Autonomy and competence satisfaction as resources for facing chronic pain disability in adolescence: a self-determination perspective.

This study aimed to test empirically the developmental goal pursuit model of paediatric chronic pain, which draws upon Self-Determination Theory for understanding risks and resources for living with chronic pain. This study examined the relationship between basic psychological need satisfaction (i.e. the satisfaction of the needs for autonomy, relatedness and competence) and the fear-avoidance model of pain in adolescents suffering from chronic pain. Hundred and twenty adolescents (mean age = 14.52, 71.6% female), receiving treatment through paediatric pain centres for chronic pain, were enrolled. Adolescents completed measures of basic psychological need satisfaction, fear and avoidance of pain, and pain-related functional impairment. Path analyses model indicated that higher levels of autonomy and competence satisfaction were associated with lower levels of functional disability, through the mediation of fear and avoidance of pain. Relatedness satisfaction was not significatively related to fear of pain, avoidance, and functional disability. The integration of Self-Determination Theory in the paediatric pain literature may further our understanding of potential resources for decreasing functional disability in children living with chronic pain.

[Do analgesic sweet solutions in neonates influence glycemia? A literature review]. / Les solutions sucrées à visée antalgique chez le nouveau-né modifient-elles la glycémie ? Synthèse de la littérature.

Sweet solutions are one of the most widely used nonpharmacologic analgesics used for newborns. They alleviate mild to moderate pain induced by painful procedures. They are used daily in neonatal intensive care units before a venepuncture or a heel stick, especially for a blood-sugar measurement. It is agreed that analgesic sweet solutions do not modify glycemia results. This nevertheless remains a recurrent question that the present review attempts to answer.

[Patient controlled analgesia in children]. / L'analgésie autocontrôlée ou PCA chez l'enfant.

Patient Controlled Analgesia is a useful technic to deliver morphine analgesia via a programmable pump: the patient himself choose to self-administer a bolus dose (usually morphine); the dosage is calculated and prescribed according to the level of pain, limits of dose and period of interdiction are planned. After initial bolus to decrease severe pain (titration), the patient from the age of 6 years can manage his analgesia. This method of administration of the analgesic allows to adapting at best the posology of morphine to the level of pain and has a high safety level. A continuous flow can be prescribed if the pain is severe, but requires a greater level of surveillance of the essential parameters: breath and sedation, in order to avoid any overdose. As for any morphine analgesia, the unwanted effects must be prevented or treated. If the child cannot handle the pump (young age, handicap, tiredness) the nurse or sometimes the relative can activate the delivery of bolus after a specific training. The education of the relatives (parents) and the child is essential. This simple and efficacious method of analgesia requires an adequate training of the nursing staff.

[Quality of life of adolescents surviving childhood acute lymphoblastic leukemia]. / Vécu des adolescents guéris d'une leucémie aiguë lymphoblastique.

PURPOSE: To evaluate how adolescents and young adults cured of acute lymphoblastic leukemia (ALL) treated during childhood have integrated the disease, and possible death related to cancer. Particularly, we have focused on experiences related to diagnosis announcement, hospitalisation and treatments and consequences on their social, psychological and somatic behaviour. PATIENTS: Forty-one patients cured of ALL have been enrolled in the study and answered one interview with clinical psychologist or research nurse. RESULTS: Although 60% of the patients argued that they think rarely of their disease, 10% thought about it every day. Traumatic evidence was detectable in most of them. Physical pain was the most reported stress, mainly during hospitalisation (93%), as well as psychological suffering (83%). Afterwards, the mostly often-reported stress was psychological pain (61%). Sixty-six percent declared that they still experience psychological and health consequences at the time of the interview, in some cases reported as a handicap in their life. In 83% of the cases they considered themselves as cured, nevertheless fear of relapse persisted in 1/3. Ninety percent said they have a pleasant life, 56% did not like to talk about leukaemia and 70% thought they could have died. For 85%, disease has been the most important event of their life and 75% testify to repercussions of the disease on their family (family relationship changes, overprotection, siblings difficulties). CONCLUSION: Most of these patients declared to be 'as the others' and developed life projects, but overcoming the pain experience of the disease remained difficult. This study emphasized the need for long-term continuous information and reinforces the importance of addressing treatment psychological and physical pain mainly after the initial hospitalisation period.

[Migraine and headache in childhood]. / Migraine et céphalées de l'enfant et de l'adolescent.

In childhood and adolescence, migraine is the main primary headache. This diagnosis is extensively underestimated and misdiagnosed in pediatric population. Lacks of specific biologic marker, specific investigation or brain imaging reduce these clinical entities too often to a psychological illness. Migraine is a severe headache evolving by stereotyped crises associated with marked digestive symptoms (nausea and vomiting); throbbing pain, sensitivity to sound, light are usual symptoms; the attack is sometimes preceded by a visual or sensory aura. During attacks, pain intensity is severe, most of children must lie down. Abdominal pain is frequently associated, rest brings relief and sleep ends often the attack. The prevalence of the migraine varies between 5% and 10% in childhood. At childhood, headache duration is quite often shorter than in adult population, it is more often frontal, bilateral (2/3 of cases) that one-sided. Migraine is a disabling illness: children with migraine lost more school days in a school year, than a matched control group. Migraine episodes are frequently triggered by several factors: emotional stress (school pressure, vexation, excitement: upset), hypoglycemia, lack of sleep or excess (week end migraine), sensorial stimulation (loud noise, bright light, strong odor, heat or cold...), sympathetic stimulation (sport, physical exercise). Attack treatments must be given at the early beginning of the crisis; oral dose of ibuprofen (10 mg/kg) is recommended. If the oral route is not available when nausea or vomiting occurs, the rectal or nasal routes have then to be used. Non pharmacological treatments (relaxation training, self hypnosis, biofeedback) have shown to have good efficacy as prophylactic measure. Daily prophylactic pharmacological treatments are prescribed in second line after failure of non-pharmacological treatment.

[Migraine, misunderstood pathology in children]. / La migraine, pathologie méconnue chez l'enfant.

Although migraine is the main chronic headache in childhood and adolescence, it remains extensively misdiagnosed. Schematically, migraine is a severe headache evolving by stereotyped attacks frequently associated with marked digestive symptoms (nausea, vomiting, abdominal pain). Throbbing pain, sensitivity to sound, and light (and sometimes odors) are frequent additional symptoms. The attack is sometimes preceded by a visual or sensory aura. Rest brings relief, and sleep often ends the attack. Childhood migraine prevalence varies between 5 and 10%. Migraine episodes are frequently triggered by several factors: emotional stress (school pressure, vexation, excitement, upset), hypoglycemia, lack or excess of sleep (weekend migraine), sensory stimulation (loud noise, bright light, strong odor, heat or cold, etc.), sympathetic stimulation (sport, physical exercise). Attack treatments must be given at an early stage, oral ibuprofen (10 mg/kg) being particularly recommended. If the oral route is not available because of nausea or vomiting, rectal or nasal routes have then to be used. Non-pharmacological treatments (biofeedback and interventions combining progressive muscle relaxation) have demonstrated good efficacy as prophylactic measures. Daily prophylactic pharmacological treatments are prescribed as the second line after failure of non-pharmacological treatments.

Migraine and headache in childhood and adolescence.

Headache is one of the most common physical complaints of children and adults. The authors have provided definitions of headache, a classification system, diagnostic evaluations appropriate for children, and treatment options for patients with acute and chronic headache. Also, this article has emphasized the importance of diagnosing and treating migraine headache, a painful malady that is extensively underestimated and misdiagnosed in the pediatric population and one that can be treated acutely and when appropriate prophylactically with great success. Lack of a specific biologic marker, specific investigation, or brain imaging reduce these clinical entities too often to a psychological illness. Nonpharmacologic treatments are pivotal to manage chronic headaches. Migraine therapy, if administered early and through the appropriate route, could provide important and rapid relief.

Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey.

OBJECTIVE: Although the equimolecular mixture of oxygen and nitrous oxide (EMONO) seems a good choice to relieve procedure-related pain in children, it has not been accepted everywhere. In France, the rapid spread of its use has elicited suspicion and doubts regarding its safety. To assess the use and the safety of this gas mixture in the pediatric settings in France, we conducted a national survey. METHODOLOGY: Centers that had accepted a nation- wide invitation to participate in the survey filled out a questionnaire after each EMONO administration during a 2-month study. Procedure and inhalation characteristics, as well as pain evaluations and side effects, were reported. RESULTS: One thousand nineteen EMONO inhalations from 31 centers that agreed to participate in this 2-month survey were analyzed. Median (range) age was 6.4 (0-18) years. Four percent (46) of children were 12 months old or younger, 29% (295) were 5 years old or younger, 45% (459) were 6 to 10 years old, and 26% (265) were older than 10 years of age. The procedures performed with EMONO inhalation were: lumbar punctures (286), bone marrow aspirations (BMA; 231), laceration repairs (215), minor procedures (75), minor surgery (53), punctures (49), fractures (45), dental care (43), and pulmonary endoscopy (22). Nine percent of procedures were undertaken without the presence of a physician; the child being observed only by the attending nurse. A drug association was noted in 182 (17.9%) of procedures: midazolam (63%), acetaminophen (18%), nalbuphine (8.5%), hydroxyzine (5%), flunitrazepam (2%), chlorazepate (2%), morphine (1%), and lorazepam (.5%). EMLA cream (Astra) was applied in 98.6% of lumbar punctures, 93.7% of BMA, and 54.2% of punctures including lymph nodes, hematoma, or renal biopsies. Lidocaine infiltration was performed in 51% of minor surgery procedures, 40% of laceration repairs, and 28% of BMA. The inhalation system included a whistle, a scented mask, and a nonrebreathing respiratory valve in 48.9%, 71.2%, and 78.3% of the patients, respectively. Initial physical restraint was needed in 18. 2% of all the patients. Inhalation refusal was noted in 129 (12.7%) children; of these, 53 had an alternative method of analgesia (EMLA or lidocaine infiltration), 15 had no other analgesia, and in the remaining 61, EMONO inhalation was maintained against the child's will. Median (interquartile) inhalation length was 4 (3-5) minutes before starting the procedure and 6 (6-15) minutes for the total inhalation. Median (interquartile) procedural pain evaluations were 9 (0-30) for children on a 0 to 100 visual analog scale, 1 (0-3) for both nurses and parents on a 0 to 10 numerical scale. Median (interquartile) procedural pain as evaluated by nurses for the 3 most frequent procedures were 0 (0-2) for lumbar punctures, 2 (0-4) for bone marrow aspiration, and 2 (0-4) for laceration repair. Comparison of pain assessed by nurses in children 3 years old or younger and those older than 3 years of age showed a median (range) score of 2 (0-10) versus 1 (0-10), respectively. Pain self-assessment was completed in 647 children 6 years of age or older. Median (interquartile) children pain assessments were as follows: lumbar puncture (5; 0-20), bone marrow aspiration (12.5; 0-40), laceration repair (12; 0-40), minor procedures (18; 0-32), minor surgery (10; 0-35), punctures (0; 0-18), fracture (15; 0-30), dental care (20; 0-40), and pulmonary endoscopy (15; 0-30). Ninety-three percent of the 647 children who were able to answer the question said they would accept EMONO analgesia if a new procedure were to be performed. Behavioral reactions during procedures varied with age of the child; cry was observed in 44.1%, 24.4%, 12.9%, and 11.2% of children 3 years or younger, 4 to 6 years, 7 to 10 years, and 11 years or older, respectively. Physical restraint was necessary in 34.2%, 22%, 13.5%, and 8.4% of children aged 3 years or younger, 4 to 6 years, 7 to 10 years, and 11 years or old

[Migraine and chronic headache in children]. / Migraine et céphalée chronique de l'enfant.

In childhood and adolescence, migraine is the main essential chronic headache. This diagnosis is extensively underestimated and misdiagnosed in pediatric population. Lacks of specific biologic marker, specific investigation or brain imaging reduce these clinical entities too often to a psychological illness. Migraine is a severe headache evolving by stereotyped crises associated with marked digestive symptoms (nausea and vomiting); throbbing pain, sensitivity to sound, light are usual symptoms; the attack is sometimes preceded by a visual or sensory aura. During attacks, pain intensity is severe, most of children must lie down. Abdominal pain is frequently associated, rest brings relief and sleep ends often the attack. The prevalence of the migraine varies between 5p.100 and 10p.100 in childhood. At childhood, headache duration is quite often shorter than in adult population, it is more often frontal, bilateral (2/3 of cases) that one-sided. Migraine is a disabling illness: children with migraine lost more school days in a school year, than a matched control group. Migraine episodes are frequently triggered by several factors: emotional stress (school pressure, vexation, excitement: upset), hypoglycemia, lack of sleep or excess (week end migraine), sensorial stimulation (loud noise, bright light, strong odor, heat or cold.), sympathetic stimulation (sport, physical exercise). Attack treatments must be given at the early beginning of the crisis; oral dose of ibuprofen (10mg/kg) is recommended. If the oral route in not available when nausea or vomiting occurs, the rectal or nasal routes have then to be used. Non pharmacological treatments (biofeedback and interventions combining progressive muscle relaxation) have shown to have good efficacy as prophylactic measure. Daily prophylactic pharmacological treatments are prescribed in second line after failure of non-pharmacological treatment.

[Klebsiella oxytoca septicemia following platelet transfusion]. / Septicémies a Klebsiella oxytoca après transfusions de plaquettes.

Two fractions of a three-day-old apheresis platelet collection from a known habitual donor were transfused to two children with thrombocytopenia and bleeding. Both patients developed evidence of severe infection during the transfusion. One died despite intensive care and antimicrobial therapy. The other, whose transfusion was cut short, recovered. A Klebsiella oxytoca strain was recovered from the two transfusion bags, from a third unused bag, and from blood samples from the patient who died. Genotyping results established that all these isolates were identical. Tests for K. oxytoca were negative on the batches of blood donation material, the bottle of antiseptic used, and throat and stool specimens from the donor and phlebotomists. The most likely hypothesis is that the donor developed transient asymptomatic bacteremia during the 136-minute-long collection procedure and that the organism subsequently grew in the platelet collections, which were kept at 20-24 degrees C with agitation for three days before being used.

[Transient erythroblastopenia in early childhood]. / L'érythroblastopénie transitoire de la petite enfance.

BACKGROUND: Transient erythroblastopenia is rare in young children although its frequency is increasing. POPULATION AND RESULTS: Six infants (four boys, two girls), aged 29-41 months (mean: 33) were admitted for polar and asthenia. Only one displayed infectious episode two months earlier. Hemoglobin ranged from 40 to 67 g/l and reticulocyte number from 1 to 10 G/l. Mean corpuscular volume was normal as was Coombs' test. There was a profound erythroblastopenia in the bone marrow in five of the six patients. Parvovirus B19 infection was excluded in all. The white cell and platelet counts were normal. All patients were given an unique blood transfusion. Reticulocytosis spontaneously appeared within a few weeks in three patients. Another patient had normal number of erythroid precursors in the bone marrow 1 month after admission. CONCLUSION: Diagnosis of transient erythroblastopenia can only be made after exclusion of known causes such as drugs, virus, immune deficiency, leukemia and of Blackfan-Diamond disease. Its persistence must lead to search for another cause.

Recurrent nephrotic syndrome after transplantation: early treatment with plasmaphaeresis and cyclophosphamide.

Steroid-resistant nephrotic syndrome (NS) with focal glomerulosclerosis (FGS) and its recurrence after transplantation are mainly seen in children. The recurrence rate approximates 30% and the graft loss is about half this. Several therapeutic regimens have been proposed, giving conflicting results. In an attempt to remove a putative circulating factor and inhibit its production by lymphocytes, three patients with biopsy-proven FGS in the native kidney were included in a prospective uncontrolled trial using early plasmaphaeresis followed by substitutive immunoglobulins in association with methylprednisolone pulses and cyclophosphamide instead of azathioprine over a 2-month period. The patients were girls, aged 6.5, 13.3 and 15.8 years, who received a cadaveric transplant; concomitant immunosuppression included prednisone and cyclosporine A. All three patients exhibited early recurrence of the NS and were treated 5-10 days after the onset of proteinuria. Rapid and sustained remission was achieved in all patients within 12-24 days on therapy. One patient experienced a late acute but steroid-sensitive rejection episode; another suffered from septic ankle arthritis as a complication of reinforced immunosuppression. The latter girl had a second late recurrence of proteinuria that was controlled within 7 weeks. With a 18- to 27-month follow-up, all three patients have normal renal function, normal blood pressure and no proteinuria. We conclude that intensive therapy using plasmaphaeresis, steroid pulses and cyclophosphamide over a 2-month period can induce complete remission in children with early recurrence of NS after transplantation.