Manuela Trapanotto

Evaluating pain induced by venipuncture in pediatric patients with developmental delay

Objectives:Little attention has been paid to the assessment of pain in children with developmental delay. The aim of this study was to explore several methods for assessing pain during venipuncture in this population of children, using classic and modified scales to evaluate the children’s response to simplified tools. Methods:Sixteen children with mild or moderate developmental delay were evaluated using three standard self-rating scales (Visual Analog Scale [VAS], Eland Scale, and Faces Scale) and three modified methods (Cube Test, Modified Eland Scale, and Modified Faces Scale), recording subjective self-ratings and behavioral expressions of pain during a venipuncture procedure, apart from the initial fear. The children’s pain and reaction time were assessed by an outside observer, while their pain and fear were also evaluated by the parents. Results:The VAS was used without difficulty by all the children and revealed a good consistency with the Cube Test. The parents’ and neutral observer’s indirect pain assessment was also consistent with the child’s evaluations. The Eland Scale proved difficult to use, especially for Down’s syndrome children, while its modified version was easier. Results emerging from the original and modified Faces Scales were inconsistent. Frightened children attributed higher pain scores, demonstrating that negative emotions exacerbate the experience of pain in developmentally delayed children. The patients showed a limited capacity for verbal and behavioral expression in reaction to the painful stimulus (especially the Down’s cases). Discussion:These findings support the conviction that even developmentally delayed children can use self-rating methods effectively. This sector demands further, more extensive study, including the development of simplified tools, to ensure an adequate pain assessment and optimal antalgic approach to this particular pediatric population.

Analysis of the Bispectral Index During Natural Sleep in Children

The Bispectral Index (BIS) is a system used to measure sedation levels. Some investigators recently analyzed changes in the BIS during natural sleep in adults and found that the BIS diminished considerably as sleep became deeper. No such studies have been undertaken to investigate changes in the BIS in sleeping children. The aim of this work was to assess the trend of the BIS in the various stages of sleep in a group of children, performing a descriptive analysis on a limited number of cases. We evaluated 15 children with negative clinical findings and a normal electroencephalogram (EEG) as part of their follow-up for prior episodes of epilepsy, recording the BIS and EEG in a waking state, in the various stages of sleep and on reawaking. For each stage, the mean value, the standard deviation, and the range of BIS values were calculated. The results showed that the BIS decreased progressively as sleep became deeper. The correlation between the stage of sleep and the BIS was significant. On reawaking, a slow increase was apparent in the BIS.

The Cold Pressor Test for the Pediatric Population: Refinement of Procedures, Development of Norms, and Study of Psychological Variables

OBJECTIVE The aims of the study were: (a) to propose focal refinements to the cold pressor test (CPT) for the pediatric population, contributing to the development of subjective and behavioral norms; (b) to analyze the influence of personal (gender, age, and skin-fold thickness), and psychological (anxiety, depression, internalization, and externalization) variables on pain perception and its correlation with room temperature. METHODS After a phase of adaptation in a water bath (24-27 degrees C), the child immersed one arm in cold water (10 degrees C) and reported pain threshold and tolerance. RESULTS The test was conducted on 141 healthy children. Pain tolerance was reached within the first minute by 50% of the children. Pain intensity affected the childrens emotional status. Older children tolerated pain for longer. Gender, psychological, and environmental variables did not influence pain perception. CONCLUSION This study provides methodological refinements to the CPT contributing to the development of norms for children.

Pediatric palliative care.

The WHO defines pediatric palliative care as the active total care of the childs body, mind and spirit, which also involves giving support to the family. Its purpose is to improve the quality of life of young patients and their families, and in the vast majority of cases the home is the best place to provide such care, but for cultural, affective, educational and organizational reasons, pediatric patients rarely benefit from such an approach. In daily practice, it is clear that pediatric patients experience all the clinical, psychological, ethical and spiritual problems that severe, irreversible disease and death entail. The international literature indicates a prevalence of incurable disease annually affecting 10/10,000 young people from 0 to 19 years old, with an annual mortality rate of 1/10,000 young people from birth to 17 years old. The needs of this category of patients, recorded in investigations conducted in various parts of the world, reveal much the same picture despite geographical, cultural, organizational and social differences, particularly as concerns their wish to be treated at home and the demand for better communications between the professionals involved in their care and a greater availability of support services. Different patient care models have been tested in Italy and abroad, two of institutional type (with children staying in hospitals for treating acute disease or in pediatric hospices) and two based at home (the so-called home-based hospitalization and integrated home-based care programs). Professional expertise, training, research and organization provide the essential foundations for coping with a situation that is all too often underestimated and neglected.

Hospitalization in Children Eligible for Palliative Care

INTRODUCTION Medical and technological progress allows newborns, children and teenagers suffering from life-limiting and life-threatening illness to survive, but not necessarily to recover. Data on the number of children eligible for pediatric palliative care [PPC] and their needs are useful for health care planning. The main aim of this study was to ascertain the prevalence and the course of children eligible for pediatric palliative care in Italy. METHODS The data source considered was the hospital discharge records (HDR), containing information on the childrens diagnosis, their personal and clinical details, hospital admissions, procedures and discharge. The list of diseases eligible for PPC was based on the ICD IX CM list, according to ACT criteria. All records of hospital admissions in Italy for the years 2001-2003 were processed. The first step was to identify hospital admissions involving individuals 0-17 years old with at least one of the selected life-limiting and life-threatening illnesses. The main features of these hospital admissions were described in terms of duration, frequency, and discharge arrangements, estimating the number of patients eligible for PPC and the number of deaths occurring in hospital. RESULTS The total number of hospital admissions concerning patients aged 0-17 years amounted to 3,578,649. Our restrictive criteria identified 323,415 hospital admissions in 3 years relating to diseases eligible for pediatric palliative care, which involved approximately 12,000 children. The most common diseases fell respectively into the following sectors: perinatal, neurological, neoplastic and congenital diseases. The number of days spent in hospital for diseases eligible for PPC ranged from 556,075 days/year to 591,983, and concerned 35,000 children every year. CONCLUSIONS Our data agree with other international surveys on the prevalence and typology of pediatric patients. The HDR could be useful for the estimation of the cases eligible for pediatric palliative care and for monitoring of deaths in hospital.