Influence of parental occupation on access to specialised treatment for paediatric chronic pain: a retrospective study.

BACKGROUND: The purpose of this study was to determine patients' travel distances to a tertiary paediatric pain clinic and to analyse the association between travel distance and the parents' occupational skill level and the patients' pain characteristics. PATIENTS AND METHODS: The retrospective study consisted of 2,248 children assessed at the first evaluation. All children (0-20 years) who visited the clinic during a 5-year period (2005-2010) were enrolled in this study. RESULTS: The mean travel distance was 81 km, and the 80 % catchment area was 109 km. Children of parents with a high occupational skill level had a 1.5-fold higher probability of travelling from outside the catchment area. The 80 % catchment area increased constantly with increasing occupational skill level. Additional significant factors for greater distance travelled were high impairment, musculoskeletal pain, long pain duration and a high number of previous physician contacts. CONCLUSION: The association between travel distance and parental occupational skill level suggests that there is social injustice due to access barriers based on socioeconomic deprivation and education. An increase in the number of health care facilities for chronic pain in children would be a first step in rectifying this injustice.

Paroxysmal hemicrania in children--symptoms, diagnostic criteria, therapy and outcome.

Whereas paroxysmal hemicrania (PH) is studied extensively in adults, even case reports of PH in children are rare. We present the first prospective follow-up study on PH in children. Our aim was to investigate whether differences exist between paediatric and adult patients. We assessed all children with chronic headache who were referred to our paediatric out-patient pain clinic within 3 years based on interviews and validated questionnaires. Among 628 patients we found five children with PH (0.8%) and three with probable PH (0.5%), in total 1.3%. Pain characteristics, autonomic symptoms and treatment response to indomethacin were similar to adult PH patients. Our results demonstrate that the International Headache Society classification of PH is also applicable to children. We suspect that PH has been underdiagnosed in children and therefore suboptimally treated thus far.

Parents' perspective on symptoms, quality of life, characteristics of death and end-of-life decisions for children dying from cancer.

BACKGROUND: In the present study, we investigated the situation of children who had succumbed to their malignancy in Germany as perceived by their parents. Specifically, we were interested in bereaved parents' perspective on five essential areas: 1) symptoms and quality of life, 2) characteristics of the child's death, 3) anticipation of their child's death and care delivery, 4) end-of-life decisions and 5) impact of the child's death on the parents and perceived social support by the health care team. MATERIALS AND METHODS: We contacted all existing departments for paediatric oncology in the German federal state of Nordrhein Westfalen and asked them to contact all parents for participation in our study who had lost their child to cancer in 1999 and 2000. Upon agreement, we interviewed the parents utilising a validated semi-structured interview on distressing symptoms and quality of life of their children during the end-of-life care period. RESULTS: Six of the 19 departments agreed to participate. Parents of 48 children (31 boys, 17 girls) were interviewed. The main distressing symptoms were fatigue, pain, loss of appetite, and dyspnoea according to the parents. While parents perceived pain and constipation to have been treated successfully, loss of appetite and anxiety were not treated effectively. 75% of the children died due to a progression of their malignancy. Of these, 50% obtained cancer-directed therapy at the end of life, which was negatively rated by the parents in hindsight. 48% of the children died at home even though 88% of the parents chose 'at home' as the most appropriate locale of death in hindsight. Parents anticipated their child's death on average 9 weeks prior to the child's death. 41% of the parents provided palliative home care for their child and the majority (88%) rated the quality of care as good or very good. 64% discussed end-of-life decisions with the health care team, 36% did not have a discussion. Parents were clearly affected by their child's death. However, 15% of the parents were not contacted by the health care team following the child's death. CONCLUSIONS: The present study demonstrated that psychological symptoms (e.g. anxiety) are frequent symptoms in the end-of-life care period and cause severe suffering in the children. Questions in terms of benefits and costs of cancer-directed therapy in the end-of-life care period need to be addressed in future prospective studies. Parents' perspective on their child's death and related end-of-life decisions highlighted the importance of communication between parents and the health care team. Future studies need to investigate potential barriers in the communication between parents and the team to optimise end-of-life decisions and hence, reduce parents' long-term distress. In line with the previous, the present data demonstrated that there is still a lack of routine contact from the health care team following the child's death despite existing guidelines. Research is therefore needed into the implementation of guidelines for routine contact into clinical practice following a child's death.

[Practical pain control in pediatric oncology. Recommendations of the German Society of Pediatric Oncology and Hematology, the German Association for the Study of Pain, the German Society of Palliative Care, and the Vodafone Institute of Children's Pain Therapy and Palliative Care]. / Praktische Schmerztherapie in der pädiatrischen Onkologie. Empfehlungen der Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH), der Deutschen Gesellschaft zum Studium des Schmerzes (DGSS), der Deutschen Gesellschaft für Palliativmedizin (DGP) und des Vodafone-Stiftungsinstituts für Kinderschmerztherapie und Pädiatrische Palliativmedizin an der Vestischen Kinder- und Jugendklinik Datteln -- Universität Witten/Herdecke (IKP).

In pediatric oncology, optimal pain control is still a challenge. A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in the prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented toward the WHO multistep therapeutic schedule. On no account should the pediatric patient have to climb up the "analgesic ladder" - strong pain requires the primary use of strong opioids. Give opioids preferably by the oral route and by the clock - short-acting opioids should be used to treat breakthrough pain. Alternatives are i.v. infusion, patient-controlled analgesia, and transdermal applications. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of pediatric nurses is of the utmost importance in pediatric pain control. Nurses deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses' task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our guideline we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.

[Unique children -- unique headaches. Case reports of pediatric headache patients from an outpatient children's pain department]. / Individuelle Kinder -- individuelle Kopfschmerzen. Fallbeispiele kindlicher Kopfschmerzen aus einer multidisziplinären Kinderschmerzambulanz.

In the industrialized nations headache prevalence is increasing in children and adolescents. The nosologic classification determines the therapeutic strategy to follow. Three case reports illustrate the optimal cooperation of both a pediatric outpatient pain clinic and a pediatric psychosomatic pain clinic. We report on (1) a girl aged 2 years and 7 months with a 4-month history of headache episodes lasting about 15 min each with concomitant symptoms; (2) an 11-year-old boy with Schimmelpenning-Feuerstein-Mims syndrome, symptomatic focal epilepsy, psychomotor retardation, mild postinfectious internal hydrocephalus, and repeated heat-triggered episodes of right-sided headache beginning suddenly with a duration of 5-30 min and concomitant flush of his hemiface; and (3) a 12-year-old boy who for about 2 years has suffered from "migraine" 3 times a week, significantly impairing his quality of life. We discuss the patients' courses, diagnostic pitfalls, and therapeutic options. For the optimal treatment of children with headache not easily fitting into one of the categories, with significant comorbidity present, or if there is no adequate response to therapy conforming with guidelines, the help of an interdisciplinary pediatric pain clinic is invaluable.

[Long-term pediatric opioid based pain control. Case reports]. / Opioidtherapie chronischer Schmerzen bei Kindern. Fallbesprechungen.

Based on 4 case reports we focus on the peculiarities of long-term pediatric opioid based pain control. Case report #1, emphasizing the importance of adequate opioid dosing with reference to body weight, illustrates that with adequate management oral sustained-release opioid therapy is safe even in infants less than one year old. Case report #2 is the first report on the usage of buccal fentanyl citrate for pediatric break-through pain control. Case report #3 focuses on the adverse effects of opioid pain control in an infant with neurological impairment. Case report #4 reports on the successful tumor pain control using transdermal buprenorphine. We conclude that proven therapeutic strategies for opioid pain control as applied in adults may be adopted for the usage on children in pediatrics. However, it is mandatory to take into account both the pharmacokinetic and pharmacodynamic peculiarities of childhood.

Interstitial deletion del(2)(q24q31) with a phenotype similar to del(2)(q31q33).

A 3 3/12-year-old girl with multiple anomalies is reported. An interstitial deletion del(2)(q24q31) was demonstrated. There is considerable overlap of symptoms in cases with del(2)(q31q33), which are reviewed.

Ring chromosome 4 in a child with mild dysmorphic signs.

We report on an 8-year-old boy exhibiting microcephaly, clinodactyly and growth retardation. Chromosome analysis showed a ring chromosome 4 in 97% of the cells and a high number of hyperploid cells with various ring formations. The breakpoints are presumed to be close to or in the telomeric regions of both arms. The patients reported with ring chromosome 4 and breakpoints close to the telomeres of both arms showed unspecific, mild clinical findings with normal or retarded mental development. These signs are probably related to the continuous generation of aneuploid cells.