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Pain in Children






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Dr Richard Howard, London UK

Increased awareness of the necessity to adequately treat pain at all ages has led to intense interest in the effects of development on both pain processing, the efficacy of analgesics, and conversely the long term effects of early experience of pain and analgesia .

Clinical practice relies heavily on a balanced approach to analgesia using a limited number of drugs. Local anaesthesia is used extensively and opioids are still the most widely used analgesics for moderate to severe pain.

Recent research findings have elucidated the effects of local anaesthetics in early life and the developmental pharmacology of opioids. The efficacy of local anaesthetics may be altered by development, specific antinociceptive properties have been identified and new compounds are now available (1, 2). The opioid receptor undergoes developmental regulation and the phannacokinetics of opioids are age dependant, the rational use of opioids will be discussed (3, 4).

The NMDA receptor is known to be important in the development of central sensitisation, the receptor is also developmentally regulated (5, 6). Potentially this group of drugs may have advantages in early life.

A2 adrenoceptor agonists have numerous effects but can provide significant analgesia with moderate sedation. Reports of paediatric use will be discussed (7).


(1) Nagy I, WoolfCJ. Lignocaine selectively reduces C fibre-evoked neuronal activity in rat spinal cord in vitro by decreasing N-methyl-D-aspartate and neurokinin receptor-mediated post-synaptic depolarizations; implications for the development of novel centrally acting analgesics. Pain. 1996 ; 64 : 59-70.

(2) Thomas JM, Schug SA. Recent advances in the phannacokinetics of local anaesthetics. Long-acting amide enantiomers and continuous infusions. Clin Phannacokinet. 1999 ; 36 : 67-83.

(3) Rahman W, Dashwood MR, Fitzgerald M, Aynsley-Green A, Dickenson AH. Postnatal development of multiple opioid receptors in the spinal cord and development of spinal morphine analgesia. Brain Res Dev Brain Res. 1998 ; 108 : 239-254.

(4) Kart T, Christrup LL, Rasmussen M. Recommended use of morphine in neonates, infants and children based on a literature review : Part 1—Phannacokinetics. Paediatr Anaesth. 1997 ; 7 : 5-11.

(5) Marhofer P, Krenn CG, Plochi W, Wallner T, Glaser C, Koinig H, Fleischmann E, Hochtl A, Semsroth M. S(+)-ketamine for caudal block in paediatric anaesthesia. British Journal of Anaesthesia. 2000 ; 84 : 341-345.

(6) SchmidRL, Sandier AN, Katz J. Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes. Pain. 1999 ; 82 : 111-125.

(7) Nishina K, Mikawa K, Shiga M, Obara H. Clonidine in paediatric anaesthesia. Paediatr Anaesth. 1999 ; 9 : 187-202.


Christina Sallfors. Lillemor R-M Hallberg The Nordic School of Public Health, Box 12133 S-402 42 Goteborg, Sweden

Aim of investigation: To gain a deeper understanding of living with chronic pain as experienced by children with Juvenile Chronic Arthritis.

Methods: In-depth interviews were conducted with 22 children (6 boys), aged between 6 and 17 years. The grounded theory method was used for analysing the taped and transcribed interviews. The aim of such a method is to generate concepts, a model or a theory from empirical data.

Results: Two core categories were identified and labelled making med different and oscillating between hope and despair. The first core category, making me different, was related to six categories, describing qualitatively different ways of coping with pain: controlling strategies, avoidance strategies, cognitive strategies, compliance with the treatment, seeking social support and recovering. The other core category, oscillating between hope and despair was related to four categories, disturbed order, dependency, ambivalence and uncertainty about the future, describing consequences of chronic pain on the children's lives.

Conclusions: Pain and disease seemed to control the children's lives making them different from healthy peers. Also, the coping strategies used by the children contributed to their feelings of being different from others. Emotionally, the children oscillated between hope and despair.

Acknowledgements: Supported in part by the Swedish Rheumatism Association, The Committee for Mental and Physical Disabilities, and The Health and Medical Care Executive Board.


Aim Kokki, RN, MSc-Student Paivi Kankkunen. RN. MSc. Assistant Lecturer Anna-Maija Pietila, RN, PhD, Professor Katri Vehvilainen-Julkunen, RN, PhD, Professor Department of Nursing Science, University of Kuopio P.O. Box 1627 70210 Kuopio FINLAND

Aim of Investigation: The purpose of the present study is to test the applicability of the PPPM in Finnish culture in children aged 1 to 6 years by examining validity and reliability of the measure. The Parents' Postoperative Pain Measure (PPPM) is a 15-item behavioural measure of postoperative pain developed by Chambers, Reid, McGrath & Finley 1996 in Canada. PPPM was developed to assist parents in the at-home assessment of their children's pain. The full version of the PPPM consists of 29 behavioural items based on cues parents reported using to assess their children's pain. This 29-item PPPM will be tested in this study. The original measure is used with the permission of the authors.

Methods: Participants (N=200) are 1 to 6 year old children undergoing day surgery at four Finnish hospitals during five consecutive months, and their parents. Parents will complete a pain diary two days following the surgery. The pain diary include ratings of their children's pain (using the visual analogue scale, VAS) and each of the 29 PPPM items. Data will be collected during the spring 2000.

Results: Results will be available at September 2000.


 Toshimitsu Kitajima. Yasuhisa Okuda, Katsuhisa Fujimaki, Mayumi Tachikawa Dept. of Anesth. Dokkyo Univ. School of Med., Mibu, Tochigi, Japan.

Aim of investigation: Lumbar sympathetic block with neurolytics has widely been used for complex regional pain syndromes and peripheral vascular diseases in the lower extremities. However, neurolytic blocks in children are controversial because they may damage the tissue surrounding the injected site. We here report two children with CRPS type 1 who underwent successful lumbar sympathetic block with phenol.

Case reports: A 15 year-old girl had a sprain of the left ankle. A local osteopath put her leg in a cast. She noticed pain, swelling and allodynia in the left foot 7 days after the injury. She was referred to our clinic by a local orthopedist. She was diagnosed as having complex regional pain syndrome (CRPS) type 1. She complained of severe pain with visual analogue scale (VAS) 80 mm. She was admitted to the hospital and received continuous lumbar epidural block. The treatment slightly alleviated her pain. Next, we performed lumbar sympathetic block with phenol water at L2 and L3. The block relieved her pain by VAS 20 mm.

Another child was a 13 year-old girl who had epiphysiolysis of the left distal tibia one year ago. She had been treated by a local orthopedist. She was referred to our clinic to treat CRPS type 1 in the left leg. She complained of severe pain. She was admitted to the hospital and received continuous lumbar epidural block. Next, we performed lumbar sympathetic block with phenol water at L2 and L3. The block relieved her pain from VAS 80 mm to 40 mm.

Conclusion: Lumbar sympathetic block with a neurolytic was performed successfully in children with CRPS type 1.


Yoshitaka Hashizume. Shigeki Yamaguchi, Mutsuo Mishio, Tetsuo Takiguchi, Yasuhisa Okuda, Toshimitsu Kitajima

Dept. of Anesth. Dokkyo Univ. School of Med., Mibu, Tochigi, Japan.

Aim of investigation: We assessed the effects of pediatric caudal block using mepivacaine, bupivacaine, or a mixture of mepivacaine and bupivacaine on postoperative analgesia and examined plasma concentrations of the local anesthetics after caudal injection.

Methods: Pediatric patients randomly received caudal block with 1 ml/kg of mepivacaine 1% (group M), 1 ml/kg of bupivacaine 0.25% (group B), or a mixture of 0.5 ml/kg of mepivacaine 1 % and 0.5 ml/kg of bupivacaine 0.25% (group MB). Anesthesia was maintained with 66% nitrous oxide in oxygen supplemented with sevoflurane at an end-tidal concentration of less than 1%. And postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured in double blind.

Results: In the group M, four patients required postoperative analgesics within the first 24 hours. However, no patients required postoperative analgesics in the groups B and MB. In the group M, the plasma concentration of mepivacaine of two patients exceeded 5 ug/kg of the toxicity level. However, they did not show any toxic symptom. Since a mixture of two local anesthetics halves the concentration of each local anesthetic, plasma concentration of mepivacaine and bupivacaine in the group MB were significantly lower than those of the groups M and B.

Conclusion: Pediatric caudal block with a mixture of mepivacaine and bupivacaine is effective for intra and postoperative analgesia and safer against toxicity of local anesthetics.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 153, 154, 239, 248, 279


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