Abraham J. Valkenburg

The COMFORT-behavior scale is useful to assess pain and distress in 0- to 3-year-old children with Down syndrome.

Summary Psychometric properties of the COMFORT‐Behavior scale were comparable between 0‐ to 3‐year‐old children with and without Down syndrome. ABSTRACT Many pediatric intensive care units use the COMFORT‐Behavior scale (COMFORT‐B) to assess pain in 0‐ to 3‐year‐old children. The objective of this study was to determine whether this scale is also valid for the assessment of pain in 0‐ to 3‐year‐old children with Down syndrome. These children often undergo cardiac or intestinal surgery early in life and therefore admission to a pediatric intensive care unit. Seventy‐six patients with Down syndrome were included and 466 without Down syndrome. Pain was regularly assessed with the COMFORT‐B scale and the pain Numeric Rating Scale (NRS). For either group, confirmatory factor analyses revealed a 1‐factor model. Internal consistency between COMFORT‐B items was good (Cronbach’s α = 0.84–0.87). Cutoff values for the COMFORT‐B set at 17 or higher discriminated between pain (NRS pain of 4 or higher) and no pain (NRS pain below 4) in both groups. We concluded that the COMFORT‐B scale is also valid for 0‐ to 3‐year‐old children with Down syndrome. This makes it even more useful in the pediatric intensive care unit setting, doing away with the need to apply another instrument for those children younger than 3.

PAIN MANAGEMENT IN INTELLECTUALLY DISABLED CHILDREN: ASSESSMENT, TREATMENT, AND TRANSLATIONAL RESEARCH

The primary focus of pain research in intellectually disabled individuals is still on pain assessment. Several observational pain assessment scales are available, each with its own characteristics, its own target group and its own validated use. Observational studies report differences in the treatment of intra- and postoperative pain of intellectually disabled children and almost all children with intellectual disability have comorbidities that need to be addressed. The scope of research has started to broaden. In this review we aim to answer the question: Can we integrate validated ways of pain assessment and postoperative pain treatment in intellectually disabled children to develop specific analgesic algorithms? Regrettably there is little knowledge on possible interaction effects and other relevant pharmacological issues. Possible genotype-phenotype associations related to pain in children with Down syndrome have several promises as six possible candidate genes are located on chromosome 21. In conclusion, the pain assessment tools for intellectually disabled children are there. We should now focus on tailoring the pain treatment. To this aim we need to perform pharmacokinetic and pharmacodynamic studies of analgesics and obtain information about the genotype-phenotype relationships for pain. This can lead to the development of specific analgesic algorithms.

Long-Term Effects of Neonatal Morphine Infusion on Pain Sensitivity: Follow-Up of a Randomized Controlled Trial

Short-term and long-term effects of neonatal pain and its analgesic treatment have been topics of translational research over the years. This study aimed to identify the long-term effects of continuous morphine infusion in the neonatal period on thermal pain sensitivity, the incidence of chronic pain, and neurological functioning. Eighty-nine of the 150 participants of a neonatal randomized controlled trial on continuous morphine infusion versus placebo during mechanical ventilation underwent quantitative sensory testing and neurological examination at the age of 8 or 9 years. Forty-three children from the morphine group and 46 children from the placebo group participated in this follow-up study. Thermal detection and pain thresholds were compared with data from 28 healthy controls. Multivariate analyses revealed no statistically significant differences in thermal detection thresholds and pain thresholds between the morphine and placebo groups. The incidence of chronic pain was comparable between both groups. The neurological examination was normal in 29 (76%) of the children in the morphine group and 25 (61%) of the children in the control group (P = .14). We found that neonatal continuous morphine infusion (10 μg/kg/h) has no adverse effects on thermal detection and pain thresholds, the incidence of chronic pain, or overall neurological functioning 8 to 9 years later. Perspective: This unique long-term follow-up study shows that neonatal continuous morphine infusion (10 μg/kg/h) has no long-term adverse effects on thermal detection and pain thresholds or overall neurological functioning. These findings will help clinicians to find the most adequate and safe analgesic dosing regimens for neonates and infants.

Pain sensitivity of children with Down syndrome and their siblings: quantitative sensory testing versus parental reports

The aim of this study was to compare thermal detection and pain thresholds in children with Down syndrome with those of their siblings.

Thermal detection thresholds in 5-year-old preterm born children; IQ does matter.

BACKGROUND Experiencing pain at newborn age may have consequences on ones somatosensory perception later in life. Childrens perception for cold and warm stimuli may be determined with the Thermal Sensory Analyzer (TSA) device by two different methods. AIM This pilot study in 5-year-old children born preterm aimed at establishing whether the TSA method of limits, which is dependent of reaction time, and the method of levels, which is independent of reaction time, would yield different cold and warm detection thresholds. The second aim was to establish possible associations between intellectual ability and the detection thresholds obtained with either method. STUDY DESIGN A convenience sample was drawn from the participants in an ongoing 5-year follow-up study of a randomized controlled trial on effects of morphine during mechanical ventilation. METHODS Thresholds were assessed using both methods and statistically compared. Possible associations between the childs intelligence quotient (IQ) and threshold levels were analyzed. RESULTS The method of levels yielded more sensitive thresholds than did the method of limits, i.e. mean (SD) cold detection thresholds: 30.3 (1.4) versus 28.4 (1.7) (Cohensd=1.2, P=0.001) and warm detection thresholds; 33.9 (1.9) versus 35.6 (2.1) (Cohens d=0.8, P=0.04). IQ was statistically significantly associated only with the detection thresholds obtained with the method of limits (cold: r=0.64, warm: r=-0.52). DISCUSSION The TSA method of levels, is to be preferred over the method of limits in 5-year-old preterm born children, as it establishes more sensitive detection thresholds and is independent of IQ.

Pain management in intellectually disabled children: a survey of perceptions and current practices among Dutch anesthesiologists

Background:  Intellectually disabled children are more likely to undergo surgical interventions and almost all have comorbidities that need to be managed. Compared with controls, intellectually disabled children tend to receive less intraoperative analgesia and fewer of them are assessed for postoperative pain.

Extremely low preanesthetic BIS values in two children with West syndrome and lissencephaly

partial surgical removal of cervicofacial lymphangyomas. Arch Otolaryngol Head Neck Surg 1999; 125: 643–648. 10 Thompson AE. Issues in airway management in infants and children. Respir Care 1999; 44: 650. 11 Berkenbosch JW, Graff GR, Stark JM et al. Use of a remifentanil–propofol mixture for pediatric flexible fiberoptic bronchoscopy sedation. Pediatr Anesth 2004; 14: 941–946. 12 Reinoso-Barbero F, Castro LE. Influencia de la edad pediátrica en la técnica de anestesia basada en la analgesia con remifentanilo. Rev Esp Anestesiol Reanim 2004; 51: 12–19. 13 Vidal MA, Velázquez A, Morgado I et al. Sedación con remifentanilo para una traqueostomı́a en un paciente pediátrico. Rev Esp Anestesiol Reanim 2004; 51: 600–603. 14 American Society of Anesthesiologist Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an update report by the American Society of Anesthesiologist Task Force of Management of Difficult Airway. Anesthesiology 2003; 98: 1269–1277. 15 Ovassapian A. Fiberoptic Airway Endoscopy in Anesthesia and Critical Care, 1st edn. New York: Raven, 1990: 149–162. 16 Omote K, Kawamata T, Imaizumi H et al. Case of Cowden’s disease that caused airway obstruction during induction of anesthesia. Anesthesiology 1999; 91: 1537–1540. 17 Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996; 684: 86.

Neugeborene: Langzeitnebenwirkungen nach Morphin?

Bei Fruh- und Neugeborenen wiesen Daten aus Tierversuchen auf mogliche negative Folgen einer fruhen und chronischen Exposition mit Morphin hin. Vor diesem Hintergrund wurde von 2000–2002 eine Studie durchgefuhrt, die 150 Sauglinge und Fruhgeborene aufnahm, die in den ersten Lebenswochen auf einer Intensivstation kunstlich beatmet wurden und entweder eine Morphindauerinfusion oder eine Placeboinfusion erhielten. In der vorliegenden Arbeit werden Langzeitdaten der mittlerweile 8–9 Jahre alten Kinder veroffentlicht, die jetzt auch eine quantitative sensorische Testung beinhalten.

Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy?

This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug–drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.