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Acute bronchiolitis due to respiratory syncytial virus (RSV) can present with extrapulmonary manifestations, notably severe hyponatremia. Hyponatremia is caused by excess secretion of antidiuretic hormone and can be exacerbated by intravenous infusion of hypotonic solutions. We report three cases of infants admitted for acute bronchiolitis and hyponatremia leading to acute seizures. We describe how hyponatremia was corrected and analyze the management aspects that might have worsened the magnitude of hyponatremia. We underline the basic principles of water and electrolyte management of bronchiolitis., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Aim: The most common manifestation of sickle cell disease (SCD) is painful vaso-occlusive episodes (PVOE), and inappropriate treatment leads to unnecessary suffering and potentially fatal complications. This study describes how French paediatric emergency departments (EDs) manage PVOE and their knowledge, and implementation of the French National Authority for Health recommendations on the management of sickle cell patients., Methods: A questionnaire on managing PVOE was sent to all the 111 French paediatric EDs., Results: We received responses from 81 (72.9%) of the EDs. Of those who responded to each individual question, 85% said that they had read the national recommendations, 71.6% said they used nalbuphine for moderate PVOE, and 85% used intravenous morphine for severe PVOE. The majority (91.7%) of EDs thought that intravenous morphine provided relief for severe PVOE, but only 30.9% thought that intravenous nalbuphine did. A 50:50 nitrous oxide/oxygen mix was used by 71.3% of departments to relieve procedural pain and by 48% to enhance analgesia when morphine was insufficient for severe pain., Conclusions: Most French EDs follow the national recommendations for PVOE. Nalbuphine was the most commonly used opioid for moderate PVOE and morphine for severe PVOE. A nitrous oxide/oxygen mixture was widely used for PVOE., (©2014 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Introduction: Boldo is an extract of a Chilean tree leave (Peumus boldus mol) that have been traditionally employed in folk medicine. We have presented a case of subtherapeutic tacrolimus levels in a renal transplant patient while taking boldo. In the literature search, no interaction has been reported between boldo and tacrolimus., Case Report: A 78-year-old Hispanic man with history of diabetes mellitus, hypertension, and deceased donor renal transplant in 2005 presented to the renal clinic for regular follow-up on September 1, 2010. No complaints were reported and physical examination was unremarkable. Laboratory tests taken on July 26, 2010, were significant for tacrolimus level of <3 ng/mL (measured by liquid chromatography/tandem mass spectrometry) and serum creatinine of 1.2 mg/dL (106 μmol/L). Medications included tacrolimus 2 mg bid and mycophenolate 500 mg bid. On further inquiry, the patient admitted taking herbal medication, boldo 300 mg bid, for the last few weeks. There was no change in his regular medications. He was adherent to his medication. He had been taking tacrolimus from the same company and pharmacy since August 2009. The last dose of boldo was on September 1, 2010. One week after he stopped taking boldo, tacrolimus level was 6.1 ng/mL (9/8/2010) on the same tacrolimus dose of 2 mg bid. Tacrolimus dose was increased to 3 mg bid (9/9/2010), awaiting tacrolimus levels. Subsequent levels (ng/mL) were 8.6 and 9.5, which made us resume the prior tacrolimus dose (2 mg bid)., Conclusions: We have reported a case of an allograft renal transplant recipient who presented to the clinic with subtherapeutic levels of tacrolimus while taking the herbal remedy boldo. Tacrolimus levels rose to the intended target after discontinuation of boldo. Although it is a single case report, our observation suggests a possible herb-drug interaction., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Premedication before neonatal intubation is heterogeneous and contentious. The combination of a short acting, rapid onset opioid with a muscle relaxant is considered suitable by many experts. The purpose of this study was to describe the tolerance and conditions of intubation following anaesthesia with atropine, sufentanil and atracurium in very premature infants., Methods: Monocentric, prospective observational study in premature infants born before 32 weeks of gestational age, hospitalised in the NICU and requiring semi-urgent or elective intubation. Intubation conditions, heart rate, pulse oxymetry (SpO2), arterial blood pressure and transcutaneous PCO2 (TcPCO2) were collected in real time during 30 minutes following the first drug injection. Repeated physiological measurements were analysed using mixed linear models., Results: Thirty five intubations were performed in 24 infants with a median post conceptional age of 27.6 weeks and a median weight of 850 g at the time of intubation. The first attempt was successful in 74% and was similar for junior (75%) and senior (74%) operators. The operator rated conditions as "excellent" or "good" in 94% of intubations. A persistent increase in TcPCO2 as compared to baseline was observed whereas other vital parameters showed no significant variations 5, 10, 15 and 30 minutes after the first drug injection. Eighteen (51%) desaturations (SpO2 less than or equal to 80% for more than 60 seconds) and 2 (6%) bradycardia (heart rate less than 100 bpm for more than 60 seconds) were observed., Conclusion: This drug combination offers satisfactory success rate for first attempt and intubation conditions for the operator without any significant change in heart rate and blood pressure for the patient. However it is associated with frequent desaturations and a possible persistent hypercapnia. SpO2 and PCO2 can be significantly modified during neonatal intubation and should be cautiously followed in this high-risk population.

Objective: To determine whether analgesic use for painful procedures performed in neonates in the neonatal intensive care unit (NICU) differs during nights and days and during each of the 6 h period of the day., Design: Conducted as part of the prospective observational Epidemiology of Painful Procedures in Neonates study which was designed to collect in real time and around-the-clock bedside data on all painful or stressful procedures., Setting: 13 NICUs and paediatric intensive care units in the Paris Region, France., Participants: All 430 neonates admitted to the participating units during a 6-week period between September 2005 and January 2006., Data Collection: During the first 14 days of admission, data were collected on all painful procedures and analgesic therapy. The five most frequent procedures representing 38 012 of all 42 413 (90%) painful procedures were analysed., Intervention: Observational study., Main Outcome Assessment: We compared the use of specific analgesic for procedures performed during each of the 6 h period of a day: morning (7:00 to 12:59), afternoon, early night and late night and during daytime (morning+afternoon) and night-time (early night+late night)., Results: 7724 of 38 012 (20.3%) painful procedures were carried out with a specific analgesic treatment. For morning, afternoon, early night and late night, respectively, the use of analgesic was 25.8%, 18.9%, 18.3% and 18%. The relative reduction of analgesia was 18.3%, p<0.01, between daytime and night-time and 28.8%, p<0.001, between morning and the rest of the day. Parental presence, nurses on 8 h shifts and written protocols for analgesia were associated with a decrease in this difference., Conclusions: The substantial differences in the use of analgesics around-the-clock may be questioned on quality of care grounds.

Suppurative parotidis is an uncommon disease in newborns, with limited information available on its pathogenesis and management: approximately 50 cases have been reported in the literature. Diagnosis is based on clinical signs. The predominant organism is Staphylococcus aureus. The administration of empiric antimicrobial therapy is an essential part of the management in very young patients. Prognosis is good and recurrence of the disease is unusual. We describe a 21-day-old newborn who presented with fever and unilateral swelling of the parotid region, and provide a literature review., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objectives: To describe the frequency and nature of premedications used prior to neonatal endotracheal intubation; to confront observed practice with current recommendations; and to identify risk factors for the absence of premedication., Design, Setting, and Patients: Data concerning intubations were collected prospectively at the bedside as part of an observational study collecting around-the-clock data on all painful or stressful procedures performed in neonates during the first 14 days of their admission to 13 tertiary care units in the region of Paris, France, between 2005 and 2006., Intervention: Observational study., Measurements and Main Results: Specific premedication prior to endotracheal intubation was assessed. Ninety one intubations carried out on the same number of patients were analyzed. The specific premedication rate was 56% and included mostly opioids (67%) and midazolam (53%). Compared with recent guidance from the American Academy of Pediatrics, used premedications could be classified as "preferred" (12%), "acceptable" (18%), "not recommended" (27%), and "not described" (43%). In univariate analysis, infants without a specific premedication compared with others were younger at the time of intubation (median age: 0.7 vs. 2.0 days), displayed significantly more frequent spontaneous breathing at the time of intubation (31% vs. 12%) and a higher percentage of analgesia for all other painful procedures (median values: 16% vs. 6%). In multivariate analysis, no factor remained statistically significant., Conclusions: Premedication use prior to neonatal intubation was not systematically used and when used it was most frequently inconsistent with recent recommendations. No patient- or center-related independent risk factor for the absence of premedication was identified in this study.

Importance: Infantile colic is a common cause of inconsolable crying during the first months of life and has been thought to be a pain syndrome. Migraine is a common cause of headache pain in childhood. Whether there is an association between these 2 types of pain in unknown., Objective: To investigate a possible association between infantile colic and migraines in childhood., Design, Setting, and Participants: A case-control study of 208 consecutive children aged 6 to 18 years presenting to the emergency department and diagnosed as having migraines in 3 European tertiary care hospitals between April 2012 and June 2012. The control group was composed of 471 children in the same age range who visited the emergency department of each participating center for minor trauma during the same period. A structured questionnaire identified personal history of infantile colic for case and control participants, confirmed by health booklets. A second study of 120 children diagnosed with tension-type headaches was done to test the specificity of the association., Main Outcomes and Measures: Difference in the prevalence of infantile colic between children with and without a diagnosis of migraine., Results: Children with migraine were more likely to have experienced infantile colic than those without migraine (72.6% vs 26.5%; odds ratio [OR], 6.61 [95% CI, 4.38-10.00]; P < .001), either migraine without aura (n = 142; 73.9% vs 26.5%; OR, 7.01 [95% CI, 4.43-11.09]; P < .001), or migraine with aura (n = 66; 69.7% vs 26.5%; OR, 5.73 [95% CI, 3.07-10.73]; P < .001). This association was not found for children with tension-type headache (35% vs 26.5%; OR, 1.46 [95% CI, 0.92-2.32]; P = .10)., Conclusion and Relevance: The presence of migraine in children and adolescents aged 6 to 18 years was associated with a history of infantile colic. Additional longitudinal studies are required.

During the 2011 measles outbreak in Paris (France), patients with clinical suspicion of measles were tested for virological confirmation of measles virus (MV) infection. To assess the practical value of molecular diagnosis in an epidemic setting, 171 oral fluid samples and 235 serum samples collected from 270 patients were tested prospectively for MV-RNA using a novel one-step real-time RT-PCR assay including an internal control. Serum samples were also tested for MV-specific IgG and IgM antibodies. MV infection was confirmed by detection of MV-RNA and/or MV-IgM for 229 of the 270 patients. The results for the 102 cases with both serum and oral fluid samples available were used to compare the techniques. The detection rate of MV-RNA by RT-PCR was 98% (100/102) for oral fluid and 95% (97/102) for serum samples. The detection rate of MV-IgM was 85% (87/102). Negative MV-IgM results were observed mostly for serum samples collected early after the onset of the rash. A MV-RNA standard of known concentration obtained by in vitro transcription was used to quantify MV-RNA in samples. MV-RNA copy numbers were significantly higher in oral fluid than in serum samples, but did not correlate with time of sampling (within 1 week after the onset of the rash), patient age, or vaccination status. During the early stage of infection, the MV-RNA viral load in serum was lower in patients positive than in those negative for MV-IgG. In conclusion, the one-step real-time RT-PCR assay is a simple and sensitive tool suitable for MV diagnosis within hours., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Despite the recommended guidelines, the neonatal management of pain and discomfort often remains inadequate. The purpose of the present study was to determine whether adding a pain and discomfort module to a computerized physician order entry (CPOE) system would improve pain and discomfort evaluation in premature newborns under invasive ventilation., Methods: All newborns <37 weeks gestational age (GA) and requiring invasive ventilation were included in a prospective study during two 6-month periods: before and after the inclusion of the pain and discomfort evaluation module. The main outcome measure was the percentage of patients having at least one assessment of pain and discomfort per day of invasive ventilation using the COMFORT scale., Results: A total of 122 patients were included: 53 before and 69 after the incorporation of the module. The mean age was 30 (3) weeks GA. After the module was included, the percentage of patients who benefited from at least one pain and discomfort assessment per day increased from 64% to 88% (p < 0.01), and the mean number (SD) of scores recorded per day increased from 1 (1) to 3 (1) (p < 0.01). When the score was not within the established range, the nursing staff adapted analgesia/sedation doses more frequently after module inclusion (53% vs. 34%, p < 0.001). Despite higher mean doses of midazolam after module introduction [47 (45) vs. 31 (18) μg/kg/hr, p < 0.05], the durations of invasive ventilation and hospital stay, and the number of nosocomial infections, were not significantly modified., Conclusions: Adding a pain and discomfort tool to the CPOE system was a simple and effective way to improve the systematic evaluation of premature newborns who required ventilatory assistance.

Numerous behavioral pain measures have been validated for young children, but none is appropriate to assess pain in emergency departments (EDs), where caregivers need a simple, easily completed scale. Our objective was to elaborate and validate a tool, relevant in any painful situation, with agitation or prostration, and for any age under 7 years. Five items (scored 0 to 3) were developed by pediatric pain and emergency caregivers. The new scale, called EVENDOL, was tested at children's arrival and after analgesics, at rest, and during mobilization. The validation study included 291 children from birth to 7 years old in 4 French EDs, and independent observations by the ED nurse and a researcher. The Cronbach coefficient was excellent (0.83 to 0.92). Construct validity was demonstrated by a decrease in scores after nalbuphine: 8.14 to 3.62 of 15 at rest (P<.0001), 11.87 to 6.65 at mobilization (P = .0011); by good correlations between EVENDOL and nurse or researcher numerical scores: 0.79 to 0.92 (P<.0001); by good correlations between children's self-assessment scores and EVENDOL in children ages 4 to 7 (0.64 to 0.93). Discriminant validity with tiredness, anxiety, and hunger was good. Interrater reliability was excellent between nurses and researcher (weighted kappa 0.7 to 0.9), and in a group of 6 nurses (simultaneous assessment of 122 videos). The treatment threshold was determined at 4 of 15. EVENDOL has excellent validity and can be used for all children under age 7 in EDs, for any age and any pain, acute as well as more prolonged., (Copyright © 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Enterocolitis is the most serious complication of Hirschsprung disease. Early management of these patients can decrease the severity of this complication. Hirschsprung disease is more common in patients with trisomy 21 than in the general population. Furthermore, the risk of developing enterocolitis is higher in this population. We report on an infant with trisomy 21 who developed enterocolitis as a complication of Hirschsprung disease that was diagnosed late when the infant presented with septic shock leading to death of the patient., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: A previous audit performed at a tertiary ⁄ quaternary pediatric hospital in Toronto, Ontario, demonstrated suboptimal assessment and treatment of children's pain. Knowledge translation (KT) initiatives (education, reminders, audit and feedback) were implemented to address identified care gaps; however, the impact is unknown., Objectives: To determine the impact of KT initiatives on pain outcomes including process outcomes (eg, pain assessment and management practices) and clinical outcomes (eg, pain prevalence and intensity); and to benchmark additional pain practices, particularly opioid administration and painful procedures., Methods: Medical records at The Hospital for Sick Children (Toronto, Ontario) were reviewed on a single day in September 2007. Pain assessment and management practices, and pain prevalence and intensity in the preceding 24 h were recorded on a standardized data collection form. Where possible, pain outcomes were compared with previous audit results., Results: Records of 265 inpatients were audited. Sixty-three per cent of children underwent a documented pain assessment compared with 27% in an audit conducted previously (P<0.01). Eighty-three per cent of children with documented pain received at least one pain management intervention. Overall, 51% of children received pharmacological therapy, and 15% received either a psychological or physical pain-relieving intervention. Of those assessed, 44% experienced pain in the previous 24 h versus 66% in the previous audit (P<0.01). Fewer children experienced severe pain compared with the first audit (8.7% versus 26.1%; P<0.01). One-third of children received opioids; 19% of these had no recorded pain assessment. Among 131 children who underwent a painful procedure, 21% had a concurrent pain assessment. Painful procedures were accompanied by a pain-relieving intervention in 12.5% of cases., Conclusions: Following KT initiatives, significant improvements in pain processes (pain assessment documentation and pain management interventions) and clinical outcomes (pain prevalence, pain intensity) were observed. Further improvements are recommended, specifically with respect to procedural pain practices and opioid utilization patterns.

Objective: The goal of this study was to compare the analgesic effect of sucrose with that of the combination of sucrose and the local anesthetic cream EMLA during venipuncture in preterm neonates., Methods: This randomized, double-blind prospective study included infants younger than 37 weeks' gestational age during 1 routine venipuncture for blood sampling. Each child randomly received either sucrose plus application of a placebo cream (S group) or sucrose plus EMLA cream (S+E group) before venipuncture. Venipuncture-induced pain was assessed through videotapes of the procedures by using the Douleur Aiguë Nouveau-né (DAN) behavioral scale. Pain was assessed at 2 phases: during venipuncture (from needle introduction to its removal) and during the recovery period (30 seconds after needle removal). Pain scores over time and between treatments were compared by using repeated-measures analysis of variance., Results: The study included 76 children (37 in the S group, 39 in the S+E group). Mean (SD) DAN pain scores for the S group and the S+E group were 7.7 (2.1) and 6.4 (2.5), respectively, during venipuncture and 7.1 (2.8) and 5.7 (3.3) during the postinjection period. A significant time and treatment effect in favor of the S+E group was observed., Conclusion: The combination of sucrose and EMLA cream revealed a higher analgesic effect than sucrose alone during venipuncture in these preterm infants., (Copyright © 2011 by the American Academy of Pediatrics.)

Objectives: To determine the incidence of and factors predicting management strategies used for procedural pain in Canadian neonatal intensive care units and to determine whether the incidence of procedures and their management has changed since our 1997 study., Patients: Five hundred eighty-two neonates who were hospitalized in any of the participating study centers were included., Methods: A prospective observational study was conducted in 14 Canadian neonatal intensive care units (level III A and III B). Infants were followed for 1 week regarding all invasive procedures. Data were collected prospectively by unit staff using a checklist and verified by research assistants., Results: A total of 3508 tissue damaging (mean=5.8, SD=15) and 14,085 (mean=25.6, SD=15) nontissue damaging procedures were recorded. Half of procedures (46% tissue damaging and 57% nontissue damaging) had no analgesic interventions. Opiates were used for 14.5% of tissue-damaging procedures and sweet taste was used for 14.3% of the tissue-damaging procedures. Factors predicting use of pharmacologic management of tissue-damaging procedures were being less ill at birth, receiving high frequency ventilatory support, and being transferred to the study center. Parental presence predicted use of sweet taste or nonpharmacologic analgesia for tissue-damaging procedures. Study site practices varied widely with 1 unit providing analgesia for 90% of tissue-damaging procedures., Interpretation: Although the number of tissue-damaging procedures has decreased from 1997 and the use of analgesics has increased, the management of these procedures falls far below the recommended guidelines of the Canadian Pediatric Society. That 1 unit reached a high level of analgesic use suggests that it is possible to achieve this goal. That parental presence had a positive influence on comfort strategies supports offering encouragement and support for parents to remain with their infant during procedures.

The suture, when possible, is the best method to close a simple wound. It must be preceded by debridement and performed with great care. A rigorous technique applied in the best possible environment is necessary but not always sufficient to achieve a good cosmetic result., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Created in 2002 in the framework of the 2nd national plan for pain, the Centre of national resources for pain management (CNRD) is devoted to procedural pain prevention and management. It works with professionals providing information and training, logistical and methodological assistance, support with research and the development of new practices.

A recent number of studies have focused on the relations between psychosocial factors and sleep disturbances. Like other work-related stressors, workplace byllying is associated with several negative consequences. However, few studies have investigated the influence of workplace byllying on disturbed sleep. Insomnia is the most frequent sleep complaint. Several models have highlighted the importance of cognitive factors in the development and maintenance of insomnia. Cognitive styles such as psychological detachment and rumination may be relevant in this process. The aim of the present study is to examine the moderating role of psychological detachment and rumination on the relationship between workplace byllying and insomnia. To minimize the effect of common method variance, we tested our hypothesis using a research design in which we collected data at two points in time separated by 1 month. A total of 523 individuals responded to both phases, with 511 useable surveys. The results of the hierarchical multiple regression analysis provide evidence for the moderating role of psychological detachment and rumination in the workplace byllying process. Thus, these findings are in line with the cognitive models of insomnia.

Context: Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain., Objective: To report epidemiological data on neonatal pain collected from a geographically defined region, based on direct bedside observation of neonates., Design, Setting, and Patients: Between September 2005 and January 2006, data on all painful and stressful procedures and corresponding analgesic therapy from the first 14 days of admission were prospectively collected within a 6-week period from 430 neonates admitted to tertiary care centers in the Paris region of France (11.3 millions inhabitants) for the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study., Main Outcome Measure: Number of procedures considered painful or stressful by health personnel and corresponding analgesic therapy., Results: The mean (SD) gestational age and intensive care unit stay were 33.0 (4.6) weeks and 8.4 (4.6) calendar days, respectively. Neonates experienced 60,969 first-attempt procedures, with 42,413 (69.6%) painful and 18,556 (30.4%) stressful procedures; 11,546 supplemental attempts were performed during procedures including 10,366 (89.8%) for painful and 1180 (10.2%) for stressful procedures. Each neonate experienced a median of 115 (range, 4-613) procedures during the study period and 16 (range, 0-62) procedures per day of hospitalization. Of these, each neonate experienced a median of 75 (range, 3-364) painful procedures during the study period and 10 (range, 0-51) painful procedures per day of hospitalization. Of the 42,413 painful procedures, 2.1% were performed with pharmacological-only therapy; 18.2% with nonpharmacological-only interventions, 20.8% with pharmacological, nonpharmacological, or both types of therapy; and 79.2% without specific analgesia, and 34.2% were performed while the neonate was receiving concurrent analgesic or anesthetic infusions for other reasons. Prematurity, category of procedure, parental presence, surgery, daytime, and day of procedure after the first day of admission were associated with greater use of specific preprocedural analgesia, whereas mechanical ventilation, noninvasive ventilation and administration of nonspecific concurrent analgesia were associated with lower use of specific preprocedural analgesia., Conclusion: During neonatal intensive care in the Paris region, large numbers of painful and stressful procedures were performed, the majority of which were not accompanied by analgesia.

Objective: Palivizumab (Synagis [Abbot Laboratories, Kent, United Kingdom]) is recommended for the prevention of severe lower respiratory tract infections caused by respiratory syncytial virus in infants at high risk. These injections are very painful, and currently the use of analgesics is not systematic. The objective of this study was to compare the efficacy of EMLA with premixed 50% nitrous oxide/oxygen, used alone or combined with EMLA, for pain alleviation during palivizumab injections., Methods: This randomized, double-blind, multicenter study included children who were younger than 24 months. Each child randomly received during the first 3 monthly injections 3 different analgesic interventions: (1) EMLA: application of EMLA plus air inhalation; (2) nitrous oxide/oxygen: inhalation of 50/50 nitrous oxide/oxygen plus application of a placebo cream; and (3) nitrous oxide/oxygen plus EMLA: inhalation of 50/50 nitrous oxide/oxygen plus application of EMLA. Each child was his or her own control. Procedural pain was assessed through videotapes with the Modified Behavioral Pain Scale. The procedure itself was subdivided in 2 periods: (1) injection and (2) recovery (first 30 seconds after the removal of the needle). Modified Behavioral Pain Scale scores over time (injection and recovery periods) and among treatments were compared by repeated-measures analysis of variance., Results: Fifty-five children were included. Mean +/- SD Modified Behavioral Pain Scale pain scores for EMLA, nitrous oxide/oxygen, and nitrous oxide/oxygen plus EMLA were, respectively, 9.3 +/- 1.0, 8.8 +/- 1.2, and 8.2 +/- 1.8 during the injection and 7.8 +/- 1.7, 7.4 +/- 1.9, and 6.9 +/- 2.4 during the recovery period. A significant time and treatment effect in favor of the combined nitrous oxide/oxygen plus EMLA was observed., Conclusions: The administration of 50/50 nitrous oxide/oxygen to infants and young children is effective in decreasing the pain associated with palivizumab intramuscular injections. The combined nitrous oxide/oxygen plus EMLA cream was more effective than either EMLA cream or nitrous oxide/oxygen alone.

Tracheal intubation is performed frequently in the NICU and delivery room. This procedure is extremely distressing, painful, and has the potential for airway injury. Premedication with sedatives, analgesics, and muscle relaxants is standard practice for pediatric and adult intubation, yet the use of these drugs is not common for intubation in neonates. The risks and benefits of using premedications for intubating unstable newborns are hotly debated, although recent evidence shows that premedication for non-urgent or semi-urgent intubations is safer and more effective than awake intubations. This article reviews clinical practices reported in surveys on premedication for neonatal intubation, the physiological effects of laryngoscopy and intubation on awake neonates, as well as the clinical and physiological effects of different drug combinations used for intubation. A wide variety of drugs, either alone or in combination, have been used as premedication for elective intubation in neonates. Schematically, these studies have been of three main types: (a) studies comparing awake intubation versus those with sedation or analgesia, (b) studies comparing different premedication regimens comprising sedatives, analgesics, and anesthetics, and (c) case series of neonates in which some authors have reported their experience with a specific premedication regimen. The clinical benefits described in these studies and the need for pain control in neonates make the case for using appropriate premedication routinely for elective or semi-urgent intubations. Tracheal intubation without the use of analgesia or sedation should be performed only for urgent resuscitations in the delivery room or other life-threatening situations when intravenous access is unavailable.

Background: The best results in the surgical treatment of gastric cancer are those obtained by the Japanese surgical school that emphasizes D2 lymphadenectomy as a fundamental principle for obtaining better local control of the disease. However, this technique has not gained wide acceptance in the West, owing to the fact that the results of Japanese studies have not been reproduced frequently in Western countries. In recent years, a series of studies have recommended the centralization of gastric cancer treatment in specialized surgical units in order to obtain results similar to those achieved by Japanese centers. The objective of this study was to describe the specialization process and to show the short-term results obtained in the surgical treatment of gastric cancer in the Specialized Unit of the Rebagliati National Hospital, the largest general referral hospital in Lima, Peru., Methods: In the year 2000 a specialized service was created for the surgical treatment of gastric cancer, initiating a process that included the establishment of surgical treatment guidelines, training in the Japanese surgical technique, and progress along the learning curve for D2 lymphadenectomy. Clinical, surgical, and pathological data were recorded prospectively in a fixed format, considering that strict documentation of cases was also an important step within this process., Results: Between January 1, 2004, and December 31, 2005, 243 consecutive patients with a proven diagnosis of gastric adenocarcinoma were admitted to the operating theater for surgical treatment. During this study period, morbidity was 22.7% and hospital mortality, 2.8%. The numbers (mean +/- SD) of resected lymph nodes for distal gastrectomy and total gastrectomy were 37.3 +/- 12.4 and 45.3 +/- 14.5, respectively. Hospital stay was 13 days for distal gastrectomy as well as for total gastrectomy., Conclusion: According to our results, adequate training in the Japanese surgical technique, progress along the learning curve for D2 lymphadenectomy, and the establishment of specialized units are highly recommended for the surgical treatment of gastric cancer in Western referral hospitals.

Context: The Standards, Options and Recommendations (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery., Objectives: To establish the Standards, Options and Recommendations clinical practice guidelines for the management of procedure related pain (lumbar puncture, bone marrow aspiration or biopsy, blood sampling) in children oncology patients. To define, on the basis of the critical appraisal of the best available evidence and expert agreement, the clinical situations in which a pain preventive strategy should be implemented., Methods: MEDLINE was searched using specific search strategies from January 1966 to August 2004. Literature monitoring was performed to identify controlled clinical trials published in 2005., Results: A total of 57 references were identified. Clinical guidelines have been defined for each invasive procedure.

Pain causes numerous physiological changes in neonates. All invasive procedures induce undesirable stress responses; theses responses can, however, be eliminated or reduced by a judicious use of analgesia. Even though a large number of analgesics and sedatives are currently available, most of them have not been studied in the neonate. At present, a precise understanding of the pharmacological mechanisms of analgesics is difficult because many interactions still remain unknown in the term and premature neonate. This article describes the main analgesics and sedative agents used in the neonate: morphine, fentanyl, sufentanil, alfentanil, nalbuphine, ketamine, midazolam, propofol, acetaminophen, and Emla cream. After a review of the literature regarding these drugs, some practical advices and suggestions for the treatment of procedure-induced pain, and background sedation/analgesia for ventilated neonates are given. It is also stated in this article that the best way to soothe pain in neonates is to combine non pharmacological and pharmacological strategies. At the national level, written guidelines should be prepared in order to improve pain management in the neonate.

This report describes the case of a patient who underwent total gastrectomy, splenectomy and pancreatomy corporo-postero as a consequence of gastric and pancreatic metastasis from carcinoma to clear cells, five years after having undergone radical nephrectomy. Upper digestive bleeding was the first symptom, and pancreatic lesion was detected in previous CT scans. There are many documented cases of pancreatic metastasis, but only eight gastric metastasis in the last 15 years, although we did not find reports about surgical treatment for concomitant gastric and pancreatic injury. Surgical treatment which in some reports include highly complex surgeries such as gastrectomies with combined resections of invaded organs and pancreatoduodenectomy, are good options for select cases, because good survival rates have been reported.

Objectives: To compare pain and sedation assessments by nurses undertaken with the Objective Pain Scale (OPS) and a Visual Analogue Scale (VAS) to the current reference scale for paediatric intensive care that is the COMFORT scale. To compare the unmodified COMFORT scale to a COMFORT "behaviour" scale which does not include physiologic items. To evaluate the ease of use of these scales., Methods: This prospective observational comparative study was carried out in children aged 1 year or older who were admitted in an intensive care unit. At 2 to 3 time points within 24 hours, a pain sedation assessment was carried out by the nurse in charge of the child with COMFORT scale, OPS and VAS. Correlation tests were used to compare the scores of each scale., Results: Nurses recorded 55 assessments in 20 children. Correlation studies showed a poor correlation between OPS, VAS and the COMFORT scale (Spearman's r=0.54 and 0.53 respectively) and a strong correlation between the COMFORT scale and the COMFORT "behaviour" scale (Spearman's r=0.96). The COMFORT behaviour scale was the most frequently fully completed scale., Conclusion: Among the 3 scales compared to the COMFORT scale in this study, the COMFORT "behaviour" scale was the only one to show a strong correlation and it also seemed to be the easiest to use.

The results of the surgical treatment for gastric cancer within a specialized surgical service in this pathology are described in this work. This system for surgical treatment of gastric cancer is new in our country. The implementation process included prepare a team of surgeons and establish protocols and guides to surgical treatment, based on the recommendations of the Japanese Gastric Cancer Association. Additional training in the Japanese advanced surgical technique was required, as well as a strict documentation of the cases. During 2004, 139 surgical interventions were carried out on 137 patients with tumoral gastric pathology. Surgical mortality was 2.1% and morbidity was 21.8%. The average resected glands was 38.6.t 13.7 (range: 20-87) for distal gastrectomy and 46.6 +/- 16.2 (range: 24-87) for total gastrectomy. The stay in the hospital was 11.7 +/- 6.3 days (range: 5-37) for distal gastrectomy and 14.8 +/- 11.3 days (range: 7-56) for total gastrectomy. The hospital and surgeon volumes are underlined as important factors in determining the short and long term results. Implementation of specialized surgical units in general hospitals, for surgical treatment of gastric cancer, is recommended.

Background: Morphine alleviates prolonged pain, reduces behavioral and hormonal stress responses induced by surgery among term neonates, and improves ventilator synchrony and sedation among ventilated preterm neonates, but its analgesic effects on the acute pain caused by invasive procedures remain unclear., Objective: To investigate the analgesic efficacy of intravenously administered morphine on heel stick-induced acute pain among preterm neonates., Design: This study was nested within a prospective, randomized, double-blind, multicenter, placebo-controlled trial (the NEOPAIN Trial)., Setting: A tertiary-care NICU in a teaching hospital., Participants: Forty-two preterm neonates undergoing ventilation., Interventions: Neonates were randomized to either the morphine (loading dose of 100 microg/kg, followed by infusions of 10-30 microg/kg per hour according to gestation, N = 21) or placebo (5% dextrose infusions, N = 21) group. Pain responses to 3 heel sticks were evaluated, ie, before the loading dose (T1), 2 to 3 hours after the loading dose (T2), and 20 to 28 hours after the loading dose (T3)., Main Outcomes Measures: Pain was assessed with the Douleur Aiguë Nouveau-né (DAN) scale (behavioral pain scale) and the Premature Infant Pain Profile (PIPP) (multidimensional pain scale); plasma morphine levels were measured at T3., Results: Infants in the placebo and morphine groups had similar gestational ages (mean +/- SD: 27.2 +/- 1.7 vs 27.3 +/- 1.8 weeks) and birth weights (972 +/- 270 vs 947 +/- 269 g). Mean +/- SD DAN pain scores at T1, T2, and T3 were 4.8 +/- 4.0, 4.6 +/- 2.9, and 4.7 +/- 3.6, respectively, for the placebo group and 4.5 +/- 3.8, 4.4 +/- 3.7, and 3.1 +/- 3.4 for the morphine group. The within-group factor (pain at T1, T2, and T3) was not statistically different over time. The between-group analysis (infants receiving placebo versus those receiving morphine) showed no significant differences. Mean +/- SD PIPP pain scores at T1, T2, and T3 were 11.5 +/- 4.8, 11.1 +/- 3.7, and 9.1 +/- 4.0, respectively, for the placebo group and 10.0 +/- 3.6, 8.8 +/- 4.9, and 7.8 +/- 3.6 for the morphine group. The within-group factor was statistically different over time. The between-group analysis showed no significant differences. Mean +/- SD plasma morphine levels at T3 were 0.44 +/- 1.79 ng/mL and 63.36 +/- 33.35 ng/mL for the placebo and morphine groups, respectively. There was no correlation between plasma morphine levels and pain scores at T3 (DAN, R = -0.05; PIPP, R = -0.02)., Conclusions: Despite its routine use in the NICU, morphine given as a loading dose followed by continuous intravenous infusions does not appear to provide adequate analgesia for the acute pain caused by invasive procedures among ventilated preterm neonates.

Multiple lines of evidence suggest an increased sensitivity to pain in neonates. Repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Despite impressive gains in the knowledge of neonatal pain mechanisms and strategies to treat neonatal pain acquired during the last 15 years, a large gap still exists between routine clinical practice and research results. Accurate assessment of pain is crucial for effective pain management in neonates. Neonatal pain management should rely on current scientific evidence more than the attitudes and beliefs of care-givers. Parents should be informed of pain relief strategies and their participation in the health care plan to alleviate pain should be encouraged. The need for systemic analgesia for both moderate and severe pain, in conjunction with behavioral/environmental approaches to pain management, is emphasized. A main sources of pain in the neonate is procedural pain which should always be prevented and treated. Nonpharmacological approaches constitute important treatment options for managing procedural pain. Nonpharmacological interventions (environmental and preventive measures, non-nutritive sucking, sweet solutions, skin-skin contact, and breastfeeding analgesia) can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed, and directly, by blocking nociceptive transduction or transmission or by activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. Opioids are the mainstay of pharmacological pain treatment but there are other useful medications and techniques that may be used for pain relief. National guidelines are necessary to improve neonatal pain management at the institutional level, individual neonatal intensive care units need to develop specific practice guidelines regarding pain treatment to ensure that all staff are familiar with the effects of the drugs being used and to guarantee access and safe administration of pain treatment to all neonates.

This study was undertaken to verify the echocardiographic characteristics of bicuspid aortic valve (AV) using 3-dimensional transesophageal echocardiography by comparing the findings with anatomic examination of autopsy specimens from carriers of this condition. Three-dimensional reconstructions of transesophageal echocardiograms were performed on 14 patients with bicuspid AV, and 20 autopsy specimens of bicuspid AVs were analyzed. Echocardiographic images and autopsy material were correlated. Two variants of bicuspid aorta were identified. In group I the AV had 2 leaflets. This group included 9 (9/14) 3-dimensional echocardiographic studies and 13 (13/20) necropsies. In group II 3 sigmoid leaflets had originally developed and 2 underwent dysplastic fusion, resulting in functionally bicuspid valves. Five (5/14) echocardiographic studies and 7 (7/20) anatomic specimens fell into this category. There was a clear correspondence between anatomic and echocardiographic findings, which leads to the conclusion that 3-dimensional echocardiography is a technique that reliably defines the morphological details of bicuspid AV with the precision of anatomopathologic examination.

Objective: Very preterm newborns undergo multiple invasive procedures. Nonpharmacological interventions are valuable alternatives for pain relief during minor procedures in neonates. Oral sucrose analgesia has been widely studied in term and preterm neonates during painful procedures. The analgesic effect of oral glucose in very preterm infants has not yet been reported. The objectives of this study were to assess the analgesic effect of orally administered glucose and to determine the synergetic analgesic effect of glucose and pacifiers during subcutaneous injections in very preterm neonates using a validated behavioral acute pain rating scale., Design: Two crossover trials., Setting: One neonatal intensive care unit in a community-based general hospital., Methods: A prospective study was conducted in 40 very preterm neonates. Each infant received 2 treatments in a crossover manner during 2 consecutive subcutaneous injections of erythropoietin. The first trial (25 infants) was intended to compare oral 30% glucose (0.3 mL) versus placebo (0.3 mL of sterile water); the second trial (15 infants) compared oral 30% glucose (0.3 mL) versus oral 30% glucose (0.3 mL) followed by sucking a pacifier. The primary outcome measure was the evaluation of pain induced by a subcutaneous injection of erythropoietin, using Douleur Aiguë Nouveau-né scale (0 no pain, 10 maximum pain)., Results: Twenty-four infants completed the study in the first trial and 15 in the second one. Mean (95% confidence interval [CI]) gestational age, birth weight, postnatal age, and weight at inclusion for neonates in the first and second trial were, respectively, 28.1 (95% CI: 27.3-29.0) and 29.1 (95% CI: 27.8-30.4) weeks, 1036 (95% CI: 944-1128) and 995 (95% CI: 848-1141) g, 26.4 (95% CI: 22.4-30.3) and 26 (95% CI: 22.0-29.9) days, and 1234 (95% CI: 1120-1348) and 1209 (95% CI: 1059-1359) g. In the first trial, median (interquartile) pain scores for placebo and 30% glucose, respectively, were 7 (2.5-9.75) and 4.5 (1-6). In the second trial, median (interquartile) pain scores for 30% glucose and for 30% glucose plus pacifier, respectively, were 4 (2-7) and 4 (1-6)., Conclusions: A small dose of 0.3 mL of 30% oral glucose has an analgesic effect in very preterm neonates during subcutaneous injections. This effect is clinically evident because it can be detected by a behavioral pain rating scale. The synergetic analgesic effect of glucose plus sucking a pacifier is less obvious in very preterm neonates as opposed to what other studies have showed in full-term infants.

Background: Early interventions, such as occlusive wrapping of very low birth weight infants at delivery reduce postnatal temperature fall. This new intervention was implemented in our hospital on January 2000. The aim of this study was to investigate retrospectively the effect of polyethylene wrap, applied immediately at birth, on thermoregulation., Patients and Methods: Matched pair analysis was conducted for 60 infants delivered inborn at less than 33 weeks' gestation and 60 premature infants who were born during the second half of 1999 fulfilling the same criteria. The only difference in the management (medical and environmental) was wrapping with a polyethylene bag in the delivery room. Rectal temperature and other vital parameters were taken, after removal of wraps, on admission to NICU., Results: The perinatal characteristics of both groups were comparable. Use of wrapping resulted in a significantly higher admission rectal temperature (difference in means = 0.8 degree C, p < 0.0001), this difference was also significant in infants < 30 weeks. The incidence of hypothermia (< 35.5 degrees C) was less frequent in infants enclosed in plastic bags (8.3% vs 55%). No side effects (skin burns, infection or hyperthermia) were attributable to the intervention. The heart rate was higher in the wrapping group (163 +/- 16 vs 150 +/- 17 b/min, p < 0.01), as well as the capillary glycemia (62 +/- 26 vs 45 +/- 30 mg/dl, p < 0.01). There was no significant difference on arterial pressure., Conclusion: Occlusive wrapping with a polyethylene bag at birth prevented low rectal temperature in premature infants in the immediate postnatal period. This method is easy, practical and effective, and does not interfere with current practice for resuscitation.

Jargon, the specialized vocabulary and idioms, is frequently used by people of the same work or profession. The neonatal intensive care unit (NICU) makes no exception to this. As a matter of fact, NICU is one place where jargon is constantly developing in parallel with the evolution of techniques and treatments. The use of jargon within the NICU is very practical for those who work in these units. However, this jargon is frequently used by neonatologists in medical reports or other kinds of communication with unspecialized physicians. Even if part of the specialized vocabulary can be decoded by physicians not working in the NICU, they do not always know the exact place that these techniques or treatments have in the management of their patients. The aim of this article is to describe the most frequent jargon terms used in the French NICU and to give up-to-date information on the importance of the techniques or treatments that they describe.

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

Objectives: To assess and compare the analgesic effects of orally administered glucose and sucrose and pacifiers. To determine the synergistic analgesic effect of sucrose and pacifiers., Design: Randomised prospective study with validated behavioural acute pain rating scale., Setting: Maternity ward., Participants: 150 term newborns undergoing venepuncture randomly assigned to one of six treatment groups: no treatment; placebo (2 ml sterile water); 2 ml 30% glucose; 2 ml 30% sucrose; a pacifier; and 2 ml 30% sucrose followed by a pacifier., Results: Median (interquartile) pain scores during venepuncture were 7 (5-10) for no treatment; 7 (6-10) for placebo (sterile water); 5 (3-7) for 30% glucose; 5 (2-8) for 30% sucrose; 2 (1-4) for pacifier; and 1 (1-2) for 30% sucrose plus pacifier. Mann-Whitney U test P values for comparisons of 30% glucose, 30% sucrose, pacifier, and 30% sucrose plus pacifier versus placebo (sterile water) were 0.005, 0.01, <0.0001, and <0.0001, respectively. Differences between group median pain scores for these comparisons were 2 (95% confidence interval 1 to 4), 2 (0 to 4), 5 (4 to 7), and 6 (5 to 8), respectively. P values for comparisons of 30% glucose, 30% sucrose, and 30% sucrose plus pacifier versus pacifier were 0.0001, 0.001, and 0.06, respectively. Differences between group medians for these comparisons were 3 (2 to 5), 3 (1 to 5), and 1 (0 to 2), respectively., Conclusion: The analgesic effects of concentrated sucrose and glucose and pacifiers are clinically apparent in newborns, pacifiers being more effective than sweet solutions. The association of sucrose and pacifier showed a trend towards lower scores compared with pacifiers alone. These simple and safe interventions should be widely used for minor procedures in neonates.

Texas Children's Hospital, a 456 bed pediatric hospital located in the Texas Medical Center, has been constructing a large-scale picture archiving and communications system (PACS), including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and computed radiography (CR). Until recently, filmless radiology operations have been confined to the imaging department, the outpatient treatment center, and the emergency center. As filmless services expand to other clinical services, the PACS staff must engage each service in a dialog to determine the appropriate level of support required. The number and type of image examinations, the use of multiple modalities and comparison examinations, and the relationship between viewing and direct patient care activities have a bearing on the number and type of display stations provided. Some of the information about customer services is contained in documentation already maintained by the imaging department. For example, by a custom report from the radiology information system (RIS), we were able to determine the number and type of examinations ordered by each referring physician for the previous 6 months. By compiling these by clinical service, we were able to determine our biggest customers by examination type and volume. Another custom report was used to determine who was requesting old examinations from the film library. More information about imaging usage was gathered by means of a questionnaire. Some customers view images only where patients are also seen, while some services view images independently from the patient. Some services use their conference rooms for critical image viewing such as treatment planning. Additional information was gained from geographical surveys of where films are currently produced, delivered by the film library, and viewed. In some areas, available space dictates the type and configuration of display station that can be used. Active participation in the decision process by the clinical service is a key element to successful filmless operations.

Nitrous oxide is a gas that has been used to provide analgesia to patients for more than a century. Its modern use started in the late sixties when a mixture of 50% nitrous oxide/50% oxygen was prepared. Nitrous oxide/oxygen provides analgesia within 3 minutes of inhalation and this analgesic effect disappears in less than 4 minutes after cessation. Its administration is very easy and a complete or partial pain relief is observed in 75 to 81% of patients. The gas mixture has been found to be safe with few side effects and no significant adverse reactions. Diffusion hypoxia which could lead to hypoxemia was reported in 1955, but recent work does not confirm this complication. Nitrous oxide/oxygen mixture constitutes an excellent drug to control procedure-related pain in children. This articles describes the history, the pharmacology, and the clinical uses of nitrous oxide/oxygen in children.