title: The efficacy of LMX versus EMLA for pain relief in boys undergoing office meatotomy. Observational pain assessment versus self-report in paediatric triage Healthcare professionals' perceptions of pain in infants at risk for neurological impairment Adjuvant local anaesthetics in the epipharyngeal space in day-case adenoidectomy: A prospective, randomized, double-blind, placebo-controlled trial Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children A multifactorial strategy of pain management is associated with less pain in scheduled vaccination of children. A study realized by family practitioners in 239 children aged 4-12 years old. Relative Efficacy of Amethocaine Gel and Lidocaine–Prilocaine Cream for Port-a-Cath Puncture in Children Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial Validation of 2 pain scales for use in the pediatric emergency department. Topical anesthetics for intravenous insertion in children: a randomized equivalency study. Analgesic efficacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy Effectiveness of Virtual Reality for Pediatric Pain Distraction during IV Placement The effective time and concentration of nitrous oxide to reduce venipuncture pain in children. Lidocaine iontophoresis for topical anesthesia before dermatologic procedures in children: a randomized controlled trial. Comparing two methods of topical anesthesia used before intravenous cannulation in pediatric patients. Development of a research-based standard for assessment, intervention, and evaluation of pain after neonatal and pediatric cardiac surgery. Pain assessment by children and adolescents during intraosseous anaesthesia using a computerized system (QuickSleeper). Alternate Oucher form testing: gender, ethnicity, and age variations. Randomized clinical trial of local anesthetic versus a combination of local anesthetic with self-hypnosis in the management of pediatric procedure-related pain. Relief of posttonsillectomy pain with low-dose tramadol given at induction of anesthesia in children. Comparison of ethyl chloride spray with topical anaesthetic in children experiencing venepuncture. Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients. Interactive Music as a Treatment for Pain and Stress in Children During Venipuncture: A Randomized Prospective Study Eutectic Mixture of Local Anesthetics Reduces Pain During Intravenous Catheter Insertion in the Pediatric Patient Further validity testing of the Abu-Saad Paediatric Pain Assessment Tool. Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures Evaluation of toothache severity in children using a visual analogue scale of faces. The effect of paracetamol, fentanyl, and systematic assessments on children's pain after tonsillectomy and adenoidectomy. Ethyl Chloride as a Cryoanalgesic in Pediatrics for Venipuncture Pain in 4- to 6-year-old children receiving intramuscular injections: a comparison of the Faces Pain Scale with other self-report and behavioral measures. An Evaluation of the Efficacy and Tolerability of Oral Tramadol Hydrochloride Tablets for the Treatment of Postsurgical Pain in Children Do cartoon stickers given after a hemoglobin finger stick influence preschoolers' pain perception? The effect of the sight of blood and use of decorative adhesive bandages on pain intensity ratings by preschool children. Limited analgesic efficacy of nitrous oxide for painful procedures in children A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Topical anaesthesia for children's lacerations: an acceptable approach? Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children. Pain, distress, and adult-child interaction during venipuncture in pediatric oncology: an examination of three types of venous access. Expected and reported pain in children undergoing ear piercing: a randomized trial of preparation by parents. Does tramadol wound infiltration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy? Reduction of topical anesthetic onset time using ultrasound: a randomized controlled trial prior to venipuncture in young children. Self-report of pain in children treated according to the atraumatic restorative treatment and the conventional restorative treatment--a pilot study. A placebo‐controlled model for assaying systemic analgesics in children Comparison of oral versus rectal administration of acetaminophen with codeine in postoperative pediatric adenotonsillectomy patients. Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection. An intrusive impact of anchors in children's faces pain scales Nitrous oxide analgesia for minor pediatric surgical procedures: an effective alternative to conscious sedation? An investigation of the placebo effect and age-related factors in the report of needle pain from venipuncture in children Effectiveness of Oxycodone, Ibuprofen, or the Combination in the Initial Management of Orthopedic Injury-Related Pain in Children Double-blind evaluation of a lignocaine-prilocaine cream (EMLA) in children. Effect on the pain associated with venous cannulation. Imagery reduces children's post-operative pain A pilot study of distraction for adolescents during allergy testing. Safety and efficacy of patient controlled epidural analgesia following pediatric spinal surgery. Can mucosal sealing reduce tonsillectomy pain? Children's ratings of the intensity and unpleasantness of post-operative pain using facial expression scales. Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study. Parents’ Positioning and Distracting Children During Venipuncture Children's responses to sequential versus simultaneous immunization injections. Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery. Ropivacaine Peritonsillar Infiltration for Analgesia after Adenotonsillectomy in Children: A Randomized, Double-Blind, Placebo-Controlled Study A comparison of warmed and room-temperature anesthetic for local anesthesia in children. Topical adrenaline and cocaine gel for anaesthetising children’s lacerations. An audit of acceptability and safety The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopaedic surgery. Use of analgesia in a paediatric accident and emergency department following limb trauma Intracapsular versus subcapsular coblation tonsillectomy Facial Expression of Children Receiving Immunizations: A Principal Components Analysis of the Child Facial Coding System Evaluation of early postoperative morbidity in pediatric tonsillectomy with the use of sucralfate. A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery. Tramadol drops in children: analgesic efficacy, lack of respiratory effects, and normal recovery times. Assessment of clinically significant changes in acute pain in children. A randomized double‐blind, placebo‐controlled trial of the EMLA® patch for the reduction of pain associated with intramuscular injection in four to six‐year‐old children [Oral morphine administration for children's traumatic pain]. Intracapsular vs. extracapsular tonsillectomy: a comparison of pain. Discordance between self-report and behavioral pain measures in children aged 3-7 years after surgery. Comparison of two pain scales in indian children Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Pain and Distress from Bone Marrow Aspirations and Lumbar Punctures Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial Differences among raters evaluating the success of EMLA cream in alleviating procedure-related pain in children with cancer. Paracetamol versus ibuprofen: a randomized controlled trial of outpatient analgesia efficacy for paediatric acute limb fractures. Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery. Randomised trial of oral morphine for painful episodes of sickle-cell disease in children Improved application of Lidocaine/Prilocaine cream in children. A randomized and prospectively controlled study of two application regimes The convergent validity of the Manchester Pain Scale. Microdebrider tonsillotomy vs electrosurgical tonsillectomy: a randomized, double-blind, paired control study of postoperative pain. Effectiveness of nitrous oxide and analgesic cream (lidocaine and prilocaine) for prevention of pain during intramuscular botulinum toxin injections in children. A comparison of faces scales for the measurement of pediatric pain: children's and parents’ ratings Tonsillectomy or tonsillotomy?--A randomized study comparing postoperative pain and long-term effects. Parental assessment and management of children's postoperative pain: a randomized clinical trial Accuracy of children's pain memories Watch needle, watch TV: Audiovisual distraction in preschool immunization. [Better postoperative pain management in children by introduction of guidelines; a prospective study]. Comparison of articaine 4% and lidocaine 2% in paediatric dental patients. Comparison of Posttonsillectomy Pain Using the Ultrasonic Scalpel, Coblator, and Electrocautery Cold dissection versus coblation-assisted adenotonsillectomy in children. The analgesic efficacy and neuroendocrine response in paediatric patients treated with two analgesic techniques: using morphine-epidural and patient-controlled analgesia. Effects of music on anxiety and pain in children with cerebral palsy receiving acupuncture: a randomized controlled trial. Topical Clindamycin in Post-Adenotonsillectomy Analgesia in Children: A Double-Blind, Randomized Clinical Trial A Randomized Controlled Trial to Evaluate S-Caine Patch™ for Reducing Pain Associated with Vascular Access in Children Unsedated upper endoscopy in children. Parents and practitioners are poor judges of young children's pain severity. Needle-Free Powder Lidocaine Delivery System Provides Rapid Effective Analgesia for Venipuncture or Cannulation Pain in Children: Randomized, Double-Blind Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment Trial Pain response to M-M-R vaccination in 4-6 year old children. Comparison of four pain scales in children with acute abdominal pain in a pediatric emergency department. Nasal sumatriptan is effective in treatment of migraine attacks in children Comparison of ropivacaine with bupivacaine and lidocaine for ilioinguinal block after ambulatory inguinal hernia repair in children. Randomized controlled trial of Coblation versus electrocautery tonsillectomy Taking the "ouch" out of injections for children. Using distraction to decrease pain. Autologous fibrin sealant reduces pain after tonsillectomy. A novel needle-free powder lidocaine delivery system for rapid local analgesia. Pain Treatment Thresholds in Children After Major Surgery An evaluation of the Faces Pain Scale with young children. The alternate forms reliability of the Oucher pain scale. Pain assessment in the paediatric Emergency Department: whose view counts? The faces pain scale for the self-assessment of the severity of pain experienced by children: Development, initial validation, and preliminary investigation for ratio scale properties Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections. A randomized controlled trial of an at-home preparation programme for Japanese preschool children: effects on children's and caregivers' anxiety associated with surgery. Platelet-rich plasma for pediatric tonsillectomy patients.
abstract: PURPOSE We determined if a difference in pain management occurred when topical anesthetics LMX ( formerly ELA-Max , lidocaine 4 % ) and EMLA ( lidocaine 2.5 % and prilocaine 2.5 % ) were compared in boys undergoing office meatotomy for symptomatic meatal stenosis . MATERIAL S AND METHODS A prospect i ve r and omized study was performed on 52 boys who underwent office meatotomy by a single pediatric urologist . Of the boys 26 , 2 to 9 years old ( mean age 4.4 ) underwent meatotomy 45 minutes after topical anesthetic application ( LMX 13 , EMLA 13 ) between February and December 2001 , 26 , ages 1 to 10 years old ( 4.6 ) underwent meatotomy 30 minutes after topical anesthetic application ( LMX 13 , EMLA 13 ) between April 2002 and January 2003 . A single pediatric urological nurse performed pain assessment using the Wong-Baker Faces scale before applying the anesthetic ointment and immediately following the procedure . Each child had either LMX or EMLA applied and covered with an occlusive dressing for either 45 or 30 minutes before the procedure . Oral acetaminophen ( 10 mg/kg ) was given at the time of anesthetic application . A meatotomy was then performed using a straight crushing hemostat for 1 to 2 minutes followed by incision . Mann-Whitney rank sum test was implemented to determine statistical significance . RESULTS Excellent procedure outcomes were experienced by all patients without recurrent meatal stenosis . CONCLUSIONS There was no significant difference between LMX and EMLA when applied 45 minutes before meatotomy . When applied 30 minutes before meatotomy LMX provided significantly superior pain management than EMLA Objective : To examine if observational pain assessment can be used for purpose s of triage in children aged > 3 years . Methods : A prospect i ve , single blind , controlled trial was undertaken in children who presented to the emergency department ( ED ) with pain .  Pain was assessed in the waiting room and again at triage before any treatment was administered using the Alder Hey Triage Pain Score ( AHTPS ) , an observational tool design ed for triage , and a self-report tool , either the Wong-Baker Faces Pain Rating Scale ( WBS ) for 3–7-year-old children or a visual analogue scale ( VAS ) for 8–15-year-old children . Scores were compared by instrument ( observational and self-report ) and ED location ( waiting room and triage room ) . Results : 75 children ( 29 aged 3–7 years and 46 aged 8–15 years ) were enrolled in the study . The AHTPS scores were significantly lower than the scores measured by the WBS/VAS ( p<0.001 ) . The level of pain measured by both methods ( self-report , observational ) was lower in the triage room . Compared with the AHTPS , the WBS and VAS scored significantly lower in the triage room than in the waiting room ( p<0.042 and p<0.006 , respectively ) . Conclusions : Observational pain assessment underestimates children ’s perception of pain and should not be recommended in children aged > 3 years . Triage has a calming effect on children Background To determine whether healthcare professionals perceive the pain of infants differently due to their underst and ing of that infant 's level of risk for neurological impairment . Method Neonatal Intensive Care Units ( NICU 's ) at two tertiary pediatric centers . Ninety-five healthcare professionals who practice in the NICU ( 50 nurses , 19 physicians , 17 respiratory therapists , 9 other ) participated . They rated the pain ( 0–10 scale and 0–6 Faces Pain Scale ) , distress ( 0–10 ) ,  effectiveness of cuddling to relieve pain  ( 0–10 ) and  time to calm without intervention  ( seconds ) for nine video clips of neonates receiving a heel stick . Prior to each rating , they were provided with descriptions that suggested the infant had mild , moderate or severe risk for neurological impairment . Ratings were examined as a function of the level of risk described . Results Professionals ' ratings of pain , distress , and time to calm did not vary significantly with level of risk , but ratings of the effectiveness of cuddling were significantly lower as risk increased [ F ( 2,93 ) = 4.4 , p = .02 ] . No differences in ratings were found due to participants ' age , gender or site of study . Physicians ' ratings were significantly lower than nurses ' across ratings . Conclusion Professionals provided with visual information regarding an infants ' pain during a procedure did not display the belief that infants ' level of risk for neurological impairment affected their pain experience . Professionals ' estimates of the effectiveness of a nonpharmacological intervention did differ due to level of risk Conclusion . Mepivacaine applied in the epipharyngeal space as an adjuvant local anaesthetic does not reduce postoperative pain after adenoidectomy in children given high-dose paracetamol preoperatively . Objective . To evaluate the pain-reducing effect of an adjuvant local anaesthetic ( mepivacaine ) applied in the epipharyngeal space after outpatient adenoidectomy . Material and methods . This was a prospect i ve , r and omized , double-blind , placebo-controlled trial . Postoperative pain was assessed in 98 children aged 3–10 years using a  visual analogue scale ( VAS ) and the Wong – Baker FACES pain rating scale . The time between the end of surgery and discharge from hospital was recorded , as well as the need for extra pain medication in addition to the high-dose paracetamol ( acetaminophen ) that had been given preoperatively . Serum levels of mepivacaine  were analysed in 10 consecutive patients . Results . No difference was seen between the mepivacaine and control groups regarding postoperative pain as estimated using either the VAS or the Wong – Baker FACES pain rating scale . There were also no differences between the groups concerning the time to discharge from hospital and the need for extra pain medication before discharge . No mepivacaine  could be detected in the patients ’ sera Background : Nausea , vomiting and pain are common complications after  strabismus surgery in children .  Diclofenac , a non‐steroid anti‐inflammatory drug , is widely used to treat acute and chronic pain but there are few reports of its use given rectally in children undergoing strabismus surgery . This open r and omised study was design ed to investigate the analgesic and anti‐emetic properties of rectally administered diclofenac compared with opioid ( morphine ) given i.v . in connection with strabismus surgery in children BACKGROUND AND AIMS The multiplicity of vaccine injections during childhood leads to iterative painful and stressful experiences which may lead in turn to anticipated pain and then possibly to a true needle phobia . We aim ed at evaluating a multifactorial strategy of pain management combining pharmacological and non-pharmacological approaches during vaccination , as compared to usual care , in 4- to 12-year-old children . METHODS In all , 239 children were enrolled by 25 family practitioners in an open-label study . After a pseudo-r and omization , usual pain management ( n = 132 ) was compared to a multifactorial strategy ( n = 107 ) associating preliminary application of an anesthesic patch , preferential use of specified vaccines , child education by the parents and the doctor , parental accompaniment and child distraction with soap bubbles during the procedure . The primary outcome ( i.e. child pain ) was assessed with a self-report scale named visual analog scale ( VAS ) of pain . RESULTS A significant decrease in pain was obtained using the multifactorial strategy , as assessed by self-reported VAS ( P < 0.0001 ) . This was confirmed by another self-report scale ( the facial pain scale revised : P = 0.005 ) , as well as with hetero-evaluations by GPs and parents [ Children 's Hospital of Eastern Ontario Pain Scale : P = 0.0007 ; GPs VAS ( P < 0.0001 ) , parents VAS ( P < 0.0001 ) ] , which were secondary outcome criteria . CONCLUSIONS This multifactorial method significantly decreases vaccination pain in 4- to 12-year-old children . This strategy could make vaccines more acceptable to children and may improve child-doctor relationships and contribute to a decrease in child fear about health care Background . Lidocaine – prilocaine cream ( EMLA ) is currently st and ard therapy to alleviate procedural pain in children . One of the disadvantages of lidocaine – prilocaine is the need to wait for 60 minutes for adequate skin anesthesia . Amethocaine gel ( Ametop ) is a new topical anesthetic that requires a shorter application time for skin anesthesia . Objectives . To compare the relative efficacy and safety of amethocaine gel and lidocaine – prilocaine cream in children with cancer undergoing Port-a-Cath puncture and to determine which patient factors influence judgments about pain . Methods . R and omized , blinded , crossover study . Each child received either 1 g of amethocaine gel for 30 minutes , preceded by a placebo gel for 30 minutes , or 1 g of lidocaine – prilocaine cream for 60 minutes . Children rated the pain using the faces scale , for which scores ranged from 0 to 5 . Parents and attending nurse operators rated pain on a 10-cm visual analog scale . Results . Thirty-nine children participated . The mean age was 10.2 years ( range : 5–16 years ) , and 69 % were male . There were no differences in mean pain assessment s between amethocaine and lidocaine – prilocaine as rated by the children ( 2.0 vs 0.5 ) , parents ( 2.6 vs 6.4 ) , or nurse operators ( 2.0 vs 0.9 ) . No serious adverse effects were detected with either preparation . Pain scores assigned by parents and children were not influenced by age , gender , duration of diagnosis , or anesthetic regimen ( amethocaine versus lidocaine – prilocaine ) in the child . Nurses , however , rated pain higher for younger children , and in males during pretreatment with lidocaine – prilocaine . Conclusion . Amethocaine achieves similar anesthesia to lidocaine – prilocaine during Port-a-Cath administration in children , with an application time that is half of lidocaine – prilocaine .  Pain assessment s were not influenced by age , gender , or duration of diagnosis of the child . Nurses may perceive that pain is greater for younger children and in males . lidocaine – prilocaine , amethocaine , pain , children , Port-a-Cath puncture Objective : Acute otitis media ( AOM ) is common in children , yet the optimal management of ear pain associated with AOM has not been well studied . We set out to determine the efficacy of topical aqueous 2 % lignocaine eardrops compared with a placebo ( saline ) for pain relief of AOM in children . Design : Double-blind , r and omised , placebo-controlled trial . Setting : Tertiary children ’s hospital emergency department . Patients and interventions : Children aged between 3 and 17 years with earache and AOM without evidence of perforation were eligible . Patients were r and omised to receive either 2 % lignocaine or saline eardrops ( placebo ) . Main outcome measures : Pain scores were measured before and after ear-drop administration . Patient and physician-interpreted pain scores were measured by using the Bieri faces pain scale and visual analogue scale at 10 , 20 and 30 minutes . The primary outcome measure was reduction in patient-measured pain scores by 50 % from the baseline . Secondary outcome measures were reduction in patient- measured pain scores by 25 % or by at least two points . Telephone follow-up occurred after 1 day and 1 week . Analysis was by intention to treat . Results : 63 children ( 31 were treated with lignocaine , 32 with placebo ) aged 3 to 12 years were enrolled . The groups were demographically and clinical ly similar , with similar proportions having received analgesia in the preceding 4 hours . Children receiving lignocaine showed significantly lower patient-measured pain scores with a reduction by 50 % from baseline at 10 minutes ( RR 2.06 , 95 % CI 1.03–4.11 , p = 0.03 ) and 30 minutes ( RR 1.44 , 95 % CI 1.07–1.93 , p = 0.009 ) but not at 20 minutes ( RR 1.35 95 % CI 0.88–2.06 ) . The response to lignocaine treatment showed significantly lower patient-measured pain scores for 25 % reduction at all time points and for two-point reduction at 10 minutes and favoured lignocaine at 20 minutes and 30 minutes without reaching statistical significance . There were no serious adverse events during the 30 minute follow-up period . Conclusion : This study suggests that topical aqueous 2 % lignocaine eardrops provide rapid relief for many young children presenting with ear pain attributed to AOM . The concurrent use of simple oral analgesia is a likely contributor to effective management of this painful childhood condition OBJECTIVE To determine the construct , content , and convergent validity of 2 self-report pain scales for use in the untrained child in the emergency department ( ED ) . METHODS A prospect i ve study was conducted of all children who presented to an urban ED between 5 and 16 years of age inclusive after written informed consent was obtained . Children were excluded if they were intoxicated , had altered sensorium , were clinical ly unstable , did not speak English , or had developmental delays . Children marked their current pain severity on a st and ardized Color Analog Scale ( CAS ) and a 7-point Faces Pain Scale ( FPS ) . They were then asked whether their pain was mild , moderate , or severe . Children were then administered an analgesic at the discretion of the attending physician and asked to repeat these measurements . For assessing content validity , the scales were also administered to age- and gender-matched children in the ED for nonpainful conditions . Convergent validity was assessed by determining the Spearman correlation coefficient between the 2 pain scales . RESULTS A total of 60 children were enrolled , 30 with pain and 30 without , with a mean age of 9.3 + /- 3.3 years . Boys accounted for 38 of the enrollees ( 63.3 % ) . The median score before analgesic administration was 6.0 cm ( interquartile range [ IQR ] : 4.0 - 8.0 ) on the CAS and 3.0 faces ( IQR : 2.0 - 5.0 ) on the FPS ; after analgesic administration , the median scores decreased to 3.1 cm ( IQR : 1.1 - 4.3 ) and 2.0 faces ( IQR : 1.0 - 3.0 ) , respectively . As the reported pain intensity increased , so did the scores on the 2 pain scales . The 30 children with no pain had a median score on the CAS of 0.0 ( IQR : 0.0 - 1.0 ) and on the FPS of 0.0 ( IQR : 0.0 - 1.0 ) , whereas the 13 children with severe pain had a median CAS of 7.0 ( IQR : 6.0 - 8.0 ) and a median FPS of 5.0 ( IQR : 4.0 - 6.0 ) . The Spearman correlation coefficient between the CAS and the FPS was positive and strong ( r = 0.894 ) . CONCLUSION The CAS and the FPS exhibit construct , content , and convergent validity in the measurement of acute pain in children in the ED OBJECTIVES Children view needle sticks as the worst source of pain and fear in the hospital setting . In an effort to minimize the pain of needle sticks , the use of eutectic mixture of lidocaine and prilocaine ( EMLA ) has become st and ard practice in many children 's hospitals . Unfortunately , EMLA requires at least 60 minutes to be fully effective and reportedly may cause vasoconstriction , leading to difficult vein cannulation . A newly available local anesthetic ( ELA-Max ) may require less time and cause less vasoconstriction . The purpose of this r and omized crossover study was to investigate the anesthetic equivalence of EMLA and ELA-Max . METHODS Thirty well children ( 14 girls and 16 boys ) who were between the ages of 7 and 13 years volunteered to have EMLA  applied to the dorsal aspect of 1 h and for 60 minutes and ELA-Max applied to the other h and for 30 minutes . Right and left h and s were r and omized to treatment type and order of intravenous ( IV ) insertion . Clinical Research Center nurses , blind to the anesthetic r and omization , attempted to insert a 22-gauge Teflon IV catheter into a vein in each h and . The children rated pain during IV insertion on the Oucher scale , and the nurse rated the difficulty of the insertion . RESULTS There was no significant difference in pain ratings for h and s that were treated with EMLA ( mean : 20.5 ) or with ELA-Max ( mean : 24 ) , and there was no difference for the difficulty of vein cannulation .  Children 's preprocedure state anxiety was positively associated with pain ratings . CONCLUSIONS ELA-Max , applied for 30 minutes before IV cannulation , has an anesthetic effectiveness similar to EMLA applied for 60 minutes . Some children rated IV insertion pain fairly high for both h and s ( eg , 60 on a 0- to 100-point scale ) despite anesthetic treatment . Preprocedural anxiety may affect the perception and /or rating of pain . There were no differences between h and s that were treated with EMLA or with ELA-Max for success of IV insertion & NA ; The efficacy of ketorolac , a non‐steroidal anti‐inflammatory drug , in the management of moderate to severe pain in adults , has led us to conduct a trial of this analgesic in children following tonsillectomy . Children were r and omized to receive intramuscular ( i.m . ) ketorolac ( 1 mg/kg , EXP group , n = 45 ) or saline ( CTL group , n = 42 ) at the completion of surgery . Intravenous ( i.v . ) fentanyl ( 0.5 & mgr;g/kg/dose ) was administered in repeated doses postoperatively . Pain intensity was measured using both the Oucher and the Children 's Hospital of Eastern Ontario Pain Scale ( CHEOPS ) to allow for comparison between self‐report and behavioral measures of pain intensity . Severity of postoperative bleeding was measured using a 4‐point rating scale . The EXP group had a significant reduction in total fentanyl dose ( mean : 35.9 & mgr;g ) compared to the CTL group ( mean : 48.3 & mgr;g , t = −2.21 , P < 0.03 ) . There was a statistically significant decrease in pre‐fentanyl CHEOPS scores in the Post‐Anesthesia Care Unit ( PACU ) in the ketorolac group ( F ( 2,30 ) = 5.34 , P < 0.01 ) , but not in the saline group ( F ( 2.24 ) = 2.46 , P > 0.05 ) . In the first hour postoperatively , the CHEOPS demonstrated significant decreases in pain intensity scores in response to opioids , in both groups . In the PACU , children were unable to provide a self‐report of pain intensity potentially due to a variety of factors ( e.g. , emergence delirium , agitation , excitement , sedation , and /or pain ) . However , during the remainder of the postoperative stay , the photographic scale of the Oucher was a more valid measure of pain intensity than the CHEOPS . There were no differences between the 2 groups in the severity of postoperative bleeding . Children in the EXP group were discharged significantly earlier ( i.e. , 30 min , t = −2.22 , P < 0.03 ) . Our data demonstrate that i.m . administration of ketorolac , at the end of surgery , significantly reduces opioid requirements and shortens length of stay without any evidence of increased bleeding . In addition , our data suggest that the patient 's altered level of consciousness and attention span may diminish the utility of self‐report measures of  pain intensity  in the immediate postoperative period The objective of this study was to test the efficacy and suitability of virtual reality ( VR ) as a pain distraction for pediatric intravenous ( i.v . ) placement . Twenty children ( 12 boys , 8 girls ) requiring i.v . placement for a magnetic resonance imaging/computed tomography ( MRI/CT ) scan were r and omly assigned to two conditions : ( 1 ) VR distraction using Street Luge ( 5DT ) , presented via a head-mounted display , or ( 2 ) st and ard of care ( topical anesthetic ) with no distraction .  Children , their parents , and nurses completed self-report question naires that assessed numerous health-related outcomes . Responses from the Faces Pain Scale-Revised indicated a fourfold increase in affective pain within the control condition ; by contrast , no significant differences were detected within the VR condition . Significant associations between multiple measures of anticipatory anxiety , affective pain , i.v . pain intensity , and measures of past procedural pain provided support for the complex interplay of a multimodal assessment of pain perception . There was also a sufficient amount of evidence supporting the efficacy of Street Luge as a pediatric pain distraction tool during i.v . placement : an adequate level of presence , no simulator sickness , and significantly more child- , parent- , and nurse-reported satisfaction with pain management . VR pain distraction was positively endorsed by all reporters and is a promising tool for decreasing pain , and anxiety in children undergoing acute medical interventions . However , further research with larger sample sizes and other routine medical procedures is warranted STUDY OBJECTIVE To investigate the time of administration and concentration of inhaled nitrous oxide ( N(2)O ) needed to reduce the pain associated with intravenous ( i.v . ) cannulation in children . DESIGN Prospect i ve , r and omized study . SETTING Operating room of a children 's hospital . PATIENTS 73 ASA physical status I and II children , aged 6 - 15 years , scheduled for elective day or non-day surgery . INTERVENTIONS Children were r and omly allocated to one of 4 groups prior to i.v . insertion of a 24-gauge catheter in the dorsum of the h and : Group 1 ( n = 18 ) : 50 % N(2)O in O(2 ) for three minutes ; Group 2 ( n = 18 ) : 50 % N(2)O in O(2 ) for 5 minutes ; Group 3 ( n = 18 ) : 70 % N(2)O in O(2 ) for three minutes ; or Group 4 ( n = 19 ) : 70 % N(2)O in O(2 ) for 5 minutes . MEASUREMENTS Just after the venous cannulation , degree of pain was assessed by examining the faces of the patient by the parent and an operating room nurse . MAIN RESULTS Pain scores obtained from parents of children in Groups 3 and 4 were significantly lower than from those in Groups 1 and 2 . Pain scores from the nurse in Group 3 was significantly lower than those in Group 1 . However , there was no significant difference in pain score between Group 3 and Group 4 . Frequency of side effects was similar among the 4 groups . CONCLUSIONS Seventy percent N(2)O in O(2 ) given for three minutes was effective for reducing venipuncture pain in children Local anesthesia by injection in pediatric patients undergoing dermatologic procedures is not well received because of the pain of injection and the fear of needles . Lidocaine iontophoresis is a method of topical anesthesia where lidocaine is driven into the skin under the influence of electric current . We performed a prospect i ve double-blind , placebo-controlled evaluation of iontophoresis of 2 % lidocaine with 1:100,000 epinephrine .  Sixty children requiring dermatologic procedures were enrolled ( 50 shave biopsy  , 7  curettage  , 2  injection  , 1  punch biopsy ) . Twenty-nine of 31 patients in the lidocaine group versus 2 of 29 placebo patients required no supplemental anesthesia ( p < 0.001 ) . The pain reported by the patients on the Oucher pain scale subsequent to the procedure was significantly lower in the lidocaine group ( p < 0.001 ) . Investigators and parents also rated pain lower in the lidocaine group ( p < 0.001 ) . Blanching and /or erythema occurred in 58 of 60 patients , but resolved within 1 hour in all patients . There were no other adverse events .  Lidocaine iontophoresis is a safe and effective method of topical anesthesia prior to dermatologic procedures in children INTRODUCTION The purpose of this study was to compare the efficacy of two methods of topical anesthesia before venipuncture or intravenous cannulation of pediatric patients to assess which type of topical anesthetic would better alleviate pain in the least amount of time with the greatest success rate of cannulation . METHODS This study was a r and omly controlled trial of 100 preoperative pediatric patients aged 5 to 21 years . The following methods of topical anesthesia were compared : ( a ) iontophoresis of a topical solution of 2 % lidocaine with epinephrine 1:100,000 using a Phoresor Dose Controller ( PDC ) with Numby Stuff electrodes and a eutectic mixture of local anesthetic and ( b ) 2.5 % lidocaine and 2.5 % prilocaine ( eutectic mixture of local anesthetics [ EMLA ] cream ) . RESULTS Children reported less pain with iontophoresis ( M = 0.08 ) compared with EMLA cream ( M = 1.88 , P < .001 ) . Time to accomplish topical anesthesia was shorter with iontophoresis ( 13 minutes ) compared with EMLA cream ( 60 minutes , P < .001 ) . Failure to accomplish venipuncture occurred 5 times with the iontophoresis method and 8 times with the EMLA method ( not significant ) . No dermal burns result ed from use of iontophoresis . DISCUSSION We conclude that use of iontophoresis in pediatric patients is safe , rapid , and significantly more effective than is EMLA cream in reducing pain associated with venipuncture or intravenous cannulation This analysis of retrospective and prospect i ve data quantified children ( age range 0 - 18 years , total n = 132 ) during their stay in a cardiothoracic intensive care unit and examined pain management and sedation practice s. Data on both factors that could potentially affect pain and its management , and analgesics/sedatives ordered for and administered to subjects were collected from chart review . In the prospect i ve group , pain intensity was measured twice daily using the Wong-Baker FACES Pain Rating Scale . Repeat cardiac surgical procedure subjects reported significantly more pain than nonrepeat subjects on the first postoperative night . Subjects with sternal incisions  reported significantly more pain than subjects with submammary incisions . Not all subjects were premedicated with analgesia for invasive procedures . Significantly greater amounts of analgesia were received by the 0 - 3 year-old subjects . Large amounts of  sedation  were used , especially in children under 3 years of age . The results prompted development of a nursing st and ard to assess and manage pain and sedation in this population BACKGROUND Intraosseous ( IO ) anaesthesia has been shown to be effective in children . However , the pain associated with anaesthetic injections , and its acceptance by children , have never been studied . AIM The aim of this study was to assess the pain associated with the IO injection of 4 % articaine with 1 : 200 000 epinephrine using the computerized QuickSleeper ' system in a population of children and adolescents . DESIGN IO anaesthesia was performed on patients aged 10.4 + /- 2.6 years of age . The patients assessed their pain on a faces pain scale ( FPS ) and on a visual analogue scale ( VAS ) . The operators were also asked to assess signs of patient pain/discomfort . RESULTS No pain or mild discomfort was reported by , respectively , 81.8 % ( FPS ) and 83.9 % ( VAS ) of the patients . Some 58.9 % of children with previous experience of dental anaesthesia reported that computerized IO anaesthesia was more comfortable than traditional infiltration methods . Operators noted signs of discomfort during penetration and injection in 18.3 % and 25.3 % of the patients , respectively . CONCLUSIONS This study showed that the majority of children reported no pain or mild pain when anaesthetic was administered by computerized needle rotation and solution deposition . This technique holds promise for use by trained paediatric dentists This study was part of a project to improve pain assessment and management for a multiethnic group of children . Based on its visual appeal for the clinical team , the Oucher was selected for trial . A reduced size and shortened screening technique were introduced . Children ( N = 79 ) aged 3 to 12 years were r and omly assigned to use the original or a reduced-size Oucher first . Scale scores were highly correlated regardless of size or presentation order . There were no differences attributable to age , gender , or ethnicity ( Black , White , Hispanic ) . There is preliminary support for using the more convenient size and screening process A prospect i ve controlled trial was conducted to compare the efficacy of an analgesic cream ( eutectic mixture of local anesthetics , or EMLA ) with a combination of EMLA with hypnosis in the relief of lumbar puncture-induced pain and anxiety in 45 pediatric cancer patients ( age 6 - 16 years ) . The study also explored whether young patients can be taught and can use hypnosis independently as well as whether the therapeutic benefit depends on hypnotizability . Patients were r and omized to 1 of 3 groups : local anesthetic , local anesthetic plus hypnosis , and local anesthetic plus attention . Results confirmed that patients in the local anesthetic plus hypnosis group reported less anticipatory anxiety and less procedure-related pain and anxiety and that they were rated as demonstrating less behavioral distress during the procedure . The level of hypnotizability was significantly associated with the magnitude of treatment benefit , and this benefit was maintained when patients used hypnosis independently OBJECTIVE Pain is major problem regarding quality of life in children undergoing tonsillectomy . Preemptive analgesia by medicine given before commencement of surgery is a new way recommended for relief of pain during and after operation . The purpose in this study to evaluate preemptive efficacy and safety of lower dose of tramadol , which was recently introduced in children undergoing tonsillectomy . METHODS This study was performed on 45 children undergoing tonsillectomy with or without adenoidectomy as a double-blinded trial , by using tramadol in two dosages ( 1 and 0.5 mg kg(-1 ) ) and placebo .  Pain assessment was done by facial pain score ( FPS ) , visual analog scale ( VAS ) and postoperative analgesic requirement ; further , duration of anesthesia and duration of awakening time , heart rate ( HR ) and mean arterial pressure ( MAP ) during and after anesthesia , postoperative nausea and vomiting ( PONV ) and recall of intraoperative events were recorded . RESULTS It was found that 73 % children in placebo group needed  analgesic medicine  at the end of the first hour after operation , although no analgesic medicine was needed in tramadol groups ( chi(2 ) test , P<0.001 ) . However , statistically significant decrease in FPS and VAS in tramadol groups were only found up to 15th and 30th min after operation , respectively ( Kruskall-Wallis test , P<0.05 ) . On the other h and , intraoperative HR ( 10th , 20th and 30th min ) and MAP ( 10th and 20th min ) were found to be higher in placebo groups ( ANOVA variance analysis , Tukey-Kramer test adjusted paired t-test , P<0.001 and < 0 . 01 , respectively ) . No significant difference was found in the other parameters , and no surgical complication and adverse side effect were occurred in this number of study sample . CONCLUSION Tramadol in lower doses ( 0.5 - 1 mg kg(-1 ) ) was an efficient preemptive analgesic that could be used at induction of anesthesia in adenotonsillectomies of children for providing both good analgesia during operation as supplementation to propofol anesthesia and postoperative analgesia in only early period AIM Initial validation of ethyl chloride spray in minimising pain for children experiencing venepuncture in comparison to Ametop cream . DESIGN A r and omised non-inferiority cross-over trial comparing ethyl chloride with Ametop in 77 children aged five to 13 years undergoing measurement of glomerular filtration rate .  Additional data were gathered on the child 's preferred choice for the third venepuncture . RESULTS Ethyl chloride spray is of equal preference to Ametop in children experiencing venepuncture , with lower self-reported pain score . It should be considered as an added alternative option to topical anaesthetic but further work is needed to clarify application technique OBJECTIVES The Wong-Baker FACES Pain Rating Scale ( WBS ) , used in children to rate pain severity , has been vali date d outside the emergency department ( ED ) , mostly for chronic pain . The authors vali date d the WBS in children presenting to the ED with pain by identifying a corresponding mean value of the visual analog scale ( VAS ) for each face of the WBS and determined the relationship between the WBS and VAS . The hypothesis was that the pain severity ratings on the WBS would be highly correlated ( Spearman 's rho > 0.80 ) with those on a VAS . METHODS This was a prospect i ve , observational study of children ages 8 - 17 years with pain presenting to a suburban , academic pediatric ED . Children rated their pain severity on a six-item ordinal faces scale ( WBS ) from none to worst and a 100-mm VAS from least to most . Analysis of variance ( ANOVA ) was used to compare mean VAS scores across the six ordinal categories . Spearman 's correlation ( rho ) was used to measure agreement between the continuous and ordinal scales . RESULTS A total of 120 patients were assessed : the median age was 13 years ( interquartile range [ IQR ] = 10 - 15 years ) , 50 % were female , 78 % were white , and six patients ( 5 % ) used a language other than English at home . The most commonly specified locations of pain were extremity ( 37 % ) , abdomen ( 19 % ) , and back/neck ( 11 % ) . The mean VAS increased uniformly across WBS categories in increments of about 17 mm . ANOVA demonstrated significant differences in mean VAS across face groups . Post hoc testing demonstrated that each mean VAS was significantly different from every other mean VAS . Agreement between the WBS and VAS was excellent ( rho = 0.90 ; 95 % confidence interval [ CI ] = 0.86 to 0.93 ) . There was no association between age , sex , or pain location with either pain score . CONCLUSIONS The VAS was found to have an excellent correlation in older children with acute pain in the ED and had a uniformly increasing relationship with WBS . This finding has implication s for research on pain management using the WBS as an assessment tool Objective : The experience of venipuncture is seen by children as one of the most fearful experiences during hospitalization . Children experience anxiety both before and during the procedure . Therefore , any intervention aim ing to prevent or reduce distress should focus on the entire experience of the procedure , including waiting , actual preparation , and conclusion . This study was design ed to determine whether the presence of musicians , who had attended specific training to work in medical setting s , could reduce distress and pain in children undergoing blood tests . Methods : Our sample population was composed of 108 unpremedicated children ( 4–13 years of age ) undergoing blood tests . They were r and omly assigned to a music group ( n = 54 ) , in which the child underwent the procedure while interacting with the musicians in the presence of a parent or to a control group ( n = 54 ) , in which only the parent provided support to the child during the procedure . The distress experienced by the child before , during and after the blood test was assessed with the Amended Form of the Observation Scale of Behavioral Distress , and pain experience with FACES scale ( Wong Baker Scale ) only after the venipuncture . Results : Our results show that distress and pain intensity was significantly lower ( p < .001 ; p < .05 ) in the music group compared with the control group before , during , and after blood sampling . Conclusions : This controlled study demonstrates that songs and music , performed by “ professional ” musicians , have a beneficial effect in reducing distress before , during , and after blood tests . This study shows , moreover , that the presence of musicians has a minor , but yet significant , effect on pain due to needle insertion Objective The objective of this study was to explore the relation between the application of a mixture of lidocaine/prilocaine cream ( eutectic mixture of local anesthetics [ EMLA ] ) before intravenous cannula insertion and perceived pain in the pediatric patient . Design Double-blind placebo-controlled trial . Setting A general inpatient pediatric ward . Patients We examined 26 male and 31 female patients between the ages of 4 and 12 years who required intravenous cannula insertion . Intravenous insertion was performed on 57 patients , with 29 patients in the placebo group ( mean age , 8.1 years ) and 28 in the EMLA group ( mean age , 8.0 years ) . Interventions Application of either EMLA cream or placebo 45 minutes before intravenous cannulation . Outcome Measures Pain was scored by the patients using a 0-to 10-cm visual analogue scale combined with a Faces pain scale as well as visual observation by a nurse . Adverse side effects were recorded in a separate table . Results Data collected and the differences between the placebo and treated groups were tested using a Mann-Whitney U test . Those children in the EMLA group ( mean pain score , 1.25 ) experienced less pain than those in the placebo group ( mean , 8.39 ) . There was no statistical significance between age , sex , and race . Conclusions The authors conclude that a topical preparation of lidocaine/prilocaine significantly reduces children 's pain during intravenous cannula insertion when applied to an intact dermal layer of the skin and that this effect occurs within 45 minutes This paper reports on the results of two studies conducted to further vali date the Abu-Saad Paediatric Pain Assessment Tool , a Dutch- language question naire developed to assess pain in school-age children . Children of 5 to 15 years of age reported in the first study their post-operative pain before and after the administration of analgesic medication using word descriptors of pain , the 10-cm scale , the Oucher , and a  visual analogue scale ( VAS ) . Lower mean pain scores at 4-hourly intervals post-analgesia supported the construct validity of the tool . Convergent validity was supported in both studies when scores on all concurrently administered measures positively correlated with the pain tool . In the second study , the correlations between pain and fear , a concurrently used measure with the pain instruments , were low , substantiating the discriminant validity of the pain tool . The significance of the results in relation to instrument development and multidimensional pain assessment in children are further discussed and elaborated Abstract Objective : To compare the effectiveness of nasal diamorphine spray with intramuscular morphine for analgesia in children and teenagers with acute pain due to a clinical fracture , and to describe the safety profile of the spray . Design : Multicentre r and omised controlled trial . Setting : Emergency departments in eight UK hospitals . Participants : Patients aged between 3 and 16 years presenting with a clinical fracture of an upper or lower limb . Main outcome measures : Patients ' reported pain using the Wong Baker face pain scale , ratings of reaction to treatment of the patients and acceptability of treatment by staff and parents , and adverse events . Results : 404 eligible patients completed the trial ( 204 patients given nasal diamorphine spray and 200 given intramuscular morphine ) . Onset of pain relief was faster in the spray group than in the intramuscular group , with lower pain scores in the spray group at 5 , 10 , and 20 minutes after treatment but no difference between the groups after 30 minutes . 80 % of patients given the spray showed no obvious discomfort compared with 9 % given intramuscular morphine ( difference 71 % , 95 % confidence interval 65 % to 78 % ) . Treatment administration was judged acceptable by staff and parents , respectively , for 98 % ( 199 of 203 ) and 97 % ( 186 of 192 ) of patients in the spray group compared with 32 % ( 64 of 199 ) and 72 % ( 142 of 197 ) in the intramuscular group . No serious adverse events occurred in the spray group , and the frequencies of all adverse events were similar in both groups ( spray 24.1 % v intramuscular morphine 18.5 % ; difference 5.6 % , -2.3 % to 13.6 % ) . Conclusion : Nasal diamorphine spray should be the preferred method of pain relief in children and teenagers presenting to emergency departments in acute pain with clinical fractures . The diamorphine spray should be used in place of intramuscular morphine PURPOSE Pain is a frequent symptom of oral disease . It is difficult to measure , however , due to its subjectivity , especially among children . The purpose of this study was to verify the utility and applicability of a  visual analogue scale of faces ( VASOF ) , adapted for 8- to 9-year-olds , to measure the severity of toothaches . METHODS A cross-sectional study was undertaken , which included 601 boys and girls r and omly selected from state and private schools in the city of Belo Horizonte , Minas Gerais , Brazil . They were interviewed and clinical ly examined , and a VASOF was applied . RESULTS The VASOF 's application revealed a high percentage of intense/very intense pain in the sample ( 39 % ) . The presence of this pain intensity was accompanied by a high incidence of children who cried , were awakened by the pain , and were unable to carry out habitual tasks . Furthermore , this severe pain was strongly associated with less-privileged economic groups and the presence of oral pathology ( P < or = .05 ) . The scale was well understood by children , independent of gender or economic group . CONCLUSIONS A VASOF was found to be capable of measuring toothache severity experienced by school-age children Various clinical protocol s are used to manage early postoperative tonsillectomy and /or adenoidectomy ( T&A ) pain in children . Although believed to be effective , these protocol s are not evidence d-based . Therefore , a double-blind , r and omized , placebo controlled ( 2 x 2 ) factorial design was used ( 1 ) to evaluate the effectiveness of 2 pain protocol s used interchangeably to manage early postoperative T&A pain and ( 2 ) to investigate whether nurses ' systematic pain assessment s improve pain management . In the first protocol children receive a loading dose ( 30 to 50 mg/kg ) of paracetamol ( acetaminophen ) Formularium der Nederl and se Apothekers ( Formulary of the Dutch Royal Society for the Advancement of Pharmacy ) intraoperatively , followed by regular doses ( 70 to 100 mg/kg/24 hours ) of paracetamol . In the second protocol children receive the first protocol , plus intramuscular fentanyl citrate ( 1 microgram/kg ) intraoperatively . Subjects were 83 healthy children between the ages of 3 and 12 years , admitted for T&A as an outpatient procedure . The child 's pain was measured using observation scales ( Children 's Hospital of Eastern Ontario Pain Scale and Face Legs Activity Cry Consolability Scale ) , a visual analogue scale , and self-report measures ( Faces Pain Scale and Oucher ) . Neither pain protocol sufficiently relieved early postoperative T&A pain , and systemic pain assessment s did not improve the effectiveness of analgesics . Further research evaluating the effectiveness of pain management protocol s is needed Introduction : Ethyl chloride can be used as a cryoanalgesic , but with the availability of alternative and relatively safer topical analgesics , its use has decreased . However , it still has the advantage of being quicker to apply compared with other topical analgesics , making it ideal for use in the outpatient departments . We wanted to compare the effectiveness of ethyl chloride as an analgesic during venipuncture in children . Methods : Venipuncture was carried out using either no analgesia ( NO ) , ethyl chloride spray ( EC ) , or application of the topical anesthetic Ametop ( TA ) on children attending the phlebotomy outpatient service by experienced pediatric phlebotomists . A pain score was recorded using either the Faces scoring system or the Faces , Legs , Activity , Cry Consolability scoring system . Results : A total of 55 patients were included in the study , 18 from group EC , 18 from group TA , and 19 from group NO . Thirteen patients from both groups EC and TA and 17 from group NO scored 2 or less on the pain scores . Discussion : The use of ethyl chloride was as effective as topical anesthetics in preventing distress to children in venipuncture . However , in the appropriate situations , the use of NO could also be comfortable to the child if venipuncture was done by specialist pediatric phlebotomists OBJECTIVE The main objective was to compare the utility of the Faces Pain Scale  ( Bieri et al. , 1990 ) with three alternative self-report measures of pain intensity in children , as well as with pain ratings based on observations of the child 's behavior . DESIGN Fifty children used 4 self-report scales to rate the severity of needle pain from routine immunization . Using videotapes , the child 's pain-related behavior was coded in detailed fashion , and a subset of the sample were also rated globally by 60 registered pediatric nurses . MAIN OUTCOME MEASURES  Faces Pain Scale ; Poker Chip Tool ; Visual Analogue Toy ; Verbal Rating Scale ;  behavioral checklist ( scoring observable facial , motor , verbal and vocal reactions ) . RESULTS AND CONCLUSIONS The  Faces Pain Scale  was simple to use , readily understood by the children , and showed a realistic distribution of scores with respect to the type of pain being measured . With the exception of verbal reactions ( which were not meaningfully related to self-report ) , observer ratings based on detailed coding of the child 's behavior correlated only poorly to moderately well with self-report scores ( r = .39 to r = .58 ) . Similarly , although confident in their judgments , the nurses ' ratings showed only moderate agreement with those of the children . In estimating the child 's pain , all observers appeared to appropriately weigh changes in the child 's facial behavior , which showed evidence of being the most sensitive behavioral index to the intensity of short sharp ( needle ) pain in 4 to 6 years olds In this double-blinded , r and omized , multicenter study , we examined analgesic efficacy and tolerability of tramadol in postoperative pediatric patients . Eighty-one postsurgical ASA physical status I and II patients ages 7–16 yr received oral tramadol ( approximately 1 or 2 mg/kg ) for postoperative analgesia when they were ready to transition from morphine patient-controlled analgesia to oral analgesics . Rescue analgesia consisted of morphine patient-controlled analgesia or an oral equivalent dose of oxycodone . Patients rated their pain just before the administration of tramadol and at regular intervals for 8 h afterwards using the Wong-Baker Faces Pain Rating Scale . The 2-mg/kg group required approximately half as much rescue analgesia as the 1-mg/kg group ( P = 0.006 ) . Parents rated the larger dose more favorably . Adverse events were generally mild to moderate in severity ( vomiting [ 10 % ] , nausea [ 9 % ] , pruritus [ 7 % ] , rash [ 4 % ] ) and similar between the two treatment groups . There were no significant changes in hemodynamic variables , respiratory rate , or Spo2 percentages between the two treatment groups or in all patients compared with pretreatment values The purpose of this study was to determine if providing a sticker after a finger stick for hemoglobin check reduced pain perception among preschool-aged children . The hypothesis was : Sticker rewards influence the perception of pain as measured by the Oucher scale following a finger stick to check hemoglobin . Preschoolers from Headstart Centers in a southeastern city were recruited for the study . The age range of participants was between 3 and 5 years . The children were assigned r and omly into two groups : those receiving stickers ( Group I ) , and those not receiving a sticker ( Group II ) . Subsequently , each participant 's pain level was assessed using the Oucher scale within 1 minute of the finger stick . There was no statistically significant difference in pain scale ratings between the two groups when comparing whether or not a cartoon sticker was given t ( -.937 , df 128 , P = .351 ; 95 % confidence interval ) . This study was clinical ly significant in that nonpharmacological interventions were utilized in an attempt to reduce pain in young children . Future research should determine whether receiving rewards ( such as a cartoon sticker , adhesive b and ages , or small toys ) alone or in conjunction with distraction measures are efficacious in pain reduction in younger children A total of 70 children between the ages of 3 and 6 years participated in two studies that tested the effect of ( a ) the sight of blood and ( b ) the application of a decorated adhesive b and age on pain intensity ratings following a fingerstick . In both studies , children were r and omly assigned to one of four groups . These groups allowed for the combinations of testing blood or no blood and the application of a decorated adhesive b and age or plain adhesive b and age . The Oucher ( Beyer , 1984 ) and the Poker Chip Tool ( Hester , 1979 ) were used as self-report measures of pain intensity at the time of the fingerstick and immediately after the application of the adhesive b and age . The pilot study recruited 20 children from two day care centers and subjected them to sham fingersticks . Results indicated that there were no differences across the groups in pain intensity ratings . However , there was a trend for the sight of blood to increase the child 's pain intensity rating . Age was a significant covariate across all groups , with younger children reporting higher levels of pain intensity . The second study took place in a pediatric test center of a metropolitan children 's hospital . Fifty outpatient children who were receiving fingersticks for preoperative or diagnostic testing were enrolled . Results indicated that there were no differences across groups , and age was only significant on the Poker Chip Tool . These results suggest that simple interventions and distractions are not sufficient to decrease perceived pain intensity ratings in young children Study objective : Nitrous oxide ( N2O ) is an attractive agent for procedural analgesia and sedation of children in the emergency department ( ED ) . Despite increasing use , efficacy data for painful procedures are limited . This study aim ed to determine pain scores during ED procedural sedation with N2O in the ED setting . Methods : Prospect i ve observational study of N2O use as a sole agent for procedural analgesia at a tertiary children ’s hospital ED .  Pain scores were obtained from patients and parents using visual analogue or faces scales , as appropriate . Parent and staff satisfaction with sedation and analgesia were assessed . Results : 124 children aged 1–17 years ( mean 8.1 ) underwent procedural analgesia with N2O for 131 procedures . Most procedures were orthopaedic ( 44 % ) or laceration repair ( 30 % ) . In 51 % of patients ( 95 % CI 42 % to 60 to 23 % ) pain scores remained unchanged and in 34 % ( 95 % CI 26 % to 43 % ) pain scores increased . Overall , 34 % ( 95 % CI 26 % to 43 % ) patients had intraprocedural scores of 50 mm or greater and 21 % ( 95 % CI 14 % to 29 % ) had pain scores of 70 mm or greater . Some procedures such as fracture reduction had a larger proportion of patients with high pain scores or 50 mm or greater ( 45 % ) and 70 mm or greater ( 29 % ) . Staff rated both sedation and analgesia as “ adequate ” in 92 % . Parents contacted in follow-up were satisfied or very satisfied with procedures in 96 % and sedations in 93 % . Conclusion : Data indicate that parents and staff are generally satisfied with N2O for procedural use in the ED . The efficacy of N2O as a sole agent in very painful procedures is limited STUDY OBJECTIVE We compare adverse events , efficacy , and length of sedation of intravenous ( i.v . ) versus intramuscular ( i.m . ) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department ( ED ) . METHODS Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospect i ve , r and omized , controlled trial in a children 's hospital ED . All patients were initially r and omized to receive ketamine either 1 mg/kg i.v . or 4 mg/kg i.m .  Demographics , adverse events , sedation efficacy , and length of sedation were recorded . RESULTS Two hundred twenty-five patients were r and omized ( 116 i.v . , 109 i.m . ) . Two hundred eight patients , aged 14 months to 15 years , completed the study , 109 i.v . and 99 i.m . Respiratory adverse events were similar between groups ( i.v . 8.3 % versus i.m . 4.0 % ; odds ratio [ OR ] 0.47 ; 95 % confidence interval [ CI ] 0.14 to 1.6 ) . Vomiting in the ED was more common in the i.m . group ( 26.3 % versus 11.9 % ; OR 2.60 ; 95 % CI 1.2 to 5.9 ) . Using the Faces Pain Scale , patients in the i.m . group reported significantly less pain from the procedure . Video observers reported significantly lower distress in the i.m . group during the painful procedure ( Observation Score of Behavioral Distress scores 0.35 i.m . versus 0.74 i.v . ; mean difference 0.38 ; 95 % CI 0.04 to 0.72 ) . Length of sedation was significantly longer in the i.m . group ( median 129 versus 80 minutes ) . Satisfaction of sedation was high in parents and physicians , with no difference in reported satisfaction between groups . This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine i.m . CONCLUSION In this study of pediatric sedation for orthopedic procedures , we found that ketamine 4 mg/kg i.m . was more effective than 1 mg/kg i.v . but demonstrated significantly longer recovery times and more vomiting OBJECTIVE --To compare the anaesthetic properties of conventional intradermal 1 % plain lignocaine with a topical gel preparation of adrenaline ( 1:2000 ) and cocaine ( 4.7 % ) for use in treatment of children 's lacerations . METHODS --Children aged 3 - 16 years with lacerations ( not of the digits or mucous membranes ) were consecutively assigned to receive either adrenaline and cocaine ( AC ) or lignocaine .  Pain scores , as perceived by patients , parents , and staff , were measured conventionally using Wong Baker faces and visual analogue scales on administration of the local anaesthetic and on suturing the wound in the AC group ( n = 56 ) and the lignocaine group ( n = 51 ) . RESULTS --Mean and median pain scores on administration of the anaesthetic in the AC group were significantly lower than in the lignocaine group as perceived by patient ( P < 0.001 ) , parent ( P < 0.001 ) , and staff ( P < 0.001 ) . There was no significant difference in mean and median pain scores between the two groups on suturing the wounds , as perceived by patient , parent and staff . There was a significantly higher number of " failed " anaesthetics ( pain scores 8 - 10 ) in the lignocaine group ( P < 0.01 ) . On direct question ing the overall procedure was considered acceptable by 84.5 % of parents in the AC group compared with 61 % of parents in the lignocaine group ( P < 0.01 ) . There were no significant complications in either group . CONCLUSIONS --Topical AC should be considered the local anaesthetic of first choice for suturing appropriate children 's lacerations BACKGROUND Untreated immunization pain causes undue distress and contributes to underimmunization through physician , and possibly parental , resistance to multiple simultaneous injections . OBJECTIVE To compare the efficacies of two pain management methods in reducing immediate immunization injection pain and distress in school-aged children . DESIGN A r and omized , controlled clinical trial of eutectic mixture of local anesthetics ( EMLA ) cream and vapocoolant spray . PATIENTS Children aged 4 to 6 years and scheduled to receive diphtheria and tetanus toxoids and acellular pertussis vaccine ( DTaP ) during health supervision visits . INTERVENTIONS Enrolled children were r and omized to one of three treatment groups : 1 ) EMLA cream + distraction ; 2 ) vapocoolant spray + distraction ; or 3 ) distraction alone ( control ) . The specific pharmacologic pain control interventions consisted of EMLA cream ( 2.5 % lidocaine , 2.5 % prilocaine [ Astra Pharmaceutical Products , Inc , Westborough , MA ] $ 15 . 00/patient ; applied 60 minutes before injection ) and vapocoolant spray ( Fluori-Methane [ Gebauer Company , Clevel and , OH ] $ 0 . 50/patient ; applied via spray-saturated cotton ball for 15 seconds immediately before injection ) . MAIN OUTCOME MEASURES The blinded investigator ( BI ) measured ( by edited videotape ) cry duration and the number of pain behaviors using the Observational Scale of Behavioral Distress . Pain visual analog scales ( linear and faces scales ) were completed by the child , parent , nurse , and the BI . RESULTS Sixty-two children , aged 4.5 + /- 0.4 years ( mean + /- SD ) were r and omized . The three treatment groups had similar subject characteristics . All pain measures and cry duration were similar for EMLA and vapocoolant spray . Both EMLA and spray were significantly better than control . Results for spray vs control : cry duration ( seconds ) : 8.5 + /- 21.0 vs 38.6 + /- 50.5 ; number of pain behaviors : 1.2 + /- 1.9 vs. 3.1 + /- 2.1 ; child-scored faces scale : 2.0 + /- 2.4 vs. 4.1 + /- 2.3 ; parent-scored faces scale : 1.6 + /- 1.6 vs. 3.0 + /- 1.7 ; nurse-scored faces scale : 1.6 + /- 1.2 vs. 3.1 + /- 1.4 ; and BI-scored faces scale : 1.0 + /- 1.5 vs. 2.4 + /- 1.4 . CONCLUSIONS When combined with distraction , vapocoolant spray significantly reduces immediate injection pain compared with distraction alone , and is equally effective as , less expensive , and faster-acting than EMLA cream . As an effective , inexpensive , and convenient pain control method , vapocoolant spray may help overcome physician and parent resistance to multiple injections that leads to missed opportunities to immunize This study examined pain and distress from needles in children undergoing blood sampling as a function of  adult-child interaction  and type of  venous  access ( i.e. , central external venous lines , internalized ports , or peripheral access via venipuncture ) . Participants were 55 pediatric oncology patients , aged 3 - 18 years , who were undergoing routine blood work .  Pain ratings were obtained using the  Faces Pain Scale-Revised  ( FPS-R ) and conversation during the procedure was audio taped for coding using the Child-Adult Medical Procedure Interaction Scale-Revised ( CAMPIS-R ) . Children 's ratings of pain using the FPS-R were similar in the port ( M=2.57/10 , st and ard deviation [SD]=3.46 ) and peripheral ( M=2.56/10 , SD=3.24 ) groups , despite the fact that most children with internal ports were given a topical anesthetic . Similarly , there were no differences between port and peripheral groups in rates of child coping or distress , or parent and nurse observations of child pain . As would be expected , external line access was not associated with pain or distress , even among very young children , suggesting that they appropriately understood the pain rating scale . Results of the transcribed CAMPIS-R data indicate that the influences in adult-child interaction are bidirectional . Support was found for the well-established positive relationship between child distress and adult reassurance and empathy . Implication s for intervention and selection of central venous access devices are discussed This study examined experimentally the effectiveness of preparatory information provided by parents  in creating accurate expectations and reducing  children 's procedural pain .  Ear piercing was used as an analogue to minor painful medical procedures . Sixty children , aged 5 - 12 years , requesting ear piercing and accompanied by their parents , were r and omly assigned to a parental information or contact-control condition . Parents in the information group were asked to read their child a description of the procedures and sensations of ear piercing . Parents in the contact-control condition played picture games for the same amount of time .  Expected pain was measured on a visual analogue scale ( VAS ) and the Faces Pain Scale-Revised ( FPS-R ) before and after the parental information or contact-control procedure . Experienced pain was measured on the same two scales immediately after the ear piercing . Prepared children had more accurate expectations and reported significantly less pain ( M=27.3 ) than non-prepared children ( M=49.8 ) . The validity of the measures was supported by strong correlations ( r=0.87 to 0.96 ) between the VAS and FPS-R. The findings suggest that parental provision of preparatory information creates accurate expectations and reduces pain for children BACKGROUND It has been demonstrated that tramadol is an effective analgesic . We aim ed to compare postoperative analgesic effects of wound infiltration with tramadol ( T ) or bupivacaine ( B ) and intramuscular tramadol ( I )  after herniotomy in children . METHODS In this study , 75 children were r and omly assigned to group T , group B and group I.  Wound infiltration was performed to the patients in group T ( 2 mg.kg-1 tramadol in 0.2 ml.kg-1 saline ) and group B ( 0.2 ml.kg-1 0.25 % bupivacaine ) into the surgical incision . Twenty minutes before the end of the surgery 2 mg.kg-1 tramadol was injected i.m . in group I. Faces pain scale was used for assessing pain severity . Patients with pain score>2 were treated with paracetamol . The frequency of side effects and analgesic use were recorded . Patients were discharged on the next day . RESULTS No side effects were recorded in any group . The pain scores of the patients at the first , fourth and eighth hours were significantly higher in group B and group I than group T ( P<0.05 ) . The pain scores of the patients at the first hour were significantly higher in group I compared with group B ( P<0.05 ) . Average time to first analgesic requirement was significantly longer in group T ( 6.72+/-4.09 h after herniotomy than both group I ( 4.49+/-3.9 h ) and group B ( 6.04+/-3.7 h ) ( P<0.05 ) . CONCLUSIONS Wound infiltration with tramadol may be a good choice for postoperative analgesia in children having inguinal herniotomy BACKGROUND Ultrasound treatment prior to topical anesthetic application has been shown to speed anesthesia onset by enhancing anesthetic penetration into the skin . OBJECTIVE To evaluate a low-frequency ultrasound device to facilitate absorption of topical anesthetic in young children who require venipuncture . METHODS This was a prospect i ve controlled comparison of analgesic effect of a 5-minute application of liposomal lidocaine cream after ultrasound treatment , with a 30-minute application of liposomal lidocaine cream , in children aged 3 to 7 years undergoing venipuncture . Children rated the pain of the venipuncture using the Wong-Baker FACES Pain Rating Scale ( FACES ) ( 0 = no pain , 10 = maximal pain ) , and parents rated their child 's pain using a 100-mm ( 0 = no pain , 100 = maximal pain ) visual analogue scale ( VAS ) . Venipuncture skin sites were evaluated for effect immediately posttreatment , and at 24 to 72 hours post phlebotomy . RESULTS Seventy subjects were enrolled : the first 10 patients comprised a pilot series , receiving the ultrasonic treatment and liposomal lidocaine cream ; the next 60 subjects were r and omized , including 29 allocated to the ultrasound treatment group , and 31 r and omized to the 30-minute control treatment with liposomal lidocaine cream .  Demographics were similar between the two groups .  Mean child 's FACES scale results were similar : Ultrasound group 4.78 ( 95 % CI ; 3.06 , 6.52 ) , CONTROL group 4.32 ( 95 % CI ; 2.82 , 5.82 ) ( P = 0.72 ) ; and mean parent VAS scores were also the same : Ultrasound : 19.1 ( 95 % CI ; 10.3 , 27.8 ) , CONTROL : 23.2 ( 95 % CI ; 14.7 , 31.7 ) ( P = 0.87 ) . Skin effects immediately after ultrasound were limited to minor redness in 9/39 children and significant redness in 2/29 patients . CONCLUSION Ultrasound treatment speeds time of onset of liposomal lidocaine cream anesthesia in young children undergoing venipuncture . Side effects were mild in our population OBJECTIVE To compare the level of pain among children treated according to the Atraumatic Restorative Treatment ( ART ) and the Conventional Restorative Treatment ( CRT ) .  STUDY DESIGN Forty children of both genders , 4- to 7-years old , presenting Class I cavitated dentin lesions in primary molars were r and omly allocated to 2 groups . One group ( CRT ) received conventional restorative treatment using rotary instruments , while in the other one ( ART ) h and instruments were used to perform the restorations . All children were treated by the same operator A high-viscosity glass-ionomer cement ( Fuji IX ) was used to restore the teeth in both groups . Children 's pain was measured at the end of the first restorative treatment session using the Wong-Baker FACES Pain Rating Scale ( dependent variable ) . Age , gender , treatment time and treatment group were independent variables . ANOVA and ANCOVA tests were used to analyze the data . RESULTS The CRT procedure took longer than the ART procedure ( p < 0.001 ) . Children from the ART group reported less pain than those from the CRT group ( p = 0.0037 ) . Four year olds reported more pain than 5- to 7-year olds ( p < 0.0001 ) in both groups . CONCLUSIONS Restorations placed using ART were less time consuming , children felt less pain when the ART approach was used , and younger children ( 4-years ) reported more pain than the older ones for both restorative treatments To assess the sore throat pain model in children as an assay for systemic analgesic agents in children under double‐blind , placebo‐controlled conditions , we conducted a single‐dose parallel study that compared 10 mg/kg ibuprofen ( n = 39 ) , a new analgesic agent for children , and 15 mg/kg acetaminophen ( n = 38 ) , an approved analgesic for children , to placebo ( n = 39 ) in children from 2 to 12 years of age with acute sore throat . At ½ , 1 , 2 , 3 , 4 , 5 , and 6 hours ( 2 hours in the pediatrician 's office followed by 4 hours at home ) , children assessed pain intensity with a pain thermometer and pain relief with a smileyface scale . The parent and pediatrician assessed pain intensity and change in pain ; the parent also provided an overall evaluation at 6 hours . The children rated ibuprofen and acetaminophen as significantly effective compared with placebo ( p < 0.05 ) on both scales at most posttreatment time points and overall . The parent and pediatrician also rated both active medications as significantly different from placebo on both of their scales ( p < 0.05 ) at several time points and overall . On the parent 's overall evaluation , ibuprofen was rated as effective compared with placebo ( p < 0.05 ) . Both active agents significantly ( p < 0.05 ) reduced oral temperature in children with baseline temperatures > 99 ° F. No treatment‐related adverse effects were observed . We conclude that the sore throat pain model is a sensitive assay for identification of the activity of oral analgesic drugs in children and that ibuprofen is an effective analgesic in children OBJECTIVE To examine whether acetaminophen with codeine administered per rectum is an effective alternative for pain control compared with oral administration after an adenotonsillectomy . STUDY DESIGN A prospect i ve , r and omized control study . METHODS Seventy-five children aged 1 to 5 were recruited for this study . Each child was assigned r and omly to receive either rectal or oral postoperative pain medication . A journal with eight questions was kept for 10 days after the operation , and an overall survey of five questions was filled out at the first postoperative visit . RESULTS Postoperative pain was adequately controlled in those patients receiving suppositories when compared with those patients receiving oral pain medication .  Adverse effects and total number of doses given per day were similar . Parents found the suppositories easy to administer , and more parents would switch or consider switching from oral pain medication to suppositories if given the choice . CONCLUSIONS The suppositories achieved equivalent pain control as oral medication with few side effects and good tolerance . Furthermore , many parents preferred the suppositories to oral medication in maintaining postoperative pain control because of ease of administration . If given the choice for future surgeries , many parents would switch or consider switching from oral pain medication to suppositories PURPOSE To compare post-operative pain in children undergoing tonsillectomy by blunt dissection or electrocautery .  METHOD Thirty-six children between the ages of 5 and 15 years were recruited for the study . Tonsillectomy was done in a st and ardized fashion with uniform anaesthetic practice s. Each child kept a pain diary for 10 days , recording pain twice daily on a Visual Analog Scale and Faces Pain Scale . Doses of analgesics were recorded . RESULTS There were no statistically significant differences in the pain scores for the groups , although there was a trend toward more pain in the blunt dissection group . There were more complications in this group , and these children used significantly more doses of acetaminophen . Sources of bias are discussed . CONCLUSION These results suggest a trend toward greater postoperative pain in children who have tonsillectomies by blunt dissection techniques & NA ; The numerous pain rating scales using faces depicting varying degrees of distress to elicit reports of pain from children fall into two categories ; those with a neutral face as the ‘ no pain ’ anchor , and those with a smiling face as the ‘ no pain ’ anchor . This study examined the potentially biasing impact of these anchor types on children 's self‐reports  of pain  in response to a series of vignettes . Participants were 100 children stratified by age ( 5–6 years , 7–8 years , 9–12 years ) and r and omly assigned to one of three groups : ( 1 ) neutral scale/sensory instructions ; ( 2 ) smiling scale/sensory instructions ; ( 3 ) smiling scale/affective instructions . Children completed a  faces scale , a VAS , and emotions ratings  in response to four scenarios depicting : ( 1 ) no pain/negative emotions ; ( 2 ) pain/negative emotions ; ( 3 ) no pain/positive emotions ; ( 4 ) pain/positive emotions . Results showed that children who used the smiling scale had significantly higher pain scores for no pain and pain/negative emotions vignettes and significantly lower faces scale scores for pain/positive vignettes than children who used the neutral faces scale . Instructions varying in focus on sensory or affective qualities of pain had no effect on children 's pain ratings . Group differences in children 's ratings with the VAS and emotions measure suggested that rating pain with a smiling faces scale may alter a child 's concept of pain . Age differences indicated the younger children rated the negative emotion vignettes as more painful than the older children . These findings suggest that children 's pain ratings vary depending on the types of faces scale used , and that faces scales with smiling anchors may confound affective states with pain ratings BACKGROUND / PURPOSE Minor surgical procedures in children , while usually not requiring general anesthesia , need effective control of pain , anxiety , and motion . Certain techniques of conscious sedation may result in loss of protective airway reflexes . Nitrous oxide , however , when inhaled at levels below 50 % maintains protective reflexes and does not require fasting or postprocedure monitoring . This study prospect ively examines the efficacy of nitrous oxide analgesia in children undergoing outpatient surgical procedures . METHODS Over a 2-year period ( 2000 to 2002 ) , 150 consecutive children were given  nitrous oxide analgesia as an alternative to a general anesthetic , sedation , or local anesthetic alone . Nitrous oxide ( < 50 % ) was administered by our practice 's sedation-certified nurse practitioner without an anesthesiologist present . The children used the Wong-Baker Faces Scale ( 0 - 5 ) to score pain at different intervals ( preprocedure , at injection , during procedure , and postprocedure ) and event memories were tabulated . RESULTS Of 150 children , 5 were uncooperative and could not participate . One hundred forty-five children , ages 1 to 20 years ( Mean , 9.83 + /- 4.92 years ) successfully underwent procedures ( 58 cyst/nevus excisions , 49 abscess drainages , 38 other ) using nitrous . Two patients were too young to score pain . Pre- and postprocedure pain scores were significantly higher in the abscess group ( P < .0001 ) ; during the procedures , however , all groups reported pain scores less than 1 , with parents citing 100 % satisfaction with the technique . Of 128 children receiving local anesthesia , 107 ( 84 % ) had no recall of the injection . Complications were limited to 4 patients ; 2 experienced nausea , and 2 vomited . All resolved without interrupting the procedure . CONCLUSIONS Nitrous oxide analgesia is a cost-effective and efficacious alternative to conscious sedation or general anesthesia for minor pediatric surgical procedures . In the office or outpatient setting , the technique provides for almost pain/anxiety-free surgery , no postoperative monitoring , and a high degree of satisfaction for patients , parents , and staff Abstract To examine the potential role for a placebo cream in reducing reported needle pain severity in children , and the impact of age‐related factors on pain self‐report , a convenience sample of 117 children scheduled for venipuncture were r and omly assigned to one of three treatments : ( a ) placebo cream with the suggestion that it might help reduce needle pain , ( b ) placebo cream with no indication as to the cream 's purpose , and ( c ) no cream ( control group ) . In allocation to treatment , children were stratified by age group , ( 3–7 , 8–11 , 12–17 years ) . They rated their needle pain severity ( both predicted and reported ) using the Faces Pain Scale , and rated their anxiety about the procedure using the Children 's Anxiety and Pain Scale . Children in the cream groups were also asked whether they thought the cream had helped . Using video‐tapes , an independent observer , blind to the placebo manipulation , rated each child 's reaction to the needle . For the two groups receiving cream , 83 % of those children told it might help stated that they believed it did , as compared with only 33 % of children who received the cream but were told nothing of its purpose . These beliefs , however , were not reflected in self‐report ratings of pain which showed no statistically significant treatment effect . Similarly , children who gave higher preprocedural anxiety ratings were no more likely to report less pain as a result of receiving the cream . There was , however , a treatment effect on the observer 's ratings : children receiving cream plus suggestion were assigned significantly lower ratings of pain‐related behaviour than those children who received the cream alone . While venipuncture was associated with only mild levels of pain , younger children , irrespective of treatment group , did report more pain than older children . Hierarchical regression analysis indicated that 60 % of the variance in self‐reported pain severity scores could be accounted for by how much the child thought the needle would hurt , how anxious the child was about receiving the needle , gender ( higher pain ratings associated with girls ) , and estimated body surface area ( higher pain ratings associated with smaller bodies ) . We conclude that the efficacy of placebo treatments for needle pain in children may depend on the suggestion of a possible benefit rather than upon treatment application per se Objective : Orthopedic injuries comprise a majority of the indications for analgesia in the emergency department . Oxycodone and ibuprofen have demonstrated efficacy for this indication , but no studies have compared these drugs in children . Our objective was to investigate the effectiveness of oxycodone , ibuprofen , or their combination for the management of orthopedic injury-related pain in children . Methods : This prospect i ve , r and omized , double-blinded , clinical trial compared the effectiveness of oxycodone , ibuprofen , and the combination in children ( age , 6 - 18 years ) , with pain from a suspected orthopedic injury . Subjects were block-r and omized to receive 1 of the 3 treatment regimens . Pain was assessed with the Faces Pain Scale ( FPS ) and Visual Analog Scale at baseline , postimmobilization , 30 , 60 , 90 , and 120 minutes postmedication . The change in the FPS score over time was compared between the 3 treatment groups using a generalized estimating equation model . Results : Although all 3 treatment groups demonstrated a decrease in the FPS score over time , there were no significant differences between the groups . Among the 66 total children enrolled in the 3 treatment groups , there were no statistically significant differences in demographics or injury characteristics . There were 28 subjects with fractures . Immobilization of the injury demonstrated a significant reduction in the FPS score . Subjects in the combination treatment group reported more adverse effects . Conclusions : Oxycodone , ibuprofen , and the combination all provide effective analgesia for mild-to-moderate orthopedic injuries in children .  Oxycodone or ibuprofen , alone , can be given , thereby avoiding the increase in adverse effects when given together The effect of the topical application of a lignocaine-prilocaine cream ( EMLA ) on the  pain of venous cannulation  was tested in a double-blind manner . Sixty boys and girls between the ages of 4 and 10 yr who were to undergo surgery participated in the study . No analgesic premedication was given and the venous cannulation was performed during the preparation for general anaesthesia . Pain was assessed by the anaesthetist and the patient using a verbal rating scale and two different pictorial scales . The effect of EMLA in the alleviation of the pain of venous cannulation was considered significantly better than placebo by both anaesthetist ( P less than 0.001 ) and patient ( P less than 0.05 ) ( verbal scales ) . One conventional pictorial scale showed a statistically significant difference ( P less than 0.05 ) , but the other , based on facial expressions , did not . Local reactions to the cream were minor and transient in both groups & NA ; This un‐blinded experimental study investigated the effectiveness of imagery , in addition to routine analgesics , in reducing tonsillectomy and /or adenoidectomy pain and anxiety after ambulatory surgery ( AS ) and at home . Seventy‐three children , aged 7–12 , were recruited from five AS setting s. Thirty‐six children r and omly assigned to the treatment group  watched a professionally developed videotape on the use of imagery and then listened to a 30‐min audio tape of imagery approximately 1 week prior to surgery ( T1 ) . They listened to only the audio tape 1–4 h after surgery ( T2 ) , and 22–27 h after discharge from AS ( T3 ) . The 37 children in the attention‐control group received st and ard care . Pain and anxiety were measured at each time‐point in both groups . Measures of sensory pain were the Oucher and amount of analgesics used in AS and home ; affective pain was measured with the Facial Affective Scale ( FAS ) . Anxiety was measured using the State Trait Anxiety Inventory for Children ( STAIC ) . When controlling for trait anxiety and opioid and non‐opioid intake 1–4 h before the pain measures , MANCOVA showed significantly lower pain and anxiety in the treatment group at T2 , but not at T3 . When controlling for trait anxiety , a two‐way RM MANCOVA indicated no significant group differences in combined opioid and non‐opioid use between the groups , or between times . Appropriately trained health care providers should use imagery to reduce post‐operative pain following tonsillectomy and /or adenoidectomy in AS . Teaching parents about adequate home administration of analgesics may increase the effectiveness of imagery at home PURPOSE This pilot study describes pain and anxiety associated with allergy testing ; tests distraction , specifically self-selected distraction ; and examines the relationship between pain , anxiety , and engagement with distraction . DESIGN AND METHODS An experimental design was used with a convenience sample of 32 adolescents from an allergist 's office r and omly assigned to three groups .  Pain was measured by the  adolescent pediatric pain tool ( APPT ) and  FACES scale .  RESULTS No differences in pain ratings were found among the groups . Less pain was associated with lower anxiety and greater engagement with distraction . Greater engagement with distraction occurred with less anxiety . PRACTICE IMPLICATION S Knowledge about allergy testing pain , anxiety , and engagement with distraction can assist nurses in preparing adolescents for this procedure BACKGROUND Patient controlled epidural analgesia ( PCEA ) is uncommon in pediatric anesthesia . Because PCEA offers superior pain control compared with continuous epidural infusions in adults , we prospect ively evaluated the analgesia efficacy and safety of PCEA in children and adolescents following extensive spinal surgery . METHODS Following ethics committee approval , 100 consecutive children [ age median ( range ) 14 ( 6 - 19 ) years ] undergoing spinal surgery were studied until the seventh postoperative day , and 98 children received a PCEA .  One or two epidural catheters were positioned under direct vision by the surgeon based on the number of vertebral segments operated upon . The epidural solution consisted of bupivacaine 0.0625 % , fentanyl 1 microg.ml(-1 ) and clonidine 0.6 microg.ml(-1 ) , delivered at a basal rate of 0.2 ml.kg(-1).h(-1 ) and a PCEA dose of 0.1 ml.kg(-1).h(-1)(max . 2 h(-1 ) ) . On the fourth postoperative day , PCEA was stopped and analgesia was continued with patient controlled analgesia ( PCA ) with morphine . RESULTS During the PCEA regimen , the maximal scores of the revized facial scale were below 4 at rest with a very high satisfaction rate ( > 90 % ) . Pain scores were higher during mobilization on the first postoperative day and when PCEA was switched to PCA . The overall incidence of adverse events was low and consisted primarily of technical problems and postoperative nausea and vomiting . Only two children experienced a complication requiring the discontinuation of the PCEA but there were no consequent adverse sequelae . CONCLUSIONS The present study demonstrates that PCEA provides excellent pain relief following extensive spinal surgery and is associated with a low incidence of adverse events . The use of PCEA should be encouraged in children and adolescents following extensive spinal surgery OBJECTIVE /HYPOTHESIS The hypothesis tests whether sealing the tonsillectomy field with posterior pillar mucosa can prevent unwanted outcomes in pediatric tonsillectomy . STUDY DESIGN A prospect i ve , r and omized , single blinded study was conducted on a sample of 39 children between 3 and 15 years of age . After dissection and snare tonsillectomy , the tonsillar fossa was covered on one side using the palatopharyngus mucosa and the other side is used as control . Pain scores , healing , edema and infection at the operation site were investigated . METHODS The tonsillectomy sites were r and omly assigned into one of two groups . First group contained the ones with mucosal flap sealed over the operation site and the second group was kept as control with the operation site left uncovered . All of the patients received mild analgesics . The pain assessment is done on Days 1 , 3 , 5 , 7 and 10 postoperatively , by using Wong-Baker faces visual analog scale . On the 10th postoperative day , the operation field of each side is scored separately for edema , healing and infection . Statistical investigation was performed through a software program . RESULTS On first postoperative day , pain level difference was not statistically significant between the two groups ( p>0.01 ) . But from 3rd to 10th postoperative day , the pain level was found out to be lower in the mucosa sealed site ( p<0.01 ) . On the 10th postoperative day , while the edema was significantly more ( p<0.01 ) , healing was better ( p<0.01 ) at the sutured site . Postoperative infection at operation site was not different between the groups ( p>0.01 ) . CONCLUSION Covering tonsillectomy field with mucosal palatopharyngeal arch flap significantly reduces pain after third postoperative day . The flap side had better healing when compared to denuded site . But the sutures in the mucosal flap may cause more tissue edema . Sutures have no significant effect on postoperative infection . Thus , mucosal flap may be used as an adjuvant surgical technique to decrease tonsillectomy pain of children in addition to the analgesic medication This study explored whether global unidimensional self-report pain scales based on facial expression help children separately estimate the sensory and affective magnitude of post-operative pain . Ninety paediatric elective surgery patients ( in two age groups : 5 - 9 and 10 - 15 years ) used each of four scales to estimate pain intensity and pain affect during the first 2 days after surgery . The four scales were :  Faces Pain Scale ( FPS ) , Facial Affective Scale ( FAS ) , and the Coloured Analogue Scale ( CAS )  ( one for intensity and one for unpleasantness ) . As hypothesised , ratings on the FPS correlated more highly with analogue scale ratings for intensity than for unpleasantness , whereas ratings on the FAS correlated more highly with those on the analogue scale for unpleasantness than for intensity . Factor analysis indicated that although all measures loaded on a single dimension of distress , there was an additional weaker factor corresponding to a unique contribution of the FAS . No systematic age effects were observed . It was concluded that the FPS and the FAS may partly measure different aspects of the postoperative pain experience in children , although shared instrument variance may obscure true estimates of covariation in ratings of intensity and affective magnitude . The clinical relevance of the present results remains to be determined OBJECTIVE To collect data on pain management in paediatric oncology with respect to the WHO ladder approach . SETTING , DESIGN , PATIENTS AND METHODS : Eight German tertiary care paediatric oncology centres prospect ively documented all their in-patient pain treatment courses from June 1999 to December 2000 .  Pain was scored using a 1 - 6 faces scale . RESULTS Two hundred and twenty four patients ( median age , 9 years ; range 0.2 - 32.1 ) were enrolled . Three hundred and thirty three pain episodes comprising a total of 2265 treatment days were documented . Pain was mostly therapy associated . The most frequently administered non-opioid analgesics were dipyrone and paracetamol . On WHO step 2 , tramadol was almost the only opioid used . During tramadol monotherapy average daily pain scores were lower than with a combination of tramadol and non-opioid analgesics . On WHO step 3 ,  morphine  was at least part of the analgesic regimen on most treatment days . Strong opioids were combined with a non-opioid analgesic on 41 % of the treatment days . The mean intravenous morphine equivalence dose was 0.034 mg/kg/h . During opioid and non-opioid combination therapy , adverse effects were more frequent , and average pain scored higher than on opioid monotherapy . CONCLUSIONS WHO- guidelines were closely followed in Germany and seem to provide effective analgesia for children with cancer pain . In our patient group there is no evidence that a combination of an opioid with a non-opioid is more effective than opioid therapy alone in in-patient paediatric oncology pain treatment The purpose of this study was to determine the effectiveness of parental positioning and distraction on the pain , fear , and distress of pediatric patients undergoing venipuncture . An experimental-comparison group design was used to evaluate 43 patients ( 20 experimental and 23 comparison ) who were 4 to 11 years old . Experimental participants used parental positioning and distraction . All participants rated their pain and fear ; parents and child life specialists ( CLS ) rated the child ’s fear , and CLS rated the child ’s distress . Self-reported pain and fear were highly correlated ( p < .001 ) but not significantly different between the two groups . Fear rated by CLS ( p < .001 ) and parents ( p = .003 ) was significantly lower in experimental participants . Although no difference was found in distress between the two groups , a significant time trend was discovered ( p < .001 ) . The parental positioning-distraction intervention has the potential to enhance positive clinical outcomes with a primary benefit of decreased fear . Further research is warranted INTRODUCTION The purpose of this study was to compare distress behaviors and perceptions of distress in 4- to 6-year-old children who received two immunization injections simultaneously with those in children who received their immunizations sequentially .  METHOD This experimental study used a convenience sample of 46 children scheduled for pre-kindergarten examinations . The children were r and omly assigned to either a sequential injection or a simultaneous injection group . Direct observation and videotapes were made of the children 's behaviors before and after injection . Distress behaviors were analyzed with the Observation Scale of Behavioral Distress-Revised , and perceptions of distress were obtained from both children ( with the Wong-Baker Pain Rating Scale [ FACES ] ) and parents ( with the Visual Analog Scale ) . RESULTS Results of the Observation Scale of Behavioral Distress-Revised showed no significant differences in children 's distress behaviors between the two groups either before or after injection . The children 's self-reports of distress also showed no group differences . Parents ' perceptions of the children 's distress before and after injection were lower for the sequential group but were judged to be unrelated to the intervention . Given the opportunity to state a preference , however , parents preferred the simultaneous method . DISCUSSION The simultaneous procedure was not found to be associated with reduced distress behaviors ; however , parents preferred the simultaneous method This prospect i ve double-blind study was design ed to assess the analgesic efficacy of ketorolac 0.5 % ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus . After paracetamol 20 mg.kg-1 preoperatively , a st and ard anaesthetic was given . There were no significant differences in Children 's Hospital of Eastern Ontario Pain Scale ( CHEOPS ) and faces pain scale ( FPS ) scores , requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol . This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model Objectives : Our r and omized , double-blind , placebo-controlled study evaluates the possible benefit of peritonsillar infiltration with 0.75 % ropivacaine hydrochloride on the pain level after adenotonsillectomy in 3- to 7-year-old children . Methods : We r and omly administered intraoperative peritonsillar infiltration with 0.2 mL/kg ropivacaine 0.75 % ( group R ) or 0.2 mL/kg saline 0.9 % ( group F ) to sixty 3- to 7-year-old children ( ASA 1 or 2 ) who were undergoing adenotonsillectomy .  Postoperative pain was assessed 6 and 24 hours after surgery by a 6-face Faces Pain Scale that allowed quantification of pain on a 100-mm horizontal line ( 0 = no pain ) . The number of rectal doses of acetaminophen-codeine required during the first postoperative day was recorded . Results : The pain scores did not differ between the groups , either 6 or 24 hours after surgery ( group F , 43 ± 26 , versus group R , 29 ± 23 , and group F , 24 ± 23 , versus group R , 30 ± 28 , respectively ) . Acetaminophen-codeine doses were similarly required in the two groups . Conclusions : Peritonsillar infiltration with 0.75 % ropivacaine does not provide any major postoperative analgesic effect in 3- to 7-year-old children after adenotonsillectomy . A possible clinical ly minor analgesia 6 hours after surgery is suggested PURPOSE The purpose of this study was to assess children 's reactions and record their sensations while receiving a warmed local anesthetic solution for dental procedures ( 37 degrees C ; W ) compared with one at room temperature ( 21 degrees C ; RT ) . METHODS Forty-four children between the ages of 6 to 11 ( mean age = 7.9 + /- 2.2 years ) who were undergoing dental treatment participated in the study . A r and om crossover design was used . Each patient was r and omly assigned to receive either a W or a RT local anesthesia on the first visit and the alternate local anesthesia on the second visit . During the injection , the modified Behavioral Pain Scale ( BPS ) was used . For subjective evaluation , the Wong-Baker FACES Pain Rating Scale ( FPS ) and the Visual Analogue Scale ( VAS ) were used . RESULTS No significant difference was found between the W or RT local anesthesia when used during the first or second visit . In all parameters , children 's reactions to both types of injection were similar , with no statistically significant difference . Using the FPS , 19 boys ( 91 % ) ranked the experience of local anesthesia as a positive experience ( 0 to 2 in the scale ) while 4 boys ( 9 % ) ranked the same experience as negative . This was true for both types ( W and RT ) . All 21 girls who participated in the study ranked the local anesthesia experience using the FPS as a positive experience ( 0 to 2 in the scale ) . No significant difference was found in the mean VAS scores between the room-temperature group and the warm group ( 23.4 + /- 21.8 and 20.8 + /- 18.9 , respectively ) . CONCLUSIONS There is no advantage to warming local anesthetic solution prior to injection Objectives : ( 1 ) To assess the acceptability of a gel solution of adrenaline ( epinephrine ) ( 1 in 2000 ) and cocaine ( 5 % ) for anaesthetising children ’s facial lacerations to the child , parent , and operator . ( 2 ) To assess the safety of the current protocol . Setting : The emergency unit of a large university hospital . Methods : All patients who were treated with topical adrenaline and cocaine ( topAC ) gel over a six month period were entered into a prospect i ve audit ( n = 75 ) . Patient details , the nature and cause of the injury , and any treatment carried out were all recorded . The acceptability to children over 3 years of age , was assessed by the use of the Wong Baker face scale , in which 0 represents “ no hurt ” and 5 represents “ hurts worst ” . The acceptability to both the parent and the operator was assessed by the use of a 0 to 9 Likert scale , where 0 represented “ very acceptable ” and 9 represented “ not at all ” acceptable . Results : ( 1 ) Children aged 3 years or older grade d their pain during the procedure as having a mean value of 1.17 on the Wong Baker ( 0 to 5 ) scale . Parents grade d acceptability on the Likert scale ( 0 to 9 ) with a mean score of 1.13 . Operators using the same grading system , recorded a mean score of 1.75 . ( 2 ) No toxic side effects were seen but the protocol was up date d in line with evidence . Conclusions : Topical adrenaline and cocaine is an effective anaesthetic for suturing children ’s facial lacerations and is acceptable to child , parent , and operator alike The analgesic efficacy and safety of propacetamol , an injectable prodrug of acetaminophen , ( paracetamol ) were studied in 87 children ( 36 boys , 51 girls ; age 6 - 13 ; mean age 9.5 years ) immediately after limb surgery . Using a double-blind , r and omized , parallel group design , the effects of a single IV infusion of 30 mg.kg-1 propacetamol ( i.e. 15 mg.kg-1 acetaminophen ) were compared with a single injection of placebo ( PL ) . Efficacy was assessed on pain scores rated on a four-point verbal scale , a five-point visual scale ( faces ) and on a four-point relief verbal scale before administration ( T0 ) and 0.25 , 0.5 , 1 , 2 , 3 , 4 , 5 , 6 h after administration . At the end the global efficacy was rated by the physician on a five-point verbal scale . Propacetamol was statistically superior to placebo on all assessment criteria . Seven side-effects were recorded : five in the propacetamol group and two in the placebo group . 30 mg.kg-1 propacetamol provided a significantly greater analgesic effect than placebo in children after orthopaedic surgery The objective of this study was to assess analgesic use and the use of a  pain scoring system  on those children presenting to a paediatric accident and emergency ( A&E ) department with a history of injury due to trauma . A r and om sample of patients who presented to a paediatric A&E department over a 6-week period with a history of limb trauma were prospect ively studied . Pain severity scores were assessed on arrival and at 10 , 30 and 60 minutes using the Douhit Faces Scale and any analgesia given or plaster application was noted . One hundred and seventy-two patients were studied . The median age was 10 years ( range 3–13 years ) and the majority , 56 % , were male . The mean initial pain scores were 2.7 ( range 1–4 ) for boys and 3.0 ( range 1–4 ) for girls . The presenting injuries were 103 upper or lower limb fractures and 69 ‘ soft tissue ’ injuries . Only 84 ( 49 % ) patients received  analgesic medication in the department ( 30 % morphine ; 70 % paracetamol ) ;  analgesia  was not given to the remaining 88 ( 51 % ) . Of these , 7 declined analgesia , and 5 had already taken analgesia on arrival to A&E. Despite prompt triage ( median time 2 minutes , range 0–10 minutes ) , the median time from arrival to paracetamol administration was 20 minutes ( range 4–105 minutes ) and for morphine was 14 minutes ( range 2–57 minutes ) . Pain is a common symptom in patients presenting to A&E. Because children 's pain can be particularly difficult to assess , a pain scoring system such as the Douhit Faces Scale can be a useful means of pain assessment in the A&E setting . Despite increased awareness , pain is still under treated in the A&E department OBJECTIVE : To compare the postoperative recovery of patients who undergo intracapsular to subcapsular Coblation tonsillectomy .  STUDY DESIGN AND SETTING : This was a prospect i ve , r and omized , double-blinded study . A total of 69 children , aged 2 to 16 years , were r and omized to intracapsular ( n = 34 ) or subcapsular ( n = 35 ) tonsillectomy . The Coblation technique was used with both groups . Outcomes measures were assessed on postoperative day 1 or 2 and 5 or 6 . These included child and parental rating of pain with the Wong Faces pain scale , analgesic use , oral intake , and activity level . RESULTS : Intracapsular tonsillectomy patients had similar levels of pain to subcapsular tonsillectomy patients on day 1 or 2 . However , at day 5 or 6 , intracapsular tonsillectomy patients had significantly less pain than the subcapsular tonsillectomy patients . Intracapsular patients ate more and were more active at both time points . CONCLUSION AND SIGNIFICANCE : Children with obstructive sleep apnea who undergo tonsillectomy  demonstrate better postoperative recovery after intracapsular tonsillectomy . The intracapsular versus subcapsular difference may be best appreciated at a delayed time point ( day 5 or 6 ) rather than early ( day 1 or 2 ) Objective To identify the structure of facial reaction to procedural pain and to determine the subset of facial actions that best describe the response . Design Observational . Setting Five rural and five urban physicians ' offices . Patients One hundred twenty-three children aged 4 to 5 years undergoing routine diphtheria , pertussis , tetanus , and polio immunization .  Outcome Measures The Child Facial Coding System , comprising 13 discrete facial actions , was used to code each second of five 10-second phases from videotape : baseline , preneedle , needle , postneedle , and posth and ling . Parents and a technician provided visual analog scale ratings of children 's pain . Children provided a self-report using a  Faces Pain Scale  , and parents and nurses rated the children 's pain and anxiety using visual analog scales . Results A “ pain face ” similar to that reported in adults emerged with the onset of pain . Principal component analyses revealed the frequency and intensity of facial action during the needle phase could be represented by components reflecting pain sensation , a “ brave face , ” and the children 's expectations for pain . Children 's Faces Pain Scale and adult visual analog scale ratings were best predicted by components reflecting pain sensation and expectations of high pain . Conclusions These results provide a preliminary indication that the Child Facial Coding System can be reduced to components that reflect several aspects of children 's acute pain experience and predict self-reports and observer reports of children 's pain OBJECTIVE The objective of this study is to evaluate the efficacy of sucralfate in alleviating posttonsilectomy morbidity in a pediatric group of patients . METHODS A prospect i ve , double-blind , r and omized , and placebo-controlled study comparing the irrigation of a solution containing either 1 g of sucralfate ( study group ) or 1 g of lactulose ( control group ) was performed on 69 children aged 3 - 12 years , who underwent tonsillectomy at the University Hospital of Brasilia Medical School . The children were r and omly assigned and each one used a solution containing sucralfate or lactulose to swish and swallow four times daily during 7 days . Eleven patients were excluded . The anesthetic was st and ardized and no premedication was used . Pain magnitude using an " Oucher " scale , nausea , vomiting , bleeding , earache , analgesic drug intake , changes in the interincisor teeth distance , and changes in the weight and temperature were assessed by the surgeon 6 , 24h , and 7 days after the surgery . RESULTS Patients in the study group had significantly lower pain scores in the initial 6 postoperative hours ( p<0.05 ) . The difference between the two groups was not statistically significant for the other periods following the procedure or on the evaluation of the other indices . CONCLUSIONS The use of the sucralfate in pediatric patients undergoing tonsillectomy was not effective in reducing the postoperative morbidity according to the parameters used in this study . The surgical technique with careful mucosal dissection associated with postoperative caries could be more important in the reduction of posttonsilectomy morbidity Parents need education about pain so they can support their hospitalized child and manage their child 's pain at home . The purpose of this study was to examine the effectiveness of a pain booklet on parental pain support to children experiencing postoperative pain . A r and omized , repeated measures , experimental design using a pain education booklet and a st and ard care comparison group was used to study parents of 51 children ( 3 to 16 years of age ) having cardiac surgery . Measurement techniques used to assess differences in parental pain management included : attitudes about pain medication , child and parent pain ratings ( Oucher ) , opioids used , recovery , satisfaction , and comfort in communication . Results indicate that children do report moderate levels of pain postoperatively . Parents who were exposed to the pain assessment and management for parents education booklet preoperatively significantly increased their knowledge and attitudes toward pain medication scores from pre- to post-test , whereas those in the control group remained stable . Post-test scores were not significantly different between groups . Child and parent pain ratings were significantly and positively correlated . Practice implication s include the use of an educational booklet about pain with parents before surgery to increase their knowledge about and attitudes toward pain management . Additionally , a parent may provide an alternative pain report when a child is unable to or unwilling to self-report their pain Tramadol hydrochloride is a racemic mixture of two enantiomers . It has analgesic activity suitable for mild to moderate pain , part of its analgesic activity being modulated via mu receptors . Adult studies have raised the question of increased electroencephalographic activity . The study examined the analgesic efficacy , respiratory effects , and behavior plus recovery-influencing properties of tramadol in the pediatric patient . Day-case dental extraction children , aged 4 - 7 years having 6 or more extraction s , were studied .  Tramadol drops , 3 mg/kg , plus oral midazolam , 0.5 mg/kg , were administered 30 minutes prior to a sevoflurane in N2O and O2 anesthetic .  Forty children received this premedication treatment ( T ) and 10 entered a  placebo control group  ( P ) , where no tramadol was administered . Entry was r and om , double blind , and parallel . Analgesic efficacy was measured using the Oucher face pain scale ( OFPS ) , with responders scoring three or less . Respiration was measured by rate and oxygen saturation . Behavior and ease of mask induction were assessed on a 4-point scale . Recovery was measured with the Aldrete scale . Parameters were measured from 30 minute preanesthetic to 120 minute postanesthetic . Analgesic efficacy was shown , with an OFPS score of 11.42 ( SD 18.66 ) ( T ) and 29.80 ( SD 25.14 ) ( P ) ( P < .05 ) . Responders on tramadol were 77.5 % versus 0 % on placebo ( P < .05 ) . No respiratory depression was seen ; rates and oxygen saturations were the same preanesthetic and postanesthetic . Similarly , the two groups had no cardiovascular differences . Preanesthetic behavior patterns were the same ( P > .05 ) , with 85 % of the tramadol group being drowsy but awake versus 90 % in the placebo group . Similarly satisfactory induction behavior was seen in 95 % of the tramadol group and 90 % of the placebo group . Recovery times were 48.6 minutes ( SD 32.3 ) ( T ) and 43.1 minutes ( SD 32.5 ) ( P ) ( P > .05 ) . It is concluded that tramadol at 3 mg/kg has no clinical respiratory depressant effect and that behavior and recovery times are unaffected . Analgesic efficacy is demonstrated OBJECTIVE To quantify , using two pain assessment scales , the amount of change in pain severity required to achieve a clinical ly significant improvement in pain in children presenting to a pediatric emergency department ( ED ) with pain . METHODS Prospect i ve , descriptive study involving all children presenting to a pediatric ED between 5 and 16 years of age inclusive with acute pain . Children were excluded if they 1 ) were intoxicated or had altered sensorium , 2 ) were clinical ly unstable , 3 ) were non-English-speaking , or 4 ) were developmentally delayed . Written informed consent was obtained . Children were asked to mark their current pain severity on the st and ardized Color Analogue Scale ( CAS ) and Faces Pain Scale ( FPS ) . After each pain control intervention the child was asked to repeat these measurements and to describe whether his or her pain was " much less , " " a little less , " " about the same , " " a little worse , " or " much worse " compared with before . This process was repeated until the child was discharged from the ED or had a score of zero . The main outcome measure was the smallest change on the CAS or FPS necessary to cause the child to describe his or her pain as a " little less . " This was defined as the clinical ly significant change in pain . The " ideal " change in pain was defined as the amount of change necessary for the child to describe the pain as " much less " or at which point the child thought he or she no longer required any medicine to help the pain go away . RESULTS One hundred twenty-one children were enrolled with a mean age of 9.8 years ( SD + /- 3.15 ) . Males accounted for 56 % . Pain was traumatic in 65 % and nontraumatic in 35 % . A total of 153 pain comparisons were made using the CAS and 154 using the FPS . Only three children complained that their pain got worse ( two a little worse and one much worse ) . Pain was described as " the same " in 20 . Of the 60 pain comparisons judged to be a " little less , " the CAS score changed by a median of 2.0 cm [ interquartile ratio ( IQR ) 1 - 3 ] , and the FPS by 1.0 face ( IQR 1 - 2 ) . In the 71 children who judged their pain to be " much less , " the CAS decreased by a median of 4.0 cm ( IQR 2 - 5 ) and the FPS by 2.0 faces ( IQR 2 - 3 ) . CONCLUSIONS The assessment and treatment of  pain in children are an important component of pediatric practice , especially in the ED . This study provides health care professionals and clinical investigators the information necessary to assess whether their method of pain control in children is clinical ly relevant The effectiveness of a eutectic mixture lidocaine‐prilocaine topical anaesthetic cream ( EMLA ® ) patch compared with a placebo patch in the reduction of pain associated with intramuscular immunization was evaluated . As part of the study , 161 children ( aged 4‐6‐y ) undergoing routine diphtheria , pertussis , tetanus and polio ( DPTP ) immunization in five urban and five rural private office setting s were r and omly assigned to an EMLA ® patch ( n= 83 ) or a placebo patch control group ( n= 78 ) . Pain measurements included : child 's self‐report on a Faces Pain Scale ; facial action on the Child Facial Coding System ; the Children 's Hospital of Eastern Ontario Pain Scale and parent and technician ratings on a Visual Analogue Scale . Parents also rated their own and their child 's immunization‐related anxiety on a Visual Analogue Scale . The EMLA ® patch group had significantly less pain on all four pain measures compared with the placebo group . Of the children in the placebo group , 43 % had clinical ly significant pain , compared with 17 % of children in the EMLA ® patch group . No severe adverse symptoms occurred as a result of either EMLA ® or placebo patch application OBJECTIVES To study the compliance of prescription , the efficacity and the adverse events of oral morphine used in the pediatric emergency department ( ED ) in traumatic pains . METHOD This prospect i ve study was conducted in the ED from october 2002 to september 2003 . Children aged six months to 16 years with a visual analogic scale ( VAS ) score higher than 70 or with a traumatic member deformation received oral morphine ( 0,5 mg/kg ) .  Pain was assessed every 30 minutes using two scales : behavioral observation by the faces scale  and  objective pain scale ( OPS ) for children less than five years , behavioral observation by the  faces scale and self-report by  VAS  for children older than five years . The compliance of prescription , the pain scores and the adverse events were studied . RESULTS Ninety-one children received oral morphine and seventy-four children were studied . Seventy per cent of prescriptions were in accordance with the recommendations . For patients younger than five years a rapid decrease of pain was observed in thirty minutes . The pain 's reduction was respectively 79 and 84 % with faces scale and OPS when they left ED . For children older than five years , pain 's reduction was more important and more rapid when pain assessment was made by nurses than when it was self-reported in the first hour ( pain reduction 58,2 and 36,1 % ) . When leaving , pain reduction was the same with the two different assessment s. No major adverse event was noted . CONCLUSION Use of oral morphine in ED is simple , with a few numbers of adverse events . None was severe . Efficiency is correct after 30 to 60 minutes OBJECTIVE To measure differences in postoperative pain in children undergoing intracapsular tonsillectomy vs. extracapsular tonsillectomy .  STUDY DESIGN Prospect i ve clinical trial carried out at a tertiary children 's hospital over 1 year . METHODS The study included 43 patients age 5 to 19 years with adenotonsillar hypertrophy , 27 undergoing extracapsular tonsillectomy and 16 undergoing intracapsular tonsillectomy . Tonsillectomy was performed in either an intracapsular or extracapsular fashion using bipolar electrosurgical scissors and monopolar suction cautery for hemostasis . Residents under faculty supervision performed all operations . Postoperative pain was assessed using the Wong-Baker Faces Pain Scale through postoperative day 10 . The patients recorded in a st and ardized diary pain scores and analgesic use . The main outcome measure was postoperative pain as measured by the Wong-Baker Faces Pain Scale . The quantity of postoperative pain medicine consumed was a secondary outcome measure . RESULTS Average postoperative pain for extracapsular tonsillectomy was 5.21 on a 10-point scale versus 2.75 for intracapsular tonsillectomy ( P < .0001 ) . CONCLUSIONS Intracapsular tonsillectomy with bipolar scissors results in less postoperative pain than extracapsular tonsillectomy with bipolar scissors in children age 5 to 19 years This study examined concurrent self-reports of pain intensity  and behavioral responses in 25 children aged 3 - 7 yr .  Behavioral (  Children 's Hospital of Eastern Ontario Pain Scale , CHEOPS ) and self-report ( the Oucher and Analogue Chromatic Continuous Scale ) measures of pain were obtained following major surgery . The two self-report measures were strongly and significantly correlated , and the pattern of scores over the 36-hr observation period was as expected . There was little relationship between the scores for the self-report and the behavioral measures . Many children who reported severe pain manifested few of the behavioral indicators of distress used in the CHEOPS . This behavioral response pattern may occur commonly in children experiencing pain after surgery and may limit the applicability of current behavioral scales as sole measures of pain intensity in younger children Objective . To compare the Faces Pain Scale and Color Analogue Scale among children aged 6–12 years undergoing selected procedures ( Venipuncture , Intravenous cannulation , Intramuscular injection , Lumbar puncture , Bone marrow aspiration )  and to compare the procedural pain in a child as perceived by the child , parents and health care professionals using the above mentioned scales Methods . This was a prospect i ve , descriptive correlational study of children aged 6–12 years , who had undergone selected procedures . Children were assessed for their pain severity using  Faces Pain Scale and Color Analogue Scale .  Parents and health care professionals also independently assessed the child 's pain using the same scales Results . 181 children who fulfilled the eligibility criteria were enrolled in the study . There was a significant positive correlation ( r = > 0.8 ) between both the pain scales . There was fair to moderate positive correlation ( r = 0.29 to 0.58 ) of pain perception of child with parents and health care professionals Conclusions . Faces Pain Scale and Color Analogue Scales seem to be appropriate instruments for measuring pain intensity among Indian children aged 6–12 years undergoing selected OBJECTIVE To compare the effectiveness of acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy and adenoidectomy . STUDY DESIGN Prospect i ve , r and omized , double-blind study . METHODS Fifty-one children ages 3 to 12 years scheduled for outpatient tonsillectomy and adenoidectomy were studied . Patients were r and omly assigned to receive acetaminophen or acetaminophen with codeine in unlabeled bottles for postoperative pain control . The Wong-Baker FACES pain rating scale was used to help children quantify their level of pain after surgery . The level of pain , quantity of pain medication required , presence of side effects , and the percentage of a normal diet consumed was recorded for 10 postoperative days . RESULTS There was no difference ( P > .05 , all time points ) in the level of postoperative pain reported by the parents and children in the two groups . The acetaminophen with codeine group tended to have increased problems with nausea , emesis , and constipation , but these differences did not reach statistical significance . Children in the acetaminophen group consumed a significantly higher percentage of a normal diet on the first 6 postoperative days ( P < .05 , all time points ) . CONCLUSION There was no difference in the level of pain control provided by acetaminophen and acetaminophen with codeine as measured by the Wong-Baker FACES pain rating scale . Postoperative oral intake was significantly higher in children treated with acetaminophen alone OBJECTIVE To compare the efficacy of 3 different pharmacologic regimens to relieve pain and distress in children with cancer undergoing bone marrow aspirations ( BMAs ) and lumbar punctures ( LPs ) . DESIGN Retrospective cohort study with crossovers for some patients . PATIENTS AND METHODS The pain and distress ratings of patients undergoing BMAs ( n = 73 ) and LPs ( n = 105 ) were examined in a comparison of 3 different interventions : ( 1 ) a topical eutectic mixture of lidocaine and prilocaine ( EMLA cream ) , ( 2 ) oral midazolam and EMLA cream , or ( 3 ) propofol/fentanyl general anesthesia . The choice of the intervention depended on patient/parent request . A vali date d faces pain scale was completed by the child or parent following each BMA or LP . The faces pain scale includes ratings of the severity of pain ( from 0 = none to 5 = severe ) and ratings of how frightened ( from 0 = not scared to 5 = scared ) the child was prior to each procedure . Comparisons of the pain and distress ratings were made among all patients for their first procedure and also within individual patients who had received > 1 of the 3 interventions . Independent comparisons between the first treatments received by each patient were analyzed using Kruskal – Wallis tests . Comparisons of different crossover treatments received by individual patients were analyzed using Wilcoxon tests . RESULTS For all first procedures , mean ± SD pain and distress ratings during LPs were significantly lower when propofol/fentanyl was used ( n = 43 ; 0.4 ± 1.0 and 1.4 ± 1.7 ) versus either EMLA ( n = 29 ; 2.4 ± 1.7 and 2.9 ± 1.9 ) or midazolam/EMLA ( n = 33 ; 2.4 ± 1.8 and 2.7 ± 1.8 ) , respectively . Pain and distress ratings during BMAs were also significantly lower with propofol/fentanyl ( n = 29 ; 0.5 ± 1.0 and 1.2 ± 1.7 ) versus EMLA ( n = 21 ; 3.5 ± 1.6 and 3.3 ± 1.8 ) or midazolam/EMLA ( n = 23 ; 3.3 ± 1.5 and 3.0 ± 1.9 ) , respectively . When data were analyzed within each patient , these differences were also present . CONCLUSIONS Children receiving propofol/fentanyl general anesthesia experienced significantly less procedure-related pain and distress than did those receiving either EMLA or oral midazolam/EMLA Background : Historically , children have been undertreated for their pain , and they continue to undergo painful cutaneous procedures without analgesics . A new topical anesthetic , liposomal lidocaine 4 % cream ( Maxilene , RGR Pharma , Windsor , Ont . ) , has become available . It has pharmacologic properties that are superior to other topical anesthetics , including an onset of action of only 30 minutes . We sought to determine the success rate of cannulation , analgesic effectiveness , procedure duration and rate of adverse skin reactions when liposomal lidocaine is used before intravenous cannulation of children . Methods : In this double-blind r and omized controlled trial , children aged 1 month to 17 years received liposomal lidocaine or placebo before cannulation . Success on first cannulation attempt was recorded , and , among children 5 years and older , pain was evaluated before and after the attempt by the child , parents and research assistant using a vali date d measure ( Faces Pain Scale-Revised ) . For children younger than 5 years , pain was evaluated by the parents and research assistant only . The total duration of the procedure and adverse skin reactions were also recorded . Results : Baseline characteristics did not differ ( p > 0.05 ) between children who received liposomal lidocaine ( n = 69 ) and those who received placebo ( n = 73 ) . Cannulation on the first attempt was achieved in 74 % of children who received liposomal lidocaine compared with 55 % of those who received placebo ( p = 0.03 ) . Among children 5 years of age and older ( n = 67 ) , lower mean pain scores during cannulation were reported by those receiving liposomal lidocaine ( p = 0.01 ) . Similarly , lower mean pain scores during cannulation were reported by the parents and research assistant for all children who received liposomal lidocaine than for all those who received placebo ( p < 0.001 ) . The mean total procedure duration was shorter with liposomal lidocaine ( 6.7 v. 8.5 minutes ; p = 0.04 ) . The incidence of transient dermal changes was 23 % in both groups ( p = 1.0 ) . Conclusions : Use of liposomal lidocaine was associated with a higher intravenous cannulation success rate , less pain , shorter total procedure time and minor dermal changes among children undergoing cannulation . Its routine use for painful cutaneous procedures should be considered whenever feasible We evaluated the analgesic efficacy of EMLA cream after repeated bone marrow aspirations or lumbar punctures ( LPs ) in children with cancer , and compared the ratings among patients , their parents , physicians , and nurses . Data from LPs were analyzed at the last procedure without EMLA ( T1 ) and the first and last procedures with EMLA ( T2 and T3 ) . Friedman 's nonparametric analysis of variance was used for statistical analysis . A total of 272 procedures in 29 children were analyzed . For 179 procedures without EMLA , physicians rated pain lower than other raters , and for the 93 with EMLA physicians rated pain less than the children . Children rated pain at T2 lower than at T1 or T3 . Physicians rated pain at T2 less than at T3 . Both children and physicians rated pain at T3 as not different from that at T1 . No differences were noted at these time points for other raters in LP distress ratings , or in bone marrow aspiration pain or distress ratings . Thus EMLA was associated with decreased pain ratings for LPs , but this effect was not sustainable with repeated procedures . The cream alone should not be relied on to control pain of bone marrow aspiration or repeated LPs in children . Physicians underestimated pain , which may have implication s for undertreatment in this patient population Paediatric limb fracture is a common injury that presents frequently to the ED . The primary objective of the present study was to determine whether ibuprofen provides better analgesia than paracetamol for paediatric patients discharged with acute limb fractures . A prospect i ve , r and omized controlled study was conducted in a children 's ED . Children aged 5 - 14 years with an acute limb fracture were r and omized to be prescribed paracetamol 15 mg/kg/dose every 4 h or ibuprofen 10 mg/kg/dose every 8 h. Objective ( child-reported ) pain scores using the ' Faces ' pain scale were measured over a 48 h period . Child-reported pain did not differ significantly between the paracetamol and ibuprofen groups ( mean pain score paracetamol 2.8 [ 95 % CI 2.4 - 3.4 ] vs 2.7 [ 95 % CI 2.1 - 3.3 ] , P = 0.73 ) . Parent-reported sleep quality did not differ between the two groups ( P = 0.78 ) . Child-reported pain score decreased over the 48 h of measurement ( P < 0.0001 ) . There were no significant differences in side-effects detected between the two groups . The present study shows that in the outpatient paediatric population , ibuprofen does not provide better analgesia than paracetamol .  Pain from an acute fracture can be managed by regular simple oral analgesia and immobilization OBJECTIVE The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery , to relate previous experiences of surgery/tonsillitis with anxiety and pain , and to compare the children 's , parent 's and nurse 's rating of pain . METHOD Ninety-two children ( 5 - 15 years ) with sleep-disordered breathing ( SDB ) and with or without recurrent tonsillitis were r and omized to partial tonsil resection/tonsillotomy ( TT ) or full tonsillectomy ( TE ) .  MEASURES Parents : Child Behavior Checklist ( CBCL ) . Children : State-Trait-Anxiety Inventory for Children ( STAIC ) and seven-point Faces Pain Scale ( FPS ) . Parents/staff : seven-point Verbal Pain Rating Scale ( VPRS ) . Pain relievers were opoids , paracetamol and diclophenac . RESULTS These children with SDB scored significantly higher on CBCL than did normative groups , but no connection was observed between CBCL rating and experience of pain . There was no relation between pre-operative anxiety and pain . The post-operative anxiety level ( STAIC ) correlated with pain . The TE-group scored higher on STAIC after surgery . Previous experience of surgery or tonsillitis did not influence post-operative pain . The TE-group rated higher experience of pain despite more medication . The nurses scored pain lower than the parents/children and under-medicated . CONCLUSION SDB may influence children 's behavior , but with no relation to post-operative pain . The surgical method predicts pain better than does the child 's behavior rating . The nurses underestimated the pain experienced by the child BACKGROUND Oral controlled-release morphine can provide effective analgesia through a non-invasive route and may facilitate outpatient management of severe episodes of sickle-cell pain . We compared the clinical efficacy and safety of oral morphine with continuous intravenous morphine in children with severe episodes of sickle-cell pain , by a double-blind , r and omised , parallel-group design . METHODS 56 children aged 5 - 17 years received loading doses of intravenous morphine of up to 0.15 mg/kg , followed by r and omly assigned oral morphine 1.9 mg/kg every 12 h plus intravenous placebo ( saline ) , or intravenous morphine 0.04 mg kg-1 h-1 , plus placebo tablet .  Breakthrough pain was treated with oral , immediate-release morphine 0.4 mg/kg every 2 - 3 h as required . Pain was assessed daily at 0900 h , 1300 h , 1700 h , and 2100 h with a picture face scale , a pictorial scale ( Oucher ) , a behavioural-observational scale ( CHEOPS ) , and by an investigator . FINDINGS 50 children completed the study ( 28 boys , 22 girls ; mean age 11.2 years [ SD 3.5 ] ; mean oral morphine dose 2.99 mg/kg daily [ 0.75 ] ; mean intravenous morphine dose , 0.81 mg/kg daily [ 0.30 ] ) . Mean overall pain scores were similar for oral and intravenous morphine ( CHEOPS , 6.3 [ 1.5 ] vs 6.4 [ 1.4 ] , p = 0.8 ; Oucher , 31.5 [ 25.4 ] vs 39.2 [ 21.7 ] , p = 0.3 ; Faces , 2.2 [ 1.4 ] vs 2.4 [ 1.3 ] , p = 0.6 ; clinical rating , 1.7 [ 0.7 ] vs 1.9 [ 0.5 ] , p = 0.3 ) .  Opioid analgesia  was required for a mean of 4.2 days ( 1.7 ) and 5.4 days ( 2.6 ) , respectively ( p = 0.0591 ) . Pain scores from all scales correlated significantly ( r = 0.5865 - 0.8980 , p = 0.0001 ) . Frequency of rescue analgesia did not differ significantly between the oral and intravenous morphine groups ( 0.7 [ 0.8 ] vs 0.9 [ 0.7 ] doses daily , p = 0.2 ) . Frequency and severity of adverse events did not differ significantly . INTERPRETATION Oral , controlled-release morphine is a reliable , non-invasive alternative to continuous intravenous morphine for the management of painful episodes of sickle-cell disease in children Summary :  Intravenous cannulation in children aged 6–12 years is less painful after a 90‐min application of a Lidocaine/ Prilocaine cream followed by a 30‐min interval without cream , than cannulation immediately after a 60‐min application OBJECTIVE To test the convergent validity of the Manchester pain scale when compared to the current ' gold st and ard ' in children 's pain assessment , the Oucher pain scale . METHOD One hundred and fifty two children presenting to the emergency department had  pain scale assessment  s using both the Manchester and Oucher pain scales .  The order of presentation of the scales was r and omised . The degree of convergence between the scales was assessed using Spearman 's rank correlation as well as Bl and and Altman plots . RESULTS One hundred and thirteen children used numerical scales ; the correlation coefficient for these was 0.802 . Thirty nine children used pictorial scales ; the correlation coefficient was 0.820 . CONCLUSION There is strong convergent validity between the scales as demonstrated by a high degree of correlation between the numerical and pictorial scores generated by the Manchester and Oucher pain scales . The  Manchester pain scale  can be used to assess pain in children presenting to emergency departments OBJECTIVE To examine whether microdebrider intracapsular tonsillotomy ( MT ) results in less postoperative pain compared with electrosurgical extracapsular tonsillectomy ( ET ) . DESIGN Prospect i ve , r and omized , double-blind , matched pair , clinical trial . SETTING Specialty care hospital . Patients Twelve male ( 48 % ) and 13 female ( 52 % ) children aged 5 to 15 years , with obstructive tonsillar hyperplasia were r and omized to have one tonsil removed by MT and the other by ET . INTERVENTIONS An angled endoscopic microdebrider was used to perform MT , and ET was performed by st and ard monopolar cautery technique .  Parents and children were blinded to the side of MT and ET . Children rated the pain 0 to 5 by side using the Faces Pain Scale-Revised . Blinded data collection was via telephone daily for 2 weeks by a study nurse . MAIN OUTCOME MEASURES Primary : postoperative pain as recorded by Faces Pain Scale-Revised ; secondary , presence or absence of otalgia and postoperative bleeding . RESULTS Twenty-two children ( 88 % ) had tonsillectomy and adenoidectomy , while 3 children ( 12 % ) had tonsillectomy alone . On postoperative days 1 to 9 , children reported significantly less pain on the MT side compared with the ET side ( paired t test ; P<.01 ) . By postoperative days 10 to 14 , the difference between sides disappeared . Twenty children ( 80 % ) reported otalgia , and it was always unilateral . For those children reporting otalgia , there was a 100 % correlation between the side of otalgia and the side of ET . There was no posttonsillectomy bleeding among the 25 children . CONCLUSION Microdebrider intracapsular tonsillotomy is significantly less painful compared with electrosurgical ET in children undergoing surgical intervention for obstructive tonsillar hypertrophy AIMS To evaluate the effectiveness of an analgesic protocol with nitrous oxide and anaesthetic cream ( lidocaine and prilocaine , EMLA ) for children undergoing botulinum toxin injections .  PATIENTS AND METHODS Prospect i ve study including 51 injection sessions , 34 children with a mean age of 5.94 ( range 2 - 15 ) and 209 injected muscles .  Pain was evaluated with the Children 's Hospital of Eastern Ontario Pain Scale ( CHEOPS ) , the Visual Analogue Scale ( VAS ) and the Face Pain Scale ( FPS ) for the children and with a VAS for the parents . RESULTS CHEOPS score for the 51 sessions was 8.50 ( S.D. 3.56 ) . Forty-nine percent of scores were above the therapeutic threshold of 9 ; 25 % of the children evaluated the pain above the therapeutic threshold of 3 ; 44.74 % of the parents ' estimations exceeded 3 . No correlation was found between age , weight , number of injected muscle and CHEOPS score . CONCLUSION The association of MEOPA and anaesthetic cream is only effective for 50 % of children . This is much lower than treatments for other types of acute induced pain in children . Botulinum toxin injections and cerebral palsy children present certain specificities which require improvements in this analgesic protocol Faces scales have become the most popular approach to eliciting children 's self-reports of pain , although different formats are available . The present study examined : ( a ) the potential for bias in children 's self-reported ratings of clinical pain when using scales with smiling rather than neutral ' no pain ' faces ; ( b ) levels of agreement between child and parent reports of pain using different faces scales ; and ( c ) preferences for scales by children and parents . Participants were 75 children between the ages of 5 and 12 years undergoing venepuncture , and their parents . Following venepuncture , children and parents independently rated the child 's pain using five different r and omly presented faces scales and indicated which of the scales they preferred and why . Children 's ratings across scales were very highly correlated ; however , they rated significantly more pain when using scales with a smiling rather than a neutral ' no pain ' face . Girls reported significantly greater levels of pain than boys , regardless of scale type . There were no age differences in children 's pain reports . Parents ' ratings across scales were also highly correlated ; however , parents also had higher pain ratings using scales with smiling ' no pain ' faces . The level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used ; parents overestimated their children 's pain using all five scales . Children and parents preferred scales that they perceived to be happy and cartoon-like . The results of this study indicate that subtle variations in the format of faces scales do influence children 's and parents ' ratings of pain in clinical setting BACKGROUND tonsillectomy ( TE ) is currently the most common treatment for children with snoring and sleep apnea . Many of these children have not had any severe throat infections . To cure such children from their obstructive problems , without influencing the immunological function of the tonsils , tonsillotomy ( TT ) with CO2-laser was performed in a r and omized study comparing it to regular tonsillectomy , with special attention to postoperative pain and symptom recurrence . METHOD 41 children 3.5 - 8 years-old were included--21 ' TT 's ' and 20 ' TE 's ' . They were all operated under the same anesthesia and followed the same postoperative scheme for analgesia . A visual analogue scale for pain measurements with faces was used for the first 24 h. After that , each day until pain-free , the parents registered the child 's pain on a three grade d scale , what the child was able to eat , and the amount of analgesic drugs used . RESULTS all the children were cured from their breathing obstruction . The mean time used for the surgery was the same and no postoperative bleeding was seen in either group . ' TT children ' were pain-free after 5 days and ' TE children ' after 8 days . Eight to ten days after surgery , the TT-children had gained weight and the TE children lost weight significantly . The TE group used twice as much analgesic drugs as the TT group during the first postoperative week . The TT group was healed with normal-looking , but small tonsils after 8 - 10 days ; the TE group often still showed edema and crusts . At the one-year follow-up 2/21 among the ' TT-children ' snored , but did not require re-surgery . CONCLUSION tonsillotomy is much less painful than TE and children recover more quickly . Results with respect to breathing obstruction are almost the same for both methods at 1-year follow-up As day case surgery increases , one needs to improve the management of pain in children at home . This study wished to determine whether the use of a self-report pain scale would result in children receiving more analgesia . Eighty-eight children aged four to 12 years undergoing tonsillectomy , whose parents agreed they could participate , were r and omly assigned into two groups . Group A received the routine postoperative advice and a three-day prescription of paracetamol , ibuprofen and codeine . In addition , group B used the Wong — Baker Faces Pain Scale .  Seventy-two children completed the study . There was no difference in the total number of analgesics administered to children in the two groups ( p = 0.26 , Mann— Whitney U-test ) . It appears that a self-report pain scale does not improve the postoperative management of pain in children at home Abstract Despite its importance in clinical practice , little research has examined memory for pain in children . This prospect i ve study tried to justify the use of  children 's pain recall  in clinical practice . The purpose of this study was to ( a ) investigate the accuracy of children 's recall of their worst and average pain intensity when controlling for the effects of repeated pain measurement and ( b ) examine the influence of children 's anxiety , age , general memory ability and pain coping strategies on this accuracy . The accuracy of children 's  recalled pain intensities was studied in 55 in patients aged 5–16 years by comparing the level of recorded pain intensity with the level of recalled pain intensity  1 day and 1 week after recording using Bieri 's Faces Pain Scale .  The accuracy of children 's recalled pain intensities was high and showed little decrement over 1 week . Older children had more accurate recall of their worst pain intensity . Anxiety , general memory ability and pain coping strategies were not related to accuracy of recalled pain intensities OBJECTIVE To evaluate the effectiveness of audiovisual distraction compared with a blank TV screen in the reduction of pain associated with intramuscular immunization . DESIGN Subjects were r and omly assigned to watch television ( TV ) ( N = 29 ) or a blank TV screen ( control ) ( N = 33 ) during immunization , and were videotaped . Immediately after the injection , the children rated their pain . Videotapes were coded for pain behaviors and for distraction . t tests determined between-group mean differences and chi-square tests compared proportions for clinical ly significant self-reported pain . SETTING Two urban pediatric practice s in Halifax , Nova Scotia , Canada . SUBJECTS Five-year-old children ( N = 62 ) , undergoing diphtheria , polio , tetanus , and pertussis immunization , and their parents . INTERVENTIONS An age-appropriate musical cartoon or a blank TV screen . OUTCOME MEASURES Pain measurements were the children 's self-reports on Faces Pain Scale , facial actions on Child Facial Coding System , and Children 's Hospital of Eastern Ontario Pain Scale . Distraction was measured by mean time spent watching the TV screen . Parents rated their own and their child 's anxiety on a visual analogue scale . RESULTS There were no significant group differences for any pain or distraction measures . The relative risk estimate for clinical ly significant pain among the distraction group was 0.64 ( range : 0.23 - 1.80 ) . Higher levels of distraction ( i.e. , greater time looking at the TV screen ) related to lower levels of pain on all three pain measures . Only correlations with objective pain measures were statistically significant . CONCLUSIONS Watching cartoons did not distract children during needle injection nor reduce their pain . Looking at the TV screen was related to lower behavioral pain scores in the total sample OBJECTIVE To investigate the influence of recommendations on the quality of postoperative pain management in children . DESIGN Prospect i ve . SETTING University Hospital Groningen , the Netherl and s. METHOD After interdisciplinary recommendations on postoperative pain were developed , the quality of postoperative pain management was investigated before implementation ( phase I ; n = 50 children aged 0 - 14 who underwent elective surgery ) , three months after the implementation ( phase II ; n = 51 ) , and nine months later ( phase III ; n = 50 ) . Quality was defined by a pain score ( for ages 0 to 4 with the ' Children 's Hospital of Eastern Ontario pain scale ' ( CHEOPS ) and for ages 4 - 14 with the Oucher scale ) and the prescription of analgetics : kind , dose , frequency , prescription by anaesthetist and doctor on the ward . Pain was scored every 2 hours during the first 24 hours after surgery . A CHEOPS score < or = 6 an Oucher score < or = 50 was defined as adequate ; higher scores were defined as inadequate . RESULTS Pain measurement showed a statistically significant improvement of pain scores in time ( phase II and III compared with phase I : odds ratio : 2.5 ; 95 % confidence interval : 1.03 - 6.00 ; p < 0.01 ) . Search ing for factors that could be responsible for this improvement , like medication , we found no statistically significant differences in everyday practice in phase II and III compared with phase I. However , children who could score their pain by self-report ( Oucher ) showed the best results in all 3 phases of the study . The youngest children , i.e. less than 6 months old , showed inadequate results during the whole study . The greatest improvement in time during the first 12 hours was seen in the group of children older than 6 months . The recommendations were followed more strictly in younger children , and when continuous morphine was given . CONCLUSION Pain scores in children  improved after the introduction of recommendations on postoperative pain . However , the improvement could not be attributed to factors like medication . Factors like a change in attitude towards pain could be responsible for this change OBJECTIVE To evaluate and compare the reaction of children who received local anaesthesia with lidocaine 2 % with 1 : 100 000 epinephrine and articaine 4 % with 1 : 200 000 epinephrine and to assess the time of the onset , efficacy , duration of numbness of the soft tissues , children 's sensation after treatment to both anaesthetic solutions , as well as the occurrence of adverse events . SAMPLE S AND METHODS Sixty-two children ( 34 girls and 28 boys ) aged 5 - 13 years ( mean age 8.4 + /- 2.3 ) from two established paediatric dental clinics who needed similar operative procedures preceded by local anaesthesia were r and omly assigned to receive either lidocaine or articaine at their first or second visit . Modified Taddio 's behavioural pain scale was used to evaluate pain reaction during injection and treatment . The sensation after injection and treatment was evaluated using the Wong-Baker FACES pain rating scale . Parents recorded the time when the feeling of local anaesthesia in soft tissues disappeared . RESULTS Duration of numbness of soft tissues was significantly longer for articaine ( 3.43 + /- 0.7 h ) than for lidocaine ( 3.0 + /- 0.8 h ) ( P = 0.003 ) . No difference regarding the efficacy of the anaesthesia was observed . Reaction to pain was similar for both local anaesthetic solutions and no significant difference was found between genders . The efficacy of the anaesthesia was similar for both solutions . The feeling after treatment was similar for both solutions . The rate of adverse effects was similar for the two solutions . CONCLUSIONS Articaine 4 % with 1 : 200 000 epinephrine is as effective as lidocaine 2 % with 1 : 100 000 epinephrine . The effect of numbness of soft tissues was longer lasting with articaine than with lidocaine OBJECTIVES : To compare postoperative tonsillectomy pain between 3 commonly used surgical devices : the Harmonic Ultrasonic Scalpel ( Ethicon Endo-Surgery , Cincinnati , OH ) , the Coblator ( ArthroCare Corp , Sunnyvale , CA ) , and electrocautery . STUDY DESIGN AND SETTING : A prospect i ve , r and omized trial . One hundred thirty-four patients were r and omly assigned to receive a tonsillectomy with 1 of 3 surgical devices . All patients were asked to fill out a postoperative diary . RESULTS : Statistically significant differences in pain scores were revealed between the Coblator and electrocautery ( P = 0.02 ) and between the Coblator and the Ultrasonic Scalpel ( P = 0.003 ) , with the Coblator having lower pain scores .  Electrocautery and the Ultrasonic Scalpel did not differ significantly from each other . The Coblation method showed a strong trend toward quicker return to normal diet . CONCLUSION : Patients undergoing tonsillectomy with the Coblator device reported less pain over a 10-day period than patients undergoing tonsillectomy  with electrocautery or the Ultrasonic Scalpel .  Pain after tonsillectomy remains a major issue for our patients . The choice of surgical instrument appears to be one way to reduce this pain . EBM rating : OBJECTIVE To compare intraoperative efficiency and postoperative recovery between cold dissection adenotonsillectomy ( CDA ) and coblation-assisted adenotonsillectomy ( CAA ) . METHODS A prospect i ve , r and omized , single-blind trial of pediatric patients aged 2 to 16 years undergoing adenotonsillectomy  was conducted . Patients were r and omized to undergo either CDA or CAA . Measured intraoperative parameters included surgical duration and intraoperative blood loss . Measured postoperative parameters included a 14 day caregiver question naire that recorded a daily pain rating using the Wong-Baker FACES pain scale , pain medication use , days to return to a normal diet , and days to return to a normal caregiver routine . Postoperative complications were also recorded . Intraoperative and postoperative measures were statistically compared between groups . RESULTS Forty-six children with a mean age of 6.7 years ( 23 CDA and 23 CAA ) were r and omized and completed the study . Mean age and sex distributions were similar between groups ( P > .05 ) . Surgical times were significantly shorter for the CAA group versus the CDA group ( 11.2 min vs. 17.0 min , P < .001 ) . Intraoperative blood loss was statistically lower for both the adenoidectomy and tonsillectomy portions of the procedure for the CAA group versus the CDA group ( P < .001 and P < .001 , respectively ) . There was no statistically significant difference in reported daily pain scores between groups ( P = .296 , analysis of variance ) . Both groups returned to normal diet ( P = .982 ) , and caregivers returned to their normal routine on similar postoperative days ( P = .631 ) . CONCLUSIONS CAA offers better operative speed and intraoperative hemostasis as compared with CDA . However , CAA does not result in poorer postoperative pain scores or recoveries despite these intraoperative advantages BACKGROUND Pain treatment is one of the main concerns of paediatric anaesthesiologists . The purpose of this study was to assess and compare the quality of analgesia and stress suppression by morphine when used [ epidural ( single shot ) ( EP ) or with intravenous ( i.v . ) for patient-controlled analgesia ( PCA ) in children ] . METHODS Forty-four children , aged 5 - 15 years , and who were undergoing major genitourinary or lower abdominal surgery with a st and ardized general anaesthesia technique , were included in this study . In the EP group ( n=24 ) 0.1 mg x kg(-1 ) morphine in 0.2 ml x kg(-1 ) saline were given epidurally at the L3 - 4 level and in the PCA group ( n=20 ) 0.1 mg x kg-1 morphine was given i.v . immediately after intubation . Postoperative PCA bolus doses were 0.5 mg for patients weighing less than 20 kg , 1 mg for children weighing 20 - 30 kg and 1.5 mg for children weighing 30 - 40 kg . Blood sample s were withdrawn following induction and at 1 , 8 , 12 and 24 h after morphine administration for measurement of blood glucose , insulin , cortisol and morphine levels . Patients were observed for 24 h postoperatively ; heart rate , systolic blood pressure , respiratory rate , FACES pain scores , sedation scores and complications were recorded . RESULTS The PCA group received 0.56 + /- 0.33 mg x kg(-1 ) x day(-1 ) morphine . The FACES pain scores , sedation scores , cortisol , blood glucose and insulin levels were similar in both groups . Haemodynamic and respiratory evaluations and cortisol levels were stable but blood glucose and insulin changes at certain time periods were significant ( P < 0.05 ) . Serum morphine levels and incidence of vomiting were different between groups ( P < 0.05 ) . Serum morphine levels were similar at the first hour . CONCLUSIONS Both techniques provided sufficient pain relief and attenuated the hormonal response without life-threatening complications OBJECTIVES To study the effects of music on anxiety and pain in children with cerebral palsy receiving acupuncture daily in a clinical setting . DESIGN A r and omized controlled trial . SETTING Acupuncture Unit at Shenzhen Hospital of Traditional Chinese Medicine in Shenzhen City of China . PARTICIPANTS Sixty children with cerebral palsy undergoing acupuncture . METHODS INTERVENTION Children listened to their favorite music or a blank disc for 30 min . MEASUREMENTS ( 1 ) the modified Yale preoperative anxiety scale for children 's anxiety ( mYPAS ) ; ( 2 ) children 's hospital of eastern Ontario pain scale ( CHEOPS ) and Wong-Baker faces pain rating scale ( FACES ) for pain intensity ; ( 3 ) vital signs including mean arterial blood pressure ( MAP ) , heart rate ( HR ) and respiratory rate ( RR ) . RESULTS An independent sample t-test showed significantly lower mYPAS scores in the music group 30 min after the intervention compared with the control group ( t=4.72 , P=0.00 ) . Significant differences between groups were found in mYPAS scores ( F=4.270 , d.f.=1 , P=0.043 , Partial eta(2)=0.069 ) and over treatment duration ( F=143.421 , d.f.=1.521 , P=0.000 , Partial eta(2)=0.712 ) . A significant interaction was also found ( F=4.298 , d.f.=1.521 , P=0.025 , Partial eta(2)=0.069 ) . LSD 's post hoc testing confirmed that the mYPAS scores significantly increased from the baseline to 1 min ( P=0.000 , 95 % CI 14.913 , 20.257 ) and then gradually decreased from 1 to 30min ( P=0.000 , 95 % CI -18.952 , -13.714 ) . For pain intensity scores , a highly significant time effect was found in both the CHEOPS ( F=87.347 , d.f.=2 , P=0.000 , Partial eta(2)=0.601 ) and FACES ( F=225.871 , d.f.=1.822 , P=0.000 , Partial eta(2)=0.796 ) , and a significant interaction effect was found as well ( F=4.369 , d.f.=2 , P=0.015 , Partial eta(2)=0.070 ; F=5.859 , d.f.=1.822 , P=0.005 , Partial eta(2)=0.092 ) . However , no significant difference between groups was present ( F=2.343 , d.f.=1 , P=0.131 , Partial eta(2)=0.039 ; F=3.738 , d.f.=1 , P=0.058 , Partial eta(2)=0.061 ) . Significant differences between groups were found in MAP and HR ( P<0.05 ) and over time ( P<0.05 ) , but no significant effects in RR were apparent ( P>0.05 ) . A significant interaction effect was found in HR ( P<0.05 ) , but not in MAP or RR ( P>0.05 ) . CONCLUSIONS This study demonstrates that listening to music while receiving acupuncture can relieve anxiety among children with cerebral palsy ; however , no effect was observed in terms of pain reduction . Further research is needed to explore the types of music which best impact an individual 's treatment . Whether music results in fewer accidents and side effects of acupuncture should be investigated . Music can be considered as adjunctive therapy in clinical situations that may be anxiety-provoking for children OBJECTIVES : Tonsillectomy , with or without adenoidectomy , is one of the most common surgical procedures in pediatric otolaryngology . Pain is the main cause of morbidity in the postoperative period , where it is serious in some cases , leading to odynophagia and result ant complications such as dehydration . We evaluated the effect of topical clindamycin in the reduction of oropharyngeal pain in children who underwent adenotonsillectomy .  Secondary outcomes were otalgia , analgesic use , oral bacterial count , type of diet , secondary bleeding , vomiting , fever , and weight loss . STUDY DESIGN : Double-blind , r and omized clinical trial . SETTING : Tertiary hospital . SUBJECTS AND METHODS : Eighty-two children of both sexes between four and 12 years of age who underwent adenotonsillectomy were allocated to receive topical clindamycin or placebo in the immediate preoperative , intraoperative , and eight-to12-hours postoperative periods . Pain was measured using a faces pain scale for five days . RESULTS : Reduction of oropharyngeal pain was significant with the use of clindamycin only on the first postoperative day ( 95 % confidence interval , 2.22 to 4.41 [ clindamycin ] vs 4.53 to 6.3 [ placebo ] ; P = .002 ) . No difference was observed in the aerobic and anaerobic counts by tongue swab between premedication and third-postoperative-day samplings . There were no differences with respect to reduction in otalgia , paracetamol use , return to normal diet , variation in weight , secondary hemorrhage , vomiting , and fever . CONCLUSION : The use of topical clindamycin was beneficial in reducing pain on the first postoperative day , without effect on subsequent days . Future investigations could examine the use of topical clindamycin not only in the first 12 hours but also during five days of follow-up Background : A r and omized , double-blinded trial was performed to evaluate the efficacy and safety of the S-Caine Patch ™ ( ZARS , Inc. , Salt Lake City , UT ) , a eutectic mixture of lidocaine and tetracaine , for pain relief during venipuncture in children . Methods : With institutional review board approval , parental consent , and patient assent , 64 children who were scheduled for medically indicated vascular access at two centers were r and omly assigned ( 2:1 ) to receive either an S-Caine Patch ™ or a placebo patch for 20 min before venipuncture procedures . The primary outcome measure was the child ’s rating of pain during venipuncture using the Oucher pain scale . Additional measures of efficacy included the blinded investigator ’s and an independent observer ’s four-point categorical scores . Variables were compared between treatments using Mantel – Haenszel summary chi-square tests or Pearson chi-square tests . Results : The S-Caine Patch ™ produced significantly greater pain relief compared with placebo ( median Oucher scores of 0 vs. 60 ; P < 0.001 ) . Fifty-nine percent of the children in the S-Caine Patch ™ group reported no pain compared with 20 % of the children in the placebo patch group . The investigator estimated that 76 % of the children in the S-Caine Patch ™ group experienced no pain during venipuncture versus 20 % in the placebo patch group ( P = 0.001 ) . Independent observer ratings also favored the S-Caine Patch ™ ( P < 0.001 ) . Mild skin erythema ( < 38 % ) and edema ( < 2 % ) occurred with similar frequencies between the groups . Conclusion : This study demonstrated that a 20-min application of the S-Caine Patch ™ is effective in lessening pain associated with venipuncture procedures . Adverse events after S-Caine Patch ™ application were mild and transient BACKGROUND EGD is essential to the investigation and treatment of GI disorders in children . Although safe , EGD has the potential for complications , in particular cardiopulmonary abnormalities associated with intravenous sedation . EGD is often performed in adults without sedation . Unse date d EGD is occasionally performed in children but has not been subjected to study . This study assessed the safety , efficacy , and feasibility of unse date d EGD in children . METHODS Selected , highly motivated children requiring EGD were offered the choice of sedation or no sedation for the procedure . Children recorded scores for pain ( face scale ) and anxiety ( vertical visual analogue scale ) before and after EGD . In addition , the times required to prepare the patient , perform the EGD , and recover the patient were recorded . RESULTS There was no difference in age , gender , or pre-EGD pain scores between children selecting sedation or no sedation . However , children selecting sedation had significantly higher pre-EGD anxiety scores than those who chose no sedation . Successful completion of EGD was similar for se date d ( 96.3 % ) and unse date d ( 95.2 % ) children . Post-EGD scores for anxiety were significantly decreased in those receiving sedation and unchanged in children who received no sedation . There was no significant change in post-EGD pain score in either group . Nearly 80 % of children undergoing unse date d EGD would elect to forego sedation if EGD was needed again . Total procedure time was significantly longer in se date d versus unse date d children , reflecting longer preparation and recovery . CONCLUSIONS Unse date d EGD can be performed safely and successfully in children with good patient tolerance . There was a significant decrease in total procedure time for children who have unse date d EGD . Unse date d EGD should be considered a viable option for motivated children OBJECTIVE Visual analog pain scales are reliable measures in older children and adults ; however , pain studies that include young children often rely on parental or practitioner assessment s for measuring pain severity . The authors correlated patient , parental , and practitioner pain assessment s for young children with acute pain . METHODS This was a prospect i ve , descriptive study of a convenience sample of 63 emergency department patients aged 4 - 7 years , with acute pain result ing from acute illness or painful invasive procedures . A trained research assistant administered a structured pain survey containing demographic and historical features to all parents/guardians . Children assessed their pain severity using a vali date d ordinal scale that uses five different faces with varying degrees of frowning ( severe pain ) or smiling ( no pain ) . Each face was converted to a numeric value from 0 ( no pain ) to 4 ( severe pain ) . Parents and practitioners independently assessed their child 's pain using a vali date d 100-mm visual analog scale ( VAS ) marked " most pain " at the high end . Pairwise correlations between child , parent , and practitioner pain assessment s were performed using Spearman 's or Pearson 's test as appropriate . The association between categorical data was assessed using chi(2 ) tests . RESULTS Sixty-three children ranging in age from 4 to 7 were included . Mean age ( + /-SD ) was 5.7 ( + /-1.1 ) ; 42 % were female . Fifty-seven successfully completed the face scale . The distribution of the children 's scores was 0 - 17 % , 1 - 9 % , 2 - 30 % , 3 - 14 % , and 4 - 30 % . Mean parental and practitioner scores ( + /-SD ) on the VAS were 61 ( + /-26 ) mm and 37 ( + /-26 ) mm , respectively ( maximal = 100 mm ) . Correlation between child and parent scores was 0.47 ( p < 0.001 ) . Correlation between child and practitioner scores was 0.08 ( p = 0.54 ) . Correlation between parent and practitioner scores was 0.04 ( p = 0.001 ) . CONCLUSIONS There is poor agreement between pain ratings by children , parents , and practitioners . It is unclear which assessment best approximates the true degree of pain the child is experiencing OBJECTIVE . The Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial was a r and omized , single-dose , double-blind , phase 3 study investigating whether a needle-free powder lidocaine delivery system ( a sterile , prefilled , disposable system that delivers lidocaine powder into the epidermis ) produces effective local analgesia within 1 to 3 minutes for venipuncture and peripheral venous cannulation procedures in children . METHODS . Pediatric patients ( 3–18 years of age ) were r and omly assigned to treatment with the needle-free powder lidocaine delivery system ( 0.5 mg of lidocaine and 21 ± 1 bar of pressure ; n = 292 ) or a sham placebo system ( n = 287 ) at the antecubital fossa or the back of the h and 1 to 3 minutes before venipuncture or cannulation . All patients rated the administration comfort of the needle-free systems and the pain of the subsequent venous access procedures with the Wong-Baker Faces Pain Rating Scale ( from 0 to 5 ) . Patients 8 to 18 years of age also provided self-reports with a visual analog scale , and parents provided observational visual analog scale scores for their child 's venous access pain . Safety also was assessed . RESULTS . Immediately after administration , mean Wong-Baker Faces scale scores were 0.54 and 0.24 in the active system and sham placebo system groups , respectively . After venipuncture or cannulation , mean Wong-Baker Faces scale scores were 1.77 ± 0.09 and 2.10 ± 0.09 and mean visual analog scale scores were 22.62 ± 1.80 mm and 31.97 ± 1.82 mm in the active system and sham placebo system groups , respectively . Parents ' assessment s of their child 's procedural pain were also lower in the active system group ( 21.35 ± 1.43 vs 28.67 ± 1.66 ) . Treatment-related adverse events were generally mild and resolved without sequelae . Erythema and petechiae were more frequent in the active system group . CONCLUSIONS . The needle-free powder lidocaine delivery system was well tolerated and produced significant analgesia within 1 to 3 minutes BACKGROUND Differences in pain response to two different M-M-R products have previously been demonstrated in 12-month old infants and in 4 â 6 year old children . Objective To determine if the acute and immediate pain response to two licensed M-M-R vaccine products ( using a self-report measure ) in children 4 - 6 years of age was similar to that demonstrated in younger infants . METHODS R and omized , double blind , study . Subjects were r and omly allocated to PriorixA ( SmithKline Beecham ) or M-M-R IIA ( Merck Frosst ) . The primary outcome measure was pain response to vaccination quantified using a self-report OUCHER pain scale . Secondary outcome measures included pain measurement by proxy ( physician and parent ) using a visual analog scale ( VAS ) and measurement of cry and cry duration immediately post-vaccination . RESULTS Of the 60 subjects enrolled , 30 received PriorixA and 30 received M-M-R IIA . There were no significant differences between the two groups on age , sex , or previous painful procedure . Post-vaccination , children in the M-M-R IIA group had higher median pain scores compared with children in the PriorixA group for VAS ( 12.5 vs. 2.0 , respectively by paediatricians , p=0.017 ; 18.5 vs. 5.0 , respectively by parents , p=0.235 ) , OUCHER ( 20 vs. 0.00 , respectively , p=0.047 ) . The median duration of crying post M-M-R IIA was higher compared with PriorixA ( 6 vs. 0 seconds , respectively , p=0.020 ) . Conclusion PriorixA was associated with significantly less pain compared with M-M-R IIA , at the time of injection STUDY OBJECTIVE In children , the agreement between the many scales used to document the intensity of pain is not well known . Thus , to determine the agreement , we evaluate the visual analog scale , the st and ardized color analog scale , the Wong-Baker FACES Pain Rating Scale , and a verbal numeric scale in children with acute abdominal pain suggestive of appendicitis in a pediatric emergency department ( ED ) . METHODS Participants were children who were aged 8 to 18 years , presented to a pediatric ED with abdominal pain suggestive of appendicitis , and were recruited to participate in a r and omized controlled trial evaluating the efficacy of morphine . Patients were initially asked to grade their pain on a plasticized color analog scale , a paper visual analog scale , a paper Wong-Baker FACES Pain Rating Scale , and then with a verbal numeric scale . Thirty minutes after morphine or placebo administration , the assessment was repeated . All scores were then converted to a value of 0 to 100 . Agreements between scores were evaluated with the Bl and -Altman method , and the 95 % lower and upper limits were reported . We defined a priori the maximum limit of agreement at + /-20 mm . RESULTS A total of 87 children were included in the study , 58 of them with confirmed appendicitis . The 95 % limits of agreement for each pair of scales were visual analog scale/color analog scale -18.6 , 14.4 ; visual analog scale/Wong-Baker FACES Pain Rating Scale -20.1 , 33.7 ; visual analog scale/verbal numeric scale -30.2 , 20.7 ; color analog scale/Wong-Baker FACES Pain Rating Scale -18.5 , 36.3 ; color analog scale/verbal numeric scale -26.9 , 22.1 ; and Wong-Baker FACES Pain Rating Scale/verbal numeric scale -38.7 , 15.7 . CONCLUSION Our study suggests that only the visual analog scale and the color analog scale have acceptable agreement in children with moderate to severe acute abdominal pain . In particular , the verbal numeric scale is not in agreement with the other evaluated scales Objective : To investigate the efficacy of nasal sumatriptan in migraine attacks of children and adolescents . Methods : A double-blind , placebo-controlled , two-way crossover trial was conducted in three hospital outpatient departments , with 8 to 17 year olds diagnosed with migraine serving as subjects ( International Headache Society 1988 ) . A single dose of sumatriptan nasal spray and a matching placebo were administered at home during two attacks . The sumatriptan dose was 10 mg for a body weight of 20 to 39 kg and 20 mg for those with a body weight of ≥40 kg . The primary efficacy endpoint was headache relief by two grade s on a 5- grade face scale at 2 hours . Results : Eighty-three patients used both treatments and 11 only the first . At 2 hours , the primary endpoint was reached nearly twice as often after sumatriptan ( n = 53/83 ; 64 % ) as after placebo ( n = 32/83 ; 39 % ) ( p = 0.003 ) . Already at 1 hour , headache relief was seen more often after sumatriptan ( n = 42/83 ; 51 % ) than after placebo ( n = 24/83 ; 29 % ) ( p = 0.014 ) . The difference was even more obvious in patients who received the 20-mg dose as well as in the intention-to-treat analyses ( n = 94 ) . Other endpoints , including child ’s preference and using rescue medication , also favored sumatriptan . The most common adverse effect was a bad taste  after sumatriptan , reported in 29 % ( n = 26/90 ) of the attacks . No serious adverse effects were observed . Conclusion : Nasal sumatriptan is an effective and well-tolerated treatment for migraine attacks in children over 8 years of age BACKGROUND We have compared ropivacaine with bupivacaine and lidocaine for ilioinguinal block in thirty children undergoing ambulatory inguinal hernia repair . METHODS Patients were assigned r and omly to receive 0.5 ml.kg(-1 ) of 0.2 % ropivacaine ( Group R , n = 10 ) , 0.25 % bupivacaine ( Group B , n = 10 ) or 1 % lidocaine ( Group L , n = 10 ) . The patients ' parents , who were not informed of the type of local anaesthetic employed , evaluated the postoperative pain at 2 h and 6 h after operation using the Wong-Baker FACES Pain Rating Scale . RESULTS There was a significant difference in the face scale score between Group R and Group L , and Group B and Group L. There was no difference in the face scale score between Group R and Group B. There were no complications or clinical evidence of local anaesthetic toxicity . CONCLUSIONS We have confirmed that bupivacaine and ropivacaine are more effective than lidocaine in the prevention of postoperative pain after children 's inguinal hernia repair . We suggest that ropivacaine 0.2 % is an alternative to bupivacaine 0.25 % for ilioinguinal block in ambulatory paediatric surgery OBJECTIVE : To compare the postoperative recovery of patients receiving Coblation-assisted ( Arthrocare , Sunnyvale , CA ) intracapsular tonsillectomy  with that of patients receiving traditional subcapsular electrocautery tonsillectomy .  STUDY DESIGN AND SETTING : This was a prospect i ve , r and omized , double-blinded , controlled study . One hundred one children , aged 2 to 16 years , were r and omized to Coblation or to conventional electrocautery tonsillectomy .  Only patients with the operative indication of obstructive sleep apnea were entered into the study .  Intracapsular tonsillectomy was performed on the Coblation group , and traditional subcapsular dissection was performed on the electrocautery group . Adenoidectomy was performed with the curette in both groups . Outcome measures were assessed on days 1 , 3 , and 5 after surgery . These included child and parental rating of pain by using the Wong Faces pain scale , analgesic use , oral intake , and activity level . Patients , parents , and the nurse practitioner obtaining the outcome data were blinded to treatment arm . RESULTS : Treatment groups were similar in age , gender , and weight . Surgical time and estimated blood loss were similar . There were no complications in either group . Coblation patients had less pain and greater oral intake at all 3 time points . Percentage of normal activity level returned to > 70 % earlier and more frequently in Coblation patients . There was slightly decreased analgesic use on postoperative day 5 in the Coblation group . CONCLUSIONS AND SIGNIFICANCE : Children with obstructive sleep apnea undergoing tonsillectomy and adenoidectomy demonstrate significantly better postoperative recovery after Coblation-assisted intracapsular tonsillectomy PURPOSE This research compared the effect of two forms of distraction on injection pain in a convenience sample of preschool children . DESIGN A quasi-experimental study of 105 children ( 53 girls and 52 boys ) ages 4 to 6 years needing DPT immunizations . Data were collected at three sites : two school-based immunization clinics and one public health center with a walk-in immunization program . METHODS Study children were r and omly assigned to receive one of three treatments with their DTP injection : touch , bubble-blowing , or st and ard care . Prior to injection , a measure of medical fear was obtained ( Child Medical Fear Scale ) and pain was measured through use of the Oucher Scale . DATA ANALYSIS Planned comparisons within analysis of variance ( ANOVA ) tested the differences in pain scores by treatment . Factorial ANOVA was used to determine the influence of age or gender on treatment , and the effect of medical fear on pain was analyzed using correlational statistics and factorial ANOVA . RESULTS Both forms of distraction , touch and bubble-blowing , significantly reduced pain perception . There were no interaction effects of either age or gender . Fear was a significant covariate , but distraction was effective even when fear was not held constant . CLINICAL IMPLICATION S Distraction appears to be an effective method for decreasing injection pain in young children . It is an easy , practical nursing intervention to help children cope with this common , painful experience OBJECTIVES /HYPOTHESIS Pain is a major cause of morbidity after  tonsillectomy .  Although various efforts have been made to reduce pain , the use of oral analgesics , which can have adverse side effects , remains the st and ard of care . It is hypothesized that fibrin sealant , used to achieve hemostasis and enhance healing in many surgical procedures , might help decrease pain after this operation . STUDY DESIGN A prospect i ve , r and omized , blinded study was performed on 20 children aged 5 to 17 years who were undergoing tonsillectomy  , to evaluate the efficacy of FIBRIN SEALANT in reducing postoperative pain . METHODS All patients pre-donated 40 mL of blood from which autologous concentrated fibrinogen was prepared by cryoprecipitation . In the fibrin sealant group , fibrinogen and topical bovine thrombin were sprayed onto the surgical site to form fibrin sealant at the conclusion of tonsillectomy . The 10 patients in the control group ( C ) received no fibrin sealant . Patients rated their level of pain immediately after surgery and at regular intervals for 3 days after surgery using the Wong-Baker Faces Pain Rating Scale ( 1 - 6 ) . Emesis , postoperative bleeding , medications , and adverse events were also evaluated . RESULTS At 7.00 P.M. on postoperative day ( POD ) 0 , the mean + /- SD fibrin sealant group pain score ( 2.9+/-0.41 units ) was significantly lower than for the C group ( 4.1+/-0.43 units ; P < or = .05 ) . There was also a trend in favor of less pain in the fibrin sealant group at 7:00 P.M. on POD 1 , with a mean of 3.5+/-0.43 units versus 2.4+/-0.48 units for C ( P = .15 ) . The odds of a patient in C experiencing emesis were 8.16 times higher , ( P < or = .05 ) than for patients in the fibrin sealant group . CONCLUSIONS Fibrin sealant significantly reduced pain the evening after pediatric tonsillectomy and also decreased the chance of experiencing emesis . Thus fibrin sealant may be clinical ly useful as an adjunct to tonsillectomy OBJECTIVE To determine the analgesic effect and tolerability of a novel needle-free powder lidocaine delivery system in children undergoing venipuncture . STUDY DESIGN In this double-blind , placebo-controlled , single-center trial , 306 children age 3 to 18 years were r and omized to receive a needle-free powder lidocaine delivery system or matching sham placebo at the back of the h and 2 to 3 minutes before venipuncture . Venipuncture pain was self-reported using the Wong-Baker FACES scale ( in 3- to 12-year-olds ) and a 100-mm visual analog scale ( in 8- to 18-year-olds ) . Safety was assessed by adverse events , investigator skin site assessment s , and children 's self-report of the administration comfort of study treatments . Effect sizes were compared by 2- sample t test and Glass 's Delta approach . RESULTS Subjects receiving the needle-free powder lidocaine delivery system exhibited mean pain reductions ( effect size ) of 33 % to 46 % relative to sham placebo .  Pain reductions were statistically significant for all ages combined and also for the youngest and oldest age strata . Self-reported administration comfort levels were similar in the active system and sham placebo groups . Incidences of adverse events and dermal reactions were low ; the most common dermal reaction was mild erythema . CONCLUSIONS The needle-free powder lidocaine delivery system was well tolerated and provided effective local analgesia when administered 2 to 3 minutes before venipuncture Objective The objectives of this study were to use a self-report pain scale to examine child pain treatment thresholds after major surgery  ( i.e. , the level of pain they are comfortable with before requiring analgesia ) , as well as to examine agreement between mother- , nurse- , and child-rated pain treatment thresholds . Methods Twenty-five children aged 6 to 16 years were interviewed for 3 consecutive days after major surgery .  Subjects used the  Faces Pain Scale  to rate their current pain , worst postoperative pain , and pain level at which  they would like to receive analgesia ( the pain treatment threshold ) . Parents and nurses also estimated the  child pain treatment thresholds . Results For day 1 , mean pain was 1.86 of a maximum of 6 , mean worst pain was 4.16 , and mean pain treatment threshold was 2.28 . For day 2 , these values were 1.90 , 4.10 , and 2.54 , and for day 3 they were 1.62 , 4.56 , and 1.85 , respectively . Mean scores for all 3 days were as follows : pain , 1.79 ; worst pain , 4.15 ; and pain treatment threshold , 2.33 . Although mother – nurse ratings were correlated ( 0.471 ) , mother – child and nurse – child ratings were not significantly correlated . Using the pain treatment threshold as the criterion , 36 % of our subjects were undermedicated after the first day of surgery . Conclusion Pain treatment thresholds seem to be lower in children after major as compared with minor surgery . Parents and nurses are not accurate in rating child pain treatment thresholds . Parents tended to overestimate their child 's pain treatment threshold , whereas nurses were less consistent in their scoring The psychometric characteristics of the  Faces Pain Scale ( FPS )  were evaluated in three groups of preschool and school-aged children ( 3 . 5 - 4.5 ; 4.5 - 5.5 and 5.5 - 6.5 years , respectively ) . The FPS was adequately comprehended by even young children . It was easily administered and was valid and discriminating . It did not , however , possess the linear scalability cl aim ed by its authors The purpose of this study was to determine the adequacy of the alternate forms reliability of three versions of the Oucher pain scale . Because the original large-sized posters were unwieldy for use by nurses with children in clinical setting s , it became necessary to reduce it in size . To determine whether the result ing tools were psychometrically equivalent to the original versions of the Oucher , this study was undertaken . In a group of 3- to 12-year-old children who underwent surgical or dental procedures ( n = 137 ) , scores were obtained after the procedure on small and large versions of the Oucher . The order of presentation of the two different Ouchers was r and omized . Findings revealed that correlation coefficients between the scores provided for the small and large versions of the Oucher were strong , positive , and significant for the Caucasian , African-American , and Hispanic versions in 3- to 12-year-old children . These results provided evidence of the adequacy of the alternate forms reliability of these scales Objectives : To compare patient , guardian and professional assessment of acute pain in children presenting to an Emergency Department , and to examine whether there was a correlation between the scores obtained using the Faces and linear scales for each group . Methods : A prospect i ve , observational cohort study of 73 children aged 4–14 years attending a paediatric hospital Emergency Department between March and April 2002 with pain caused by an acute injury . The child 's pain on admission , as estimated by the child , their guardian and a healthcare professional ( nurse/doctor/emergency nurse practitioner ) was recorded using a Faces scale and a linear scale . Results : Professionals consistently score pain lower [ median linear scale score 3.1 ; interquartile range ( IQR ) 1.6–5.3 ] than do patients ( 6.6 ; 4.9–7.4 ) or guardians ( 6.0 ; 3.9–7.1 ) using both linear and Faces scales . There is a significant correlation between pain scores obtained using the two scales for professionals [ Spearman R value 0.88 ; 95 % confidence interval ( CI ) 0.82–0.93 ] , guardians ( 0.83 ; 0.74–0.89 ) and patients ( 0.42 ; 0.21–0.59 ) . Conclusion : Professionals score pain lower than do children or guardians . Similar pain scores are obtained using both a Faces and a linear scale . This study offers no support for the introduction of a uniform pain assessment tool in a paediatric Emergency Department setting & NA ; Altogether 553 children ( 195 first grade rs , mean age 6.8 years , and 358 third grade rs , mean age 8.7 years ) participated in the development of a self‐report measure to assess the intensity of children 's pain .  The first step was the derivation , from children 's drawings of facial expressions of pain , of 5 sets of 7 schematic faces depicting changes in severity of expressed pain from no pain to the most pain possible . With the set of faces that achieved the highest agreement in pain ordering , additional studies were conducted to determine whether the set had the properties of a scale . In one study , children rank‐ordered the faces on 2 occasions , separated by 1 week . All 7 faces were correctly ranked by 64 % ( retest 1 week later , 61 % ) of grade 1 children and by 86 % ( retest 89 % ) of grade 3 children . In a second study , the faces were presented in all possible paired combinations . All 7 faces were correctly placed by 62 % ( retest 86 % ) of the younger and by 75 % ( retest 71 % ) of the older subjects . A third study asked children to place faces along scale : a procedure allowing a check on the e quality of intervals . The fourth study checked on whether pain was acting as an underlying construct for ordering the faces in memory . We asked whether children perceived the set as a scale by asking if memory for an ordered set of faces was more accurate than for a r and om set . The final study checked , with 6‐year‐old children , the test‐retest reliability of ratings for recalled experiences of pain . Overall , the faces pain scale incorporates conventions used by children , has achieved strong agreement in the rank ordering of pain , has indications that the intervals are close to equal , and is treated by children as a scale . The test‐retest data suggest that it may prove to be a reliable index over time of self‐reported pain OBJECTIVE The aim of the study was to determine the efficacy of ShotBlocker ( Bionix , Toledo , Ohio ) in reducing  pediatric pain with intramuscular ( IM ) injections .  METHODS A prospect i ve r and omized controlled trial was conducted in children aged 2 months to 17 years who required an IM injection . Children were r and omized to the no-intervention group or the ShotBlocker group . Demographic data and the number of IM injections were recorded . Perceived pain scores were obtained from nurses and caregivers using a 6-point Likert-type scale . Baker Wong Faces scale was used in children 36 months or older .  Difficulty using the device was also rated by nurses on a 6-point scale . RESULTS One hundred sixty-five children were enrolled with 80 in the no-intervention arm and 85 in the ShotBlocker arm . The mean age of children was 45 months and 56 % were male .  Perceived pain scores by nurses were higher for the no-intervention group ( 2.6 vs 1.8 , P < .001 ) as well as by caregivers ( 2.6 vs 2.1 , P = .04 ) . Children aged 36 months and older ( n = 64 ) did not report a difference in pain scores ( 1.5 vs 1.3 , P = .6 ) ; however , in a subgroup of children 72 months or older , pain scores trended higher in the no-intervention group ( 1.3 vs 0.5 , P = .051 ) . Nurse-perceived difficulty of ShotBlocker use was low 1.39 ( + /-1.1 ) . CONCLUSIONS Nurses and caregivers noted lower pain scores in children assigned to the ShotBlocker group . These differences were not as evident when children rated their own pain OBJECTIVES To determine whether the implementation of at-home psychological preparation programme for children and family prior to surgery can reduce anxiety for Japanese preschool children undergoing herniorrhaphy and their caregivers assessed as an appropriate outpatient care . METHODS Patients were r and omly assigned to either of two groups : the usual care group or the at-home preparation group . Both two groups viewed a patient-educational video for herniorrhaphy once as out patients with other patients prior to hospitalization . The control group later underwent surgery without any further preparation . The experimental group watched the same educational video at home again with an auxiliary booklet prior to hospitalization . Children 's anxiety was measured by the Wong-Baker FACES Rating Scale ( FACES Rating Scale ) , while caregivers ' anxiety was measured by the Spielberger 's State Trait Anxiety Inventory ( STAI ) . Both outcomes were measured repeatedly from pre-intervention to 1 month after surgery . RESULTS Of the eligible 161 patients participating , 158 ( 98.1 % ) were r and omly assigned to the control group ( n = 81 ) and the experimental group ( n = 77 ) , and 144 ( 89.4 % ) completed the study . The experimental group gained more information and knowledge about surgery from parents and showed significantly lower scores than the controls for FACES and STAI . CONCLUSION A specially design ed at-home preparation programme as an outpatient care is effective to encourage parent-child verbal interaction concerning surgery and reduce both children and caregivers ' anxiety associated with surgery OBJECTIVES /HYPOTHESIS To determine if placement of autologous platelet-rich plasma ( PRP ) on the tonsil beds at the time of tonsillectomy would decrease postoperative pain and complications . STUDY DESIGN Double blind , r and omized , prospect i ve study . METHODS Seventy children were recruited to participate in the study , ranging in age from 4 to 15 years . They were r and omized to treatment ( PRP ) or control groups . The parents , patients , and nurses were blinded as to which group they were in . Postoperative pain scores were obtained using the FACES pain scale and recorded in a home diary . RESULTS Seventy patients were recruited to the study , and 12 did not su bmi t their diaries and were considered to drop out of the study . Demographic data were similar for both control and treatment groups . Median pain scores , medication use , days to normal diet , and office visits did not differ between the two groups . CONCLUSIONS PRP applied once at the time of tonsillectomy does not improve postoperative pain or recovery in pediatric patients
target: All 4 faces pain scales were found to be adequately supported by psychometric data .
  When given a choice between faces scales , children preferred the WBFPRS .
  Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS .
  : For clinical use , we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use .
background: CONTEXT : Numerous faces scales have been developed for the measurement of  pain intensity in children .
  It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity , reliability , feasibility , and preference .
  OBJECTIVES : To summarize and systematic ally review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility .