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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

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

PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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. STUDY REGISTRATION: ClinicalTrials.gov ( NCT04909060 ); first submitted 26 May 2021.

RéSUMé: OBJECTIF: Les enfants qui se remettent d'une anesthésie font fréquemment preuve d'un comportement négatif en début de période postopératoire. Ce comportement est causé par la douleur et le délire d'émergence, mais il est difficile de les distinguer chez les jeunes enfants. La douleur périopératoire a un impact sur l'indice d'évaluation parasympathique du nouveau-né et du nourrisson (NIPE) dérivé de la variabilité de la fréquence cardiaque et peut également affecter le délire d'émergence. Nous avons cherché à déterminer si l'indice NIPE périopératoire permettait de différencier des niveaux de douleur légers, modérés ou sévères et de détecter le délire d'émergence. MéTHODE: Cette étude observationnelle prospective a recruté des enfants de trois ans ou moins ayant bénéficié d'une adéno-amygdalectomie, d'une amygdalectomie ou d'une adénoïdectomie non urgente. L'indice NIPE, le score FLACC (Faces, Legs, Activity, Cry, Consolability) et le score PAED (Pediatric Anesthesia Emergence Delirium) ont été enregistrés en salle de réveil. L'objectif principal était d'étudier la relation entre l'indice NIPE postopératoire et la sévérité de la douleur postopératoire. Les objectifs secondaires étaient d'évaluer l'association entre l'indice NIPE et le délire d'émergence (PAED ≥ 10) et ses composantes spécifiques au délire (ED-I) et à la douleur (ED-II). RéSULTATS: Nous avons recruté soixante-neuf enfants. En salle de réveil, les valeurs NIPE moyennes (écart type [ET]) chez les enfants souffrant de douleurs modérées et sévères étaient respectivement de 50 (12) et de 49 (14). Ces valeurs étaient significativement inférieures à la valeur moyenne (ET) de 64 (13) observée chez les enfants présentant une douleur légère (différence moyenne modérée vs pas de douleur ou douleur légère, −14; intervalle de confiance [IC] à 95 %, −17 à −11; P < 0,001, et différence moyenne entre douleur sévère vs pas de douleur ou douleur légère, −17; IC 95 %, −20 à −14; P < 0,001, respectivement). L'indice NIPE était significativement plus faible chez les enfants présentant un ED-II spécifique à la douleur (moyenne [ET] NIPE instantanée [NIPEi] pour ED-II, 49 [10] vs pas de ED-II, 55 [13]; différence moyenne, −6; IC 95 %, −11 à −2; P = 0,009). L'indice NIPE n'a pas été en mesure de détecter le délire d'émergence (NIPEi moyen [ET] pour le délire d'émergence, 54 [15] vs pas de délire d'émergence, 51 [10]; différence moyenne, 3; IC 95 %, −2 à 8; P = 0,23) ou la composante spécifique au délire de l'ED-I (NIPEi moyen [ET] pour ED-I, 55 [15] vs pas d'ED-I, 51 [11]; différence moyenne, 4; IC 95 %, 0 à 8; P = 0,06). CONCLUSION: L'indice NIPE permet d'identifier une douleur postopératoire modérée et sévère après une adéno-amygdalectomie mais pas le délire d'émergence chez les enfants de trois ans et moins. Cette discrimination peut être utile dans la phase postopératoire précoce lorsqu'il est difficile de différencier la douleur et le délire d'émergence. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT04909060 ); première soumission le 26 mai 2021.

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

OBJECTIVE: To assess whether music therapy (MT) is effective to reduce pain during daily personal hygiene care (DPHC), a procedure performed in all patients in a pediatric intensive care unit. METHODS: Fifty critically ill children were enrolled in a crossover controlled clinical trial with random ordering of the intervention, that is, passive MT, and standard conditions, and blind assessment of pain on film recordings. The primary outcome was variation of the Face Legs Activity Cry Consolability (FLACC) score (range, 0-10) 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). RESULTS: The median (Q25-Q75) age and weight of the patients were 3.5 years (1.0-7.6 years) and 15.0 kg (10.0-26.8 kg). Consecutive DPHC were assessed on days 3 (2-5) and 4 (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 MT, these values were, respectively, 0.0 (0.0-1.0) and 2.0 (0.5-4.0). Rates of FLACC scores of >4 during DPHC, which indicates severe pain, were 42% in standard conditions and 17% with MT (P = .013). Mixed-effects model analysis found smaller increases in FLACC scores (-0.54 [-1.08 to -0.01]; P = .04) and heart rate (-9.00; [-14.53; -3.40]; P = .001) with MT. CONCLUSIONS: MT is effective to improve analgesia in critically ill children exposed to DPHC. TRIAL REGISTRATION: This study was recorded (April 16, 2019) before patient recruitment on the National Library of Medicine registry (NCT03916835; https://clinicaltrials.gov/ct2/show/NCT03916835).

Effectiveness of an extraoral cold and vibrating device in reducing pain perception during deposition of local anesthesia in pediatric patients aged 3-12 years: a split-mouth crossover study.

Background: Local anesthetic injections may induce pain in children, leading to fear and anxiety during subsequent visits. Among the various approaches recommended to reduce pain, one is the use of a Buzzy Bee™ device that operates on the concept of gate control theory and distraction. The literature regarding its effectiveness during the deposition of local anesthesia remains limited; hence, the aim of the present study was to determine the efficacy of extraoral cold and vibrating devices in reducing pain perception during the deposition of local anesthesia. Methods: A split-mouth crossover study in which 40 children aged 3-12 years requiring maxillary infiltration or inferior alveolar nerve block for extractions or pulp therapy in the maxillary or mandibular posterior teeth were included. The control intervention involved the application of topical anesthetic gel for one minute (5% lignocaine gel), followed by the administration of local anesthetic (2% lignocaine with 1:80,000 adrenaline) at a rate of 1 ml/minute. Along with the control protocol, the test intervention involved using the Buzzy Bee™ device for 2 minutes before and during the deposition of the local anesthetic injection. The heart rate and face, legs, arms, cry, and consolability revised (FLACC-R) scale scores were recorded by the dentist to assess the child's pain perception. Results: The mean age of the participants in Group A and Group B was 7.050 ± 3.12 years and 7.9 ± 2.65 years respectively. A reduction in the mean heart rate and FLACC-R score was observed during the deposition of local anesthetic solution in the tissues when the Buzzy Bee™ was used in both groups at different visits in the same subjects (P < 0.05) The Buzzy Bee™ device was effective in reducing the heart rate and FLACC-R scores when used during maxillary infiltration and inferior alveolar nerve block local anesthesia techniques (P < 0.05). Conclusion: The use of extraoral cold and vibrating devices significantly reduces pain perception during local anesthetic deposition in pediatric patients. Considering the results of this study, the device may be incorporated as an adjunct in routine dental practice while administering local anesthesia in children.

A Systematic Review of the Measurement Properties of Face, Legs, Activity, Cry and Consolability Scale for Pediatric Pain Assessment.

Purpose: We performed this systematic review to summarize the psychometric properties of Face, Legs, Activity, Cry and Consolability (FLACC) scale in pediatric patients in different settings. Methods: Two investigators independently searched PubMed, EMBASE, OVID and China National Knowledge Infrastructure (CNKI) for eligible studies through July 2021. We assessed the psychometric properties using the modified critical appraisal tool (CAT). Finally, we systematically reviewed the results of the included studies. Results: A total of 15 studies were eventually included. The overall quality of each eligible study was low to moderate. The FLACC scale has been available in different versions and in different settings. Although eligible studies have demonstrated significant clinical benefit in assessing postoperative pain in pediatric patients aged 0 to 10 years from post-anesthetic care unit (PACU), pediatric intensive care unit (PICU) and inpatient unit, and in assessing procedural pain in pediatric patients aged 0.5 to 7 years from emergency unit, immunization center and PICU, mostly without test-retest analysis. Conclusion: Although the absence of a gold standard of pain assessment, the currently available data support the usefulness of the FLACC from the perspective of criterion validity. Therefore, the FLACC scale can be considered for measuring observational pain in infants and children. However, further studies are still needed to provide more robust evidence.

Effect of Chest Physiotherapy on Improving Pulmonary Function in Dealing With Congenital Heart Disease and Lung Collapse: A Case Report.

Patent ductus arteriosus (PDA) is a condition in which the ductus arteriosus fails to close after birth. We present the case of a three-month-old female infant admitted to a tertiary care center with the complaint of cough, poor feeding, and breathing difficulties. Based on the investigatory finding, she was diagnosed with PDA with pulmonary arterial hypertension (PAH), an atrial septal defect (ASD), coarctation of the aorta (COA), and pneumonia. In this patient, a left posterolateral thoracotomy was done to accomplish PDA ligation and coarctation repair. The outcomes of the infants were documented using the face, legs, activity, cry, consolability (FLACC) scale, and arterial blood gas analysis. The therapeutic aim specified an increase in oxygen saturation, enhanced total functional capacity, optimized respiration, cleared chest secretions, and normalized cardiovascular function. The effectiveness of the cardiorespiratory physiotherapy treatment regimen based on the patient's existing state of health is the focus of this case report. The outcome variable indicated that the patient's functional recovery was optimal.

Ultrasound-guided Erector Spinae Muscle Block Versus Ultrasound-guided Caudal Block in Pediatric Patients Undergoing Lower Abdominal Surgeries.

BACKGROUND: The erector spinae plane block is a new regional anesthetic technique that is gaining popularity in pediatric medicine. OBJECTIVES: This study aimed to evaluate the safety and efficacy of ultrasound-guided erector spinae block and compare its analgesic effect with that of the ultrasound-guided caudal block in pediatric patients. STUDY DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: Department of Anesthesia and Intensive Care, faculty of medicine, Minia University, Egypt. METHODS: Sixty-three children scheduled for unilateral lower abdominal surgeries, under general anesthesia were randomly allocated into 3 parallel equal groups: Group I (erector spinae block [ESB] group) received ultrasound-guided an erector spinae muscle block in a dose of 0.4 mg/kg of 0.25% bupivacaine between the 10th transverse process and the erector spinae muscles. Group II (caudal block [CB] group) received an ultrasound-guided caudal block in a dose of 2.5 mg/kg of 0.25% bupivacaine. The last group, Group III (control [C] group), did not receive any regional block. Our primary outcome was to evaluate the quality of postoperative analgesia using the Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale; secondary outcomes were to assess the time to first analgesic request, total analgesic requests during the first 24 hours, and the occurrence of any side effects. RESULTS: The early postoperative FLACC score was less in the ESB group than the CB group; both were lower than the control group. The erector spinae block had a longer duration of analgesia than the caudal block as the median (interquartile range [IQR]) ``of the duration of analgesia in the ESB group was 8 (8-12) hours while it was 6 (6-8) hours in group the CB group; both groups had a longer duration of analgesia compared to the C group 0.25 (0.17-4) hours. The total amount of analgesia was less in the ESB group than the CB group. The number of patients who needed rescue intravenous fentanyl analgesia was 14 patients in the C group while no patient needed intravenous fentanyl in the ESB and CB groups. LIMITATIONS: Sensory evaluation of the patients was not done since the 2 blocks were done under general anesthesia but did not affect the outcome. CONCLUSIONS: Ultrasound-guided erector spinae block was safe and effective in pediatric patients undergoing unilateral lower abdominal surgery as it provided a longer duration of analgesia and less analgesic requirement than caudal block and fewer side effects.

Validation of the parent's postoperative pain measure with an age-appropriate reference pain scale for children 2-12 years old during a 14-day recovery after tonsillectomy: A prospective cohort study.

BACKGROUND: Adenotonsillectomy is associated with severe postoperative pain. The parent's postoperative pain measure (PPPM), a 15-item instrument to measure a child's pain at home, has been validated with a seven-point faces scale in children 7-12 years and with the parents' global report of pain in children 2-6 years. AIMS: Our primary objective was to validate the PPPM with a recommended age-appropriate pain scale in children 2-12 years after adenotonsillectomy. Our secondary objective was to reduce the PPPM components and validate this reduced PPPM. METHODS: We recruited 319 children out of the 563 adenotonsillectomies performed between December 19, 2017, and December 18, 2018. Parents recorded administration of analgesics and their child's pain scores twice daily for 14 days: PPPM for all children and either the face, legs, arms, crying, consolability (FLACC) pain scale for children 2-3 years or the faces pain scale-revised (FPS-R) for children 4-12 years. In addition, parents recorded analgesics. RESULTS: Among the 354 eligible children, 9% of parents declined. 252 (79%) families submitted pain diaries. The median age was 2.9 [2.5-3.3] years for FLACC (n = 114) and 5.6 [4.5-7.2] years for FPS-R (n = 138). Across the 14-day recovery period, Cronbach's alpha for PPPM was 0.77 to 0.87. Generalized linear mixed models evaluated the association between PPPM and reference pain scales after adjustment for potential confounders. Time of day and postoperative days were included as predictors in the models. PPPM was strongly associated with FLACC and FPS-R (beta coefficient = 0.4; p < 0.0001). The association decreased over time, and the reduction was more significant for FPS-R than FLACC (beta coefficient = -0.13 vs. -0.04, respectively; p < 0.0001). There was a positive association between PPPM and the use of analgesics. A reduction analysis eliminated items from the original PPPM: four for FLACC and five for FPS-R, suggesting age-related differences. The reduced PPPM instruments achieved similar associations with their respective reference pain scales (beta coefficient = 0.5; p < 0.0001). CONCLUSIONS: This study extends previous work by validating the PPPM in children as young as 2 years with a recommended age-appropriate pain scale over 14-day convalescence after adenotonsillectomy. The reduced PPPM instruments differed in the two age groups. Future studies might explore these age-appropriate reduced PPPM instruments to assess pain at home following adenotonsillectomy.

Evaluation of the Analgesia Nociception Index and videopupillometry to predict post-tonsillectomy morphine requirements in children: a single-centre, prospective interventional study.

Background: Tonsil surgery causes significant and challenging postoperative pain. The Analgesia Nociception Index (ANI) and videopupillometry are two techniques of interest to monitor nociception in adults and may predict postoperative morphine requirements. We hypothesised that these techniques could predict the need for morphine after tonsillectomy in children. The main objective was to assess the prognostic significance of ANI and videopupillometry, measured at the end of surgery, on morphine consumption determined by a Face, Legs, Activity, Cry, Consolability (FLACC) scale score >3 in the Post Anesthesia Care Unit (PACU). Methods: A single-centre, prospective, interventional study evaluating children between 2 and 7 yr old undergoing tonsil surgery was performed. ANI and videopupillometry with tetanic stimulation were measured under general anaesthesia 4 min after the end of the surgical procedure. Each child was evaluated every 10 min by a nurse using the FLACC scale in the PACU and blinded to the measurements performed in the operating theatre. Results: Eighty-nine children were analysed and 39 (44%) received morphine in the PACU. Neither ANI values nor videopupillometry values were predictive of postoperative morphine consumption (areas under the receiver operating characteristic curve 0.54, 95% confidence interval [CI; 0.42-0.65], and P=0.57; and 0.52, 95% CI [0.41-0.63], and P=0.69, respectively). Neither ANI values nor videopupillometry values were correlated to the maximum FLACC scale score in the PACU with ρ=0.04 (P=0.71) and ρ=0.06 (P=0.57), respectively. Conclusions: Neither ANI nor videopupillometry performed at the end of surgery can predict morphine consumption in the PACU in children undergoing tonsillectomy.

Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls.

OBJECTIVE: To analyze safety and efficacy of single-dose ketorolac after primary palatoplasty (PP). DESIGN: Consecutive cohort of patients undergoing PP, comparing to historical controls. Setting: A large academic children's hospital. PATIENTS, PARTICIPANTS: A consecutive cohort of 111 patients undergoing PP (study n = 47) compared to historical controls (n = 64). INTERVENTIONS: All patients received intraoperative acetaminophen, dexmedetomidine, and opioids while the study group received an additional single dose of ketorolac (0.5 mg/kg) at the conclusion of PP. MAIN OUTCOME MEASURES: Safety of ketorolac was measured by significant bleeding complications and need for supplementary oxygen. Efficacy was assessed through bleeding, Face Legs Activity Cry Consolability (FLACC) scale, and opioid dose. RESULTS: Length of stay was similar for both groups (control group 38.5 hours [95% CI: 3.6-43.3] versus study group 37.6 hours [95% CI: 31.3-44.0], P = .84). There were no significant differences in all postoperative FLACC scales. The mean dose of opioid rescue medication measured as morphine milligram equivalents did not differ between groups (P = .56). Significant postoperative hemorrhage was not observed. CONCLUSIONS: This is the first prospective study to evaluate the safety and efficacy of single-dose ketorolac after PP. Although lack of standardization between study and historical control groups may have precluded observation of an analgesic benefit, analysis demonstrated a single dose of ketorolac after PP is safe. Further investigations with more patients and different postoperative regimens may clarify the role of ketorolac in improving pain after PP.

Comparative Evaluation of Changes in Physiological and Psychomotor Effects in Pediatric Patients during Extraction under Different Concentrations of Nitrous Oxide-Oxygen Inhalation Sedation.

INTRODUCTION: Nonpharmacological behavioral management techniques are routinely used to create an environment that facilitates and builds a rapport between the child and the dentist to carry out procedures with minimal disruption. However, the discomfort associated with oral injections produces varying degrees of stress in all patients. Nitrous oxide (N2O)-oxygen (O2) inhalation sedation is one of the most widely used modalities for the management of fear and anxiety in children. OBJECTIVE: The objective was to evaluate changes in physiological and psychomotor effects in pediatric patients during extraction under different concentrations of N2O-O2 inhalation sedation. MATERIALS AND METHODS: A total of 300 healthy patients in the age range of 6-12 years (mean 8.9 years), who needed extraction of primary tooth, were included in the study. Pulse rate, SpO2, blood pressure (BP), and temperature were recorded at baseline, 30% N2O concentration, 50% N2O concentration, and again postoperatively. In addition, anxiety levels and neuromuscular coordination were recorded at the respective intervals. RESULTS: The results revealed a mean decrease in pulse rate and BP from baseline and an increase in temperature and O2 saturation during the sedation procedure. The findings were statistically significant. Significant impairment of coordination and psychomotor ability was seen at each step. Anxiety had significantly reduced after the onset of sedation due to the anxiolytic effect of N2O. CONCLUSION: N2O-O2 inhalation sedation under different concentrations reduces the anxiety of the patient and produces adequate sedation with vital signs within normal limits along with temporary impairment of psychomotor ability and coordination.

Feasibility and Clinical Utility of the Finnish Version of the FLACC Pain Scale in PICU.

PURPOSE: To describe the feasibility and clinical utility of the Finnish FLACC scale when assessing children's pain in a Pediatric Intensive Care Unit (PICU). DESIGN AND METHODS: A non-experimental, descriptive cross-sectional study design was used to describe the feasibility and clinical utility in a Finnish PICU between May and August 2018. The nurses were asked to complete a data collection questionnaire about the feasibility and clinical utility of the Finnish FLACC every time they used the scale to assess pain in children. In total, the data consisted of 157 pain assessments cases. Quantitative data were analyzed statistically and responses to open-ended questions were analyzed using content analysis. RESULTS: In most cases, the nurses agreed that the Finnish FLACC scale was clearly structured (97%), easy to use (98%), helpful in assessing pain intensity (77%), and useful when reassessing pain after interventions (67%). Nurses found the scale more useable for children over one year old than for younger children. When assessing cry and consolability, pain was easier to score if the child was not intubated. CONCLUSIONS: The Finnish FLACC scale exhibits adequate feasibility and clinical utility when assessing pain in children in a PICU. However, more information is needed about its use during painful short-term procedures and with children under one year old. PRACTICE IMPLICATIONS: The Finnish FLACC scale is a helpful tool for nurses when assessing children's pain in a PICU. However, the Finnish version of the modified FLACC is needed for use with intubated children in the future.

Pain assessment during mandibular nerve block injection with the aid of dental vibe tool in pediatric dental patients: a randomized clinical trial.

OBJECTIVE: This study aimed to evaluate the effectiveness of DentalVibe in pain reduction during local anesthetic injection compared to traditional injection in pediatric patients. METHOD AND MATERIALS: This cross-over randomized controlled clinical trial included a sample of 60 children, aged 5 to 7 years, who were selected based on the need for local anesthesia for bilateral mandibular pulpotomy treatment. They were randomly allocated into two groups. Each group received two mandibular nerve block injections, with a 2-week interval as the washing out period. At first appointment, mandibular nerve block injection was performed either with vibration using DentalVibe at the injection site or benzocaine gel 20% applied before local anesthetic injection; the alternative technique was used at the second appointment. In each visit subjective pain was evaluated using the Wong-Baker FACES Pain Rating Scale and objective pain was evaluated using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. RESULTS: Assessment using the Wong-Baker FACES Pain Rating Scale showed that the mean pain levels in DentalVibe and traditional injection groups were 0.80 ± 1.34 and 2.60 ± 3.22, respectively. The mean pain levels according to the FLACC scale were 2.20 ± 2.04 and 3.13 ± 2.30 in the DentalVibe and traditional injection groups, respectively. Both scales showed statistically significant differences between the two groups in favor of DentalVibe (P < .001). A positive significant correlation between the two scales in the two interventions was recorded, where the Spearman rho was 0.41 for the DentalVibe group, and 0.52 for traditional injection group (P < .001). CONCLUSION: Compared to the traditional approach, DentalVibe reduced pain sensation during mandibular nerve block injection in pediatric patients.

Grommet and adenoid pain evaluation (GRAPE) study.

In the GRAPE study an analysis is made of postoperative pain sensation in children between 6 months and 6 years after adenotomy and placement of ear grommets. Intraoperative treatment with paracetamol versus placebo shows no statistically significant difference in pain between both groups indicating that this type of surgery causes little discomfort and does not require specific intraoperative analgesic treatment.

The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain.

The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most commonly and widely used behavioral observation pain scales. The aim of this study was to test the psychometric and practical properties of the FLACC scale to quantify procedural pain in infants and young children. Twenty-six clinicians independently applied the FLACC scale to segments of video collected from 100 children aged 6 to 42 months undergoing a procedure. Video segments were scored by 4 reviewers. Inter- and intrarater reliability coefficients were high (.92 and .87, respectively). Linear mixed modeling confirmed scale responsiveness (differences in difference between FLACC scores across phases for painful versus nonpainful procedures was 4.2, 95% confidence interval = 3.67-4.81). Sensitivity and specificity were 94.9% and 73.5%, respectively, at a cutoff of 2. However, the mean difference across phases for children with baseline scores >3 was much lower than for children with scores <3, P = .0001. Correlations between FLACC and Visual Analog Scale observer pain and distress were good (r = .74 and r = .89, respectively). This study supports the reliability and sensitivity of the FLACC scale for procedural pain assessment. However, the circumstances of procedures interfered with application of the scale and the findings question the capacity of the scale to differentiate between pain- and nonpain-related distress. PERSPECTIVE: This article provides evidence that the FLACC scale is reliable and sensitive to pain for procedural pain assessment. Concerns remain about specificity and scale design. Identification of a scale valid for this purpose is needed to provide a platform for improved procedural pain management in infants and young children.

Zc3h13/Flacc is required for adenosine methylation by bridging the mRNA-binding factor Rbm15/Spenito to the m6A machinery component Wtap/Fl(2)d.

N6-methyladenosine (m6A) is the most abundant mRNA modification in eukaryotes, playing crucial roles in multiple biological processes. m6A is catalyzed by the activity of methyltransferase-like 3 (Mettl3), which depends on additional proteins whose precise functions remain poorly understood. Here we identified Zc3h13 (zinc finger CCCH domain-containing protein 13)/Flacc [Fl(2)d-associated complex component] as a novel interactor of m6A methyltransferase complex components in Drosophila and mice. Like other components of this complex, Flacc controls m6A levels and is involved in sex determination in Drosophila We demonstrate that Flacc promotes m6A deposition by bridging Fl(2)d to the mRNA-binding factor Nito. Altogether, our work advances the molecular understanding of conservation and regulation of the m6A machinery.

Diagnosis and treatment of urethral prolapse in children: 16 years' experience with 89 Chinese girls.

OBJECTIVE: To review our experience and results in the diagnosis and treatment of urethral prolapse (UP) in Chinese girls. PATIENTS AND METHODS: We conducted a retrospective chart review of 89 consecutive girls (aged <16 years) with UP and without other complications, who received treatment for UP from January 1999 to January 2015 (a study period of 16 years) at the Children's Hospital of Chongqing Medical University, China. Data analysed included: age, symptoms, clinical findings, predisposing factors, management, and outcomes. RESULTS: The presenting symptoms in the 89 girls were: mass (54 girls), bleeding (34), and dysuria/straining at micturition (one). In all, 14 patients received conservative treatment as their symptoms were mild, and 75 were successfully treated by excision of the prolapsed urethral mucosa or ligation over a Foley catheter, as their symptoms were severe and recurred too frequently to be managed conservatively. The mean postoperative length of stay for ligation was 7.76 days and for excision was 4.57 days. Ligation over a Foley catheter had a longer hospital stay. CONCLUSIONS: UP is a rare condition occurring in prepubertal girls, evidenced by a urethral mass and bleeding. Increased physician awareness and early recognition of UP avoids unnecessary examinations and patient anxiety.

Laparoscopic re-implantation of refluxing ureter in children: A feasibility study.

OBJECTIVE: To report our initial experience in the application of laparoscopy in the management of children with unilateral vesico-ureteric reflux (VUR) using the laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique, and to evaluate the results and benefits of this technique for such patients. PATIENTS AND METHODS: Between February 2013 and August 2014, 17 children [13 girls and four boys, with a median (range) age of 60 (24-120) months] presented with recurrent febrile urinary tract infections and were diagnosed with unilateral VUR. They underwent transperitoneal extravesical laparoscopic ureteric re-implantation following the Lich-Gregoir technique. Postoperatively abdomino-pelvic ultrasonography was done at 1 month after surgery and voiding cystourethrography (VCUG) at 3 months after surgery, and in cases with persistent VUR or de novo contralateral VUR another VCUG was done at 6 months after surgery. RESULTS: The median (range) operative time was 90 (80-120) min and the postoperative hospital stay was 2 (2-5) days. Intraoperative and postoperative complications were minimal. Patients were followed-up for a median (range) of 6 (3-21) months. All the children had complete resolution symptomatically and on VCUG, without further intervention. CONCLUSIONS: The laparoscopic extravesical transperitoneal approach for ureteric re-implantation, following the Lich-Gregoir technique, is feasible and very effective in the management of VUR. Prospective randomised studies are eagerly awaited to define the benefits of this technique to patients, as well as to determine the cost-effectiveness of this approach.

Detecting autonomic response to pain in Rett syndrome.

OBJECTIVE: To quantify pain response in girls affected by Rett syndrome (RTT) using electrodermal activity (EDA), a measure of skin conductance, reflecting sympathetic activity known to be modulated by physical and environmental stress. METHODS: EDA increase, heart rate (HR) increase and Face Legs Activity Cry Consolability (FLACC) values calculated during venipuncture (invasive) and vital signs collection (non-invasive) events were compared with values calculated during a prior baseline and a RTT clinical severity score (CSS). RESULTS: EDA and HR increase were significantly higher than baseline during venipuncture only and not significantly correlated with FLACC or CSS. EDA increase was the most sensitive measure of pain response. CONCLUSIONS: These preliminary findings revealed that motor impairment might bias non-verbal pain scales, underscore the importance of using autonomic measures when assessing pain and warrant further investigation into the utility of using EDA to objectively quantify RTT pain response to inform future RTT pain management.