tumor resection (surgery for treatment, not diagnosis) between October 2016 and September 2021. The ERAS protocols for NB excision were implemented in 28 children (ERAS group), while 20 children received traditional care (TRAD group). The same group of pediatric surgeons performed all the tumor resections. Intraoperative fluid infusion, the extent of NB resection, time of early ambulation and time of first flatus, time to total enteral nutrition (TEN) after surgery, abdominal drainages, nasogastric tubes and urinary catheters used and duration, the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table on a postoperative day 1 (POD1), 3, 5, length of stay after surgery (LOS), hospitalization expense, postoperative complications, parental satisfaction rate and readmission rate of surgical wards within 30days after operation were analyzed. The median postoperative period of early mobilization, first flatus, TEN, LOS and total cost during hospitalization were 1.0days, 2.0days, 5.5days, 9.0days and 33,397.3 yuan in the ERAS group and 3.0days, 3.0days, 7.0days, 11.0days and 38,120.3 Yuan in the TRAD group, respectively (all p < 0.05). Median intraoperative fluid volume was 5.0mL/kg/h compared to 8.0mL/kg/h and the magnitude of decrease in FLACC scores from POD1 to POD5 was greater in the ERAS group (all p < 0.05). Abdominal drainages, urinary catheters and nasogastric tubes were removed earlier in the ERAS group (p < 0.05). The satisfaction of parents in the ERAS group was slightly higher, but the difference was not statistically significant (P = 0.762). There were no marked differences between the two groups in aspects of the extent of NB resection, operation-related complications and 30-day readmissions (all P = 1.000). Application of ERAS protocols in localized retroperitoneal NBs resection in children is feasible and safe. However, applying ERAS protocols in the surgical resection of solid tumors in children still requires much more research, especially randomized prospective research.

Oral Morphine versus Rectal Ketamine in Pain Management during Burn Wound Dressing: An Open Label Randomized Clinical Trial

Background: Oral morphine has been widely used to manage children’s pain during burn wound dressing. Rectal ketamine may also be safely administered to children.&#x0D; Objective: To evaluate and compare the efficacy of oral morphine vs. rectal racemic ketamine in management of pain during burn wound dressing in a pediatric population in a rural study population.&#x0D; Methods: This was a randomized open-label clinical trial done in a rural hospital in Uganda. Study participants were randomly assigned to one of the treatment groups, either oral morphine or rectal ketamine, with a ratio of 1:1. Overall, we enrolled 44 participants, with 22 in each treatment arm.&#x0D; Assessment of baseline vital signs, including pulse rate, blood pressure, respiratory rate, temperature, oxygen saturation (SPO2), pain assessment (using Face Legs Activity Cry Consolability [FLACC]), and sedation scores (using Richmond’s agitation and sedation scale [RASS]) among others was done. Study participants were followed up hourly for 8 hours for outcomes of interest: adequate pain management/adverse events.&#x0D; Results: The mean age of the study participants was 2.56 (±1.59) years. The overall mean intra-procedural pain difference score for children who received oral morphine was 2.7 (SD±2.2) compared to 0 (SD±0) among those who received rectal ketamine, and the mean difference of 2.7 was statistically significant (p &lt; 0.0001). Sialorrhea (hyper-salivation) was the only significant adverse event, with more occurrence in the rectal Ketamine treatment arm (n= 8, 36.3%) compared to 1 (5%) in the oral Morphine treatment arm, p = 0.009. There were no significant adverse effects noted in either treatment arm.&#x0D; Conclusion: The study showed the non-inferiority of rectal ketamine over oral morphine and concluded that administration of rectal ketamine was better at pain management and safety compared to oral morphine. Rectal ketamine is associated with an increased incidence of sialorrhea compared to oral morphine.

Comparative Assessment of Anxiety during Inferior Alveolar Nerve Block under Nitrous Oxide + Oxygen and Oxygen Inhalation Sedation in Children Aged 3-12 Years: A Randomized Clinical Trial.

A comparative evaluation of children's anxiety with the use of nitrous oxide-oxygen (N2O-O2) inhalation sedation during the administration of inferior alveolar nerve block (IANB). A total of 60 children between 3 and 12 years of age, with Frankl's behavior rating of 2-3 requiring IANB for any dental procedure were enrolled in this randomized clinical study. Group I (n = 30) received N2O and oxygen inhalation sedation at a concentration in the range of 25-50%, whereas group II (n = 30) received 100% O2 as a placebo. The physiological parameters like pulse rate, respiration, blood pressure, and O2 saturation were measured at the baseline, intraoperatively [during and after administration of local anesthesia (LA)] and postoperatively after the termination of the gases in both groups. The sedation level was measured intraoperatively (before administration of LA) using the Ramsay Sedation Score (RSS). The discomfort and anxiety were measured at the baseline, intraoperatively, and postoperatively using the Face, Legs, Activity, Cry, Consolability (FLACC) behavior scale. The data were evaluated using the statistical software International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) statistics 20.0. There was a significant difference in the FLACC scores between the two groups, intraoperatively (p-value-0.002), and postoperatively (p-value-0.049). The mean of the RSS for group I was 2.80 + 1.03, and for group II was 1.80 + 0.81. All the physiological parameters recorded were within the normal range. The use of N2O-O2 inhalation improved the anxiety levels in children while receiving the IANB and showed significant anxiolytic and sedative effects as compared to O2 inhalation. Nitrous oxide-oxygen (N2O-O2) inhalation can be used as a nonpharmacological behavior management adjunct for invasive treatments for children with utmost comfort for the child. Thomas PS, Dave BH, Shah DJ, et al. Comparative Assessment of Anxiety during Inferior Alveolar Nerve Block under Nitrous Oxide + Oxygen and Oxygen Inhalation Sedation in Children Aged 3-12 Years: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2023;16(1):30-36.

Evaluation of pain response in children to the SoftClamp™ as an alternative to the metal rubber dam clamp: A randomized clinical trial.

The use of a rubber dam is more important than ever in today's COVID-19 era to limit cross infections. In children, the placement of the metal clamp to retain the rubber dam is perceived to be painful and often requiring a local anesthetic injection. This dissuades many clinicians from placing the rubber dam. Hence, this study evaluated the pain response of children to a SoftClamp™ compared to the conventional metal clamp. This was a randomized controlled, equal allocation ratio, split-mouth clinical trial. Forty-two children aged between 8 and 12 years, having two permanent mandibular molars in need of sealants, were divided into Groups A and B (metal clamp and SoftClamp™, respectively). The pain response was recorded using both an objective and a subjective scale i.e., the Faces Legs Activity Cry Consolability (FLACC) scale and the Wong Baker Faces Pain Rating Scale (WBFPRS). The level of significance was set at 5% (P < 0.05). The pain response recorded from the WBFPRS and the FLACC scale for the metal and the SoftClamp™ were analyzed using the Wilcoxon signed rank test. The difference in pain response between genders and between two age groups (below and above 10 years of age) was analyzed using the Mann-Whitney U-test. The children reported mild discomfort to clamp placement in both the scales. The P values for the FLACC and WBFPRS scores comparing the pain response to the metal and SoftClamp™ were 0.311 and 0.149, respectively. There was no significant difference in the pain response of children to both the clamps. Good rubber dam application practices in children through the use of behavior guidance and a proper topical anesthesia technique may play a far more important role regardless of the clamp used. But the SoftClamp™, with its more child friendly appearance could be a viable alternative to the metal clamp in children.

Reliability of the electric pulp tester as an indicator of pulpal anesthesia in primary maxillary posterior teeth to assess the need for supplemental injections: An observational clinical study.

The primary maxillary molars occasionally remain sensitive during operative procedures even post the buccal supraperiosteal injection. This could be due to the widely flared palatal roots receiving accessory innervation from the palatal nerves. Identifying inadequate anesthesia upfront using the electric pulp test (EPT) would give vital information to the clinician on the need of a supplemental palatal injection. Aim: The aim of this study was to assess and evaluate the reliability of the EPT as an indicator of pulpal anesthesia in primary maxillary molars. Methodology: Fifty one primary maxillary molars were subjected to the EPT following a buccal supraperiosteal injection. During the operative procedure, the " Face Legs Activity Cry Consolability" (FLACC) scores were recorded. The outcome of the EPT was correlated with the results of the FLACC score using Pearson's Chi-square test.

Comparison of Dental Anxiety Between Aerosol and Non-Aerosol Dental Procedures in Children Aged Between 5-13 Years

Background Fear is an unpleasant emotional state consisting of psychological and physiological changes in response to real external threats or dangers. In contrast anxiety is an emotion similar to fear but arising without any objective source of danger. Dental treatments are well known to trigger anxiety and fear in children as most commonly used instruments such as airotor and suction create a sense of fear and anxiety in them. This impacts not only the quality of outcome of treatment but also the attitude of a child towards dentists and dental care.Objective The aim of the study was to compare the levels of anxiety during various aerosol and non-aerosol dental treatments in children.Method One hundred and twenty children aged 5 to 13 years were evaluated for anxiety levels by undergoing various dental treatments aerosol and non-aerosol techniques. The level of dental fear was measured before during and after the treatment with a pulse oximeter Animated Emoji Scale AES and Face Legs Activity Cry Consolability FLACC scale.Results Subjects belonging to the non-aerosol technique group showed least anxiety levels. Maximum relaxation was seen in children undergoing atraumatic restorative treatment ART followed by the HALL technique group and then the conventional restorative procedures. Least comfort was seen in the conventional stainless steel crown group. Conclusion Non-aerosol techniques generate least anxiety in children and should be considered for treatment procedures involving children with higher anxiety levels.

Efficacy of oral mefenamic acid versus paracetamol as a prophylactic analgesic for needle pain in children receiving vaccination: a three-arm, parallel, triple-blind, placebo-controlled MAP VaC randomized controlled trial

Background: Needle pain due to routine vaccination is an important factor contributing to low vaccine adherence and immunization coverage. Prophylactic oral analgesics can address this important issue of needle pain related to vaccination. Paracetamol and mefenamic acid are commonly used nonsteroidal anti-inflammatory drugs for pain relief, but there is little published literature on whether the same can be used for needle pain related to vaccination. Objectives: This study was planned to compare the efficacy of oral mefenamic acid and paracetamol over placebo as a prophylactic analgesic during vaccination and prophylactic antipyretic during the post-vaccination period. Designs: Three-arm, triple-blind, randomized controlled trial. Methods: This study was conducted at the outpatient department of a tertiary-level medical college in South India from January 2021 to June 2022. In this three-arm interventional trial, each arm had either a single dose of placebo or mefenamic acid (4 mg/kg/dose) or paracetamol (10 mg/kg/dose). These medicines were administered orally 30 min before vaccination to reduce needle pain. Main outcome and measures: Outcome was measured with the change of FLACC (Face, Leg, Activity, Cry, Consolability) scoring at the time of vaccination, subsequently at 15 and 30 min of vaccination in all three groups. Appearance of fever, grade of fever, and need for antipyretics 24 h after vaccination were also noted. Results: There was a significant difference in FLACC scores at the time of administration ( p = 0.010) and at 15 min ( p = 0.014) with mefenamic acid compared to placebo. Although the paracetamol group showed a difference when compared to the placebo, it was not significant at the time of administration ( p = 0.401), at 15 min ( p = 0.451), or 30 min ( p = 0.892) post-vaccination. The appearance of fever, grade of fever, and use of antipyretic up to 24 h post-vaccination had no significant difference among any of the three groups. Conclusion: Mefenamic acid was more potent than placebo for pre-vaccination pain prophylaxis in children. There was no difference in the appearance of fever and its grade among the three groups. The promising results from this trial warrant further large-scale studies to recommend a single oral dose of mefenamic acid to tackle needle pain related to vaccination in children to improve vaccine adherence and coverage. Trial registration: CTRI (Clinical trials registry-India) (CTRI/2021/01/030239). [Date of Commencement: 13 Jan 2021, Date of last recruitment: 30 June 2022 (now closed for new participants)]

Low Dose Bupivacaine (0.25%) with Fentanyl vs Ropivacaine (0.25%) with Fentanyl for Caudal Analgesia in Paediatric Patients: A Randomised Clinical Study

Introduction: Caudal epidural block is one of the most common regional techniques in paediatric anaesthesia for infraumbilical surgeries. Though bupivacaine is widely used because of its long duration, ropivacaine is a newly emerging drug having differential neuraxial blockade with less motor block and reduced cardiovascular and Central Nervous System (CNS) toxicity. To further increase the duration and quality various adjuvants have been added. Aim: To compare low dose bupivacaine-fentanyl with ropivacaine-fentanyl in terms of hemodynamic stability, duration of analgesia, postoperative pain, level of sedation, and side-effects profile among patients undergoing infraumbilical surgery. Materials and Methods: A double-blind, randomised study was conducted on 60 children undergoing elective infraumbilical surgery. Patients were randomly divided into two groups of 30 each into Bupivacaine-Fentanyl (BF) group and RopivacaineFentanyl (RF) group, using a simple envelope method. After securing airway, caudal block was given. Group BF received 0.25% bupivacaine 0.5 mL/kg with fentanyl 0.5 mcg/kg and Group RF received 0.25% ropivacaine 0.5 mL/kg with fentanyl 0.5 mcg/kg. Postoperative pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) pain assessment scale, for 12 hours. The hemodynamics, duration of analgesia, rescue analgesia requirement and side effects (bradycardia, hypotension, respiratory depression, retching, urinary retention, vomiting) were noted and analysed statistically. Results: The mean duration of analgesia in the BF group was 270±46.60 minutes and in the RF group was 430±68.83 minutes (p-value &lt;0.001). Patients requiring rescue analgesia were 12 in Group BF and 5 in Group RF. Mean FLACC reached ≥4 at 4.5 hours in group BF and at 7 hours in group RF. There was no significant difference in hemodynamics and side-effects profile (bradycardia, hypotension, respiratory depression, retching, urinary retention, vomiting) between the two groups. Conclusion: Low dose caudal ropivacaine-fentanyl combination is superior to that of caudal bupivacaine-fentanyl with respect to duration and intensity of intraoperative and postoperative analgesia.

Comparison of dexmedetomidine and clonidine for the prevention of emergence delirium in children undergoing lower abdominal surgery under sevoflurane anesthesia

Abstract Objective: In this study, we compared the efficacy of dexmedetomidine, clonidine, and placebo in the prevention of emergence delirium (ED) in children undergoing lower abdominal surgeries under sevoflurane anesthesia. Materials and Methods: We conducted a prospective randomized double-blinded study on 75 patients aged 4–10 years belonging to the American Society of Anesthesiologists I or II, undergoing lower abdominal surgeries of 1–2 h duration under sevoflurane anesthesia. The children were randomly distributed into three groups: dexmedetomidine (Group D), clonidine (Group C), and saline group (Group S). The study drug was administered 10 min after induction of anesthesia. Intraoperative hemodynamic parameters were recorded. The Pediatric Anesthesia Emergence Delirium (PAED) score was used to assess the incidence and severity of ED at 0, 5, 10, 15, 20, 30, 45, and 60 min of arrival to the postanesthesia care unit. A score of ≥10 was considered to have ED. The Ramsay Sedation Score and the Face, Legs, Activity, Cry, Consolability (FLACC) score were used to assess the degree of sedation and the severity of pain, respectively. Results: Dexmedetomidine showed the lowest incidence of ED while the highest incidence was seen in the saline group. The PAED score was lowest in the dexmedetomidine group, followed by clonidine, and highest in the control group at all time intervals. The Ramsay Sedation Score and FLACC score were also lower in the dexmedetomidine group as compared to the clonidine and saline groups. Conclusion: Dexmedetomidine was found to be more efficacious in preventing ED as compared to clonidine in children.