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Resume Avec pour principe actif un produit d’anesthesie originellement reserve au bloc operatoire, le Melange equimolaire d’oxygene et de protoxyde d’azote (MEOPA) s’impose peu a peu comme un antalgique efficace et sur pour prevenir la douleur provoquee par les soins, d’abord dans les services hospitaliers et enfin en secteur de ville. En France, bien qu’autorise, peu de medecins de ville l’ont integre dans leur activite. Neanmoins des indications legitimes existent (pansements, sutures, mobilisations…), mais les rares travaux autour de cet usage decrivent quasiment tous un frein financier a son developpement. Peu recherche par les praticiens, les connaissances a son sujet semblent modestes et aucune etude d’envergure ne vient documenter son rapport cout/efficacite. Moyennant une « formation MEOPA » attestee au fournisseur, tout praticien de ville peut s’equiper, sous reserve de respecter les consignes du Plan de gestion des risques mis en place par l’Agence nationale de securite du medicament. L’impact pour la comptabilite du cabinet comprend une depense initiale d’installation, et une depense reguliere de consommables. Certains praticiens ayant des honoraires libres le facturent aux patients, alors que la possibilite de deduire cette charge du revenu imposable du cabinet reste meconnue et sous-exploitee. Alors que les autorites de sante souhaitent engager massivement le systeme de soins vers l’ambulatoire, la creation a la nomenclature d’un acte correspondant a l’inhalation de MEOPA est attendue des professionnels, pour pouvoir le facturer a l’Assurance maladie et permettre une equite d’acces au soulagement de la douleur provoquee par les soins.

Aim Benign paroxysmal torticollis (BPT), benign paroxysmal vertigo (BPV), and benign tonic upward gaze (BTU) are characterized by transient and recurrent episodes of neurological manifestations. The purpose of this study was to analyse the clinical relationships between these syndromes, associated comorbidities, and genetic bases. Method In this cross-sectional study, clinical data of patients with BPT, BPV, or BTU were collected with a focus on developmental achievements, learning abilities, and rehabilitation. Neuropsychological assessment and genetic testing were performed. Results Fifty patients (median age at inclusion 6y) were enrolled. Psychomotor delay, abnormal neurological examination, and low or borderline IQ were found in 19%, 32%, and 26% of the patients respectively. Cognitive dysfunction was present in 27% of the patients. CACNA1A gene mutation was identified in eight families, and KCNA1 and FGF14 mutation in one family respectively. The identification of a CACNA1A mutation was significantly associated with BTU (p=0.03) and with cognitive dysfunction (p=0.01). Patients with BPV were less likely to have cognitive dysfunction. Interpretation Children with BPT, BPV, or BTU are at high risk of impaired psychomotor and cognitive development. These syndromes should not be regarded as benign and should be considered as part of the spectrum of a neurodevelopmental disorder. What this paper adds ok Patients with benign paroxysmal torticollis (BPT), benign paroxysmal vertigo (BPV), and benign tonic upward gaze (BTU) have an increased risk of psychomotor delay. These patients also have an increased risk of abnormal neurological examination and cognitive dysfunction. Gene mutations, especially in CACNA1A, were identified in 21% of the families. BPT, BTU, and BPV should not be regarded as benign. BPT, BTU, and BPV should be considered as part of the spectrum of a neurodevelopmental disorder.

Purpose Restraint is often used when administering procedures to children. However, no metrologically scale to measure the restraint intensity had yet been validated. This study validated the metrological criteria of a scale measuring the restraint intensity, Procedural Restraint Intensity in Children (PRIC), used during procedures in children. Design and methods The PRIC scale performance was measured by a group of 7 health professionals working in a children's hospital, by watching 20 videos of health care procedures. This group included 2 physicians, 1 pediatric resident, and 4 nurses. The intra-class correlation coefficients were calculated to evaluate the inter-rater and test-retest reliability and the construct validity with the correlation between PRIC scale and a numerical rating scale. Results One hundred and forty measurements were made. Inter-rater and test-retest correlation coefficients were 0.98 and 0.98, respectively. The 2 scales were positively correlated with a Spearman coefficient of 0.93. Conclusions This study validated the Procedural Restraint Intensity in Children (PRIC) scale in metrological terms with some limitation. However, there is not gold standard scale to precisely validate the reliability of this tool and this study has been conducted in "experimental" conditions. Nevertheless, this is the first scale measuring the intensity of physical restraint with a metrological validation. The next step will be to validate it in real clinical situations.

BACKGROUND: The prevalence of migraine in individuals younger than 20 years old is 8%, with a mean age at onset of younger than 8 years. However, the long-term prognosis of migraine attacks has not been clearly established. OBJECTIVE: Our main objective was to evaluate disease course 10 years after migraine diagnosis in a cohort of children and adolescents. METHODS: Migraine was diagnosed in 1999 in a pediatric headache reference center using International Headache Society criteria. In 2009, all patients were interviewed by telephone on the persistence and characteristics of any headaches. The main end point was prevalence of persistent migraine attacks in 2009. Variables associated with persistent attacks were analyzed. RESULTS: Overall, 142 children were diagnosed with migraine in 1999. Of these, 84 were interviewed by telephone in 2009. In 1999, the mean age was 11.6 � 3.1 years, 54% were male, and 50% had migraine without aura. Migraine attacks were common (1-3 attacks/ week in 38%). Mean age at onset was 7 years and 4 months (� 3 years). In 2009, migraine prevalence was 39/84 (46% [95% confidence interval 36-56]), 12 patients (14%) were headache-free, and 62 patients (74%) had tensiontype headaches that were isolated headaches in 33 (39%) patients. The rate of patients with at least one migraine attack per week fell from 37% to 8% (P ¼ 0.001) over the 10-year period. Age at the first visit to the center was significantly higher in 2009 migraine sufferers than nonsufferers (12.5 � 3.0 versus 10.9 � 3.1 years (P ¼ 0.02)). In multivariate analysis, age � 12 years at the time of first presentation was the only significant factor associated with long-term chronic migraine (odds ratio ¼ 3.0 [1.1-8.0]). CONCLUSIONS: Ten years after first presentation, 46% of patients had migraine but the frequency of attacks had diminished. The only factor associated with chronic migraine was age � 12 years at first presentation.

International audience; IntroductionDespite numerous studies on the association between headache and psychological difficulties in children, the results remain inconclusive.ObjectiveThis cross-sectional study was conducted to clarify the links between anxiety-depression and headache in children. We evaluated the levels of anxious and depressive symptoms and the influence of risk factors: age, sex, headache diagnosis, frequency and history to identify and treat headache sufferers most at risk.MethodData were collected from a clinical sample of 368 children aged 8 to 17 years. First, a structured interview using the International Classification of Headache Disorders (ICHD-II) was used to diagnose 88 patients with migraine (M), 32 with tension-type headache (TTH), and 248 with a combination syndrome (M + TTH). Second, levels of anxiety and depressive symptoms were assessed with the Revised Children's Manifest Anxiety Scale (R-CMAS) and the Multiscore Depression Inventory for Children (MDI-C).ResultsAn ANOVA analysis showed that the mean scores for anxiety and depressive symptom levels were significantly higher among older patients and that only the M + TTH diagnosis was significantly associated with anxiety. Children with clinically significant levels of anxiety symptoms were more prevalent in our sample than in the general population (13% versus 5%). Anxiety and depression were not associated with child sex, headache frequency and history.ConclusionWe propose systematic screening for anxiety in children presenting with headache, particularly adolescents and patients with a combination diagnosis.; RésuméIntroductionPlusieurs études chez l’enfant sur la comorbidité entre céphalées et troubles psychologiques montrent des résultats contradictoires.ObjectifCette étude transversale a été menée afin de clarifier les liens entre anxiété/dépression et les céphalées chez l’enfant. Nous avons évalué les niveaux de symptomatologie anxieuse et dépressive ainsi que l’influence de facteurs de risque (âge, sexe, diagnostic, fréquence et histoire des céphalées) afin d’identifier et de prendre en charge les patients les plus « à risque ».MéthodeLes données ont été recueillies auprès d’un échantillon clinique de 368 enfants âgés de huit à 17 ans. Un entretien structuré utilisant les critères de l’International Classification of Headache Disorders (ICHD-II) a permis de diagnostiquer 88 patients souffrant de migraine (M), 32 présentant des céphalées de tension (CDT) et 248 avec les deux diagnostics (M + CDT). Les niveaux d’anxiété et de dépression ont été évalués avec la Revised Children's Manifest Anxiety Scale (R-CMAS) et la Multiscore Depression Inventory for Children (MDI-C).RésultatsL’analyse statistique (Anova) a montré que les moyennes des scores d’anxiété et de dépression étaient significativement plus élevées chez les adolescents et que seul le diagnostic M + CDT était significativement associé avec l’anxiété. De plus, les enfants avec des scores d’anxiété considérés comme pathologiques étaient plus nombreux dans notre échantillon que dans la population générale (13 % versus 5 %). L’anxiété et la dépression n’étaient pas associées avec le sexe, la fréquence et l’histoire des céphalées.ConclusionNous proposons un dépistage systématique de l’anxiété chez l’enfant céphalalgique, particulièrement chez les adolescents et les patients présentant un diagnostic combiné.

Aim The aim of this study was to examine the course of headache diagnosis, headache frequency, anxiety, comorbid depressive symptoms and school absenteeism in adolescents with migraine and tension-type headaches five years after baseline. Methods We followed a group of 122 children with a mean age of 10.1 (±1.3) years, with headache from a paediatric migraine centre in Paris who had taken part in a previous study from September 2007 to June 2008. This five-year longitudinal study took place in January to June 2012. The measures that were used included demographic variables, headache diagnosis, headache data and a psychological assessment. Results At the five-year point, about 22% of the children had become headache free, 34% had little to no disability and 36% had a changed diagnosis. Moreover, a longer history of headache at baseline was associated with a worse evolution of headache at follow up. Lastly, high depression scores, but not anxiety, was a predictor of more headache disability at follow up. Conclusion High depression scores in childhood was a risk factor that was associated with persistence and worsening of headaches in adolescence. This suggests that mental health assessments should be carried out in paediatric headache pain clinics. This article is protected by copyright. All rights reserved.

We present the results of the use of a protocol of inhalational oxygen/nitrous oxide mixtures associated with oral opioids on a prospective cohort of 33 children undergoing local care for acute but limited burned skin lesions.All the children were orally administered 0.4 mg/kg morphine chlorydrate, and nitrous oxide was administered as an equimolar mixture (50% N2O, 50% O2) via a face mask during the procedure. Pain and comfort of the patient were evaluated by the use of a validated behavioural score. After the end of the procedure, child and parent satisfactions were noted.Mean age was 3 years 6 months (10 months-11 years). A successful detersion procedure was performed in all the cases. Behavioural score was 6 in 15 cases out of 33, comprising between 7 and 9 in 15 patients and 10 in three patients. Subjective satisfaction of pain management was noted in 16 out of 20 patients after the procedure. Subjective satisfaction of the parents was noted in all the cases.Our study demonstrates that the use of a simple protocol of inhalational oxygen/nitrous oxide mixtures associated with oral opioids could be safe and effective. This association was well tolerated without any adverse effect.

Resume Objectifs Cette etude avait pour but d’evaluer la douleur postoperatoire apres adenoidectomie (VG) et/ou pose d’aerateur transtympanique (ATT) a l’hopital et au domicile et les troubles comportementaux postoperatoires (TCPO) au domicile. Type d’etude Etude observationnelle. Patients et methodes Soixante quatre enfants (4,3 ± 2,4 ans) : 28 VG, 16 ATT, 20 VG-ATT. La douleur postoperatoire a ete evaluee (entree SSPI, sortie SSPI, sortie hopital) avec l’Objective Pain Scale (OPS). Les parents ont evalue au domicile pendant sept jours la douleur de leur enfant avec l’echelle numerique simple (ENS). Les TCPO ont ete evalues (24 heures et a 7 jours) avec le Post-Hospital Behavior Questionnaire (PHBQ). Resultats Entree SSPI, OPS = 3,5 [0–6]. Il existait une difference significative (p Discussion Dans les trois groupes, les parents rapportent des TCPO malgre une analgesie correcte. Conclusion La frequence importante des TCPO implique de les evaluer systematiquement pour l’amelioration de la prise en charge globale de l’enfant.

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.

BACKGROUND: Multiple distraction strategies have been proposed to reduce the incidence of anxiety and pain in children. Animal-assisted therapy is acknowledged and used in children as an adjunctive treatment with cognitive, physical, psychosocial and spiritual benefits.OBJECTIVE: To determine the effect of fish aquarium animal-assisted therapy (FA-AAT) on pain perception in a cohort of healthy volunteers.METHODS: Sixty-nine healthy subjects (mean age 27.3 years) were exposed to >20 different species of soft or hard corals and >25 fish in a 1000 L saltwater aquarium. Pain perception was assessed using an electrical stimulation device, the Pain Matcher (Cefar Medical AB, Sweden), after 5 min, 10 min, 20 min and 30 min of continuous aquarium viewing. The measurements were repeated 10 min after stopping aquarium viewing.RESULTS: A statistically significant pain perception threshold augmentation was observed after a 5 min aquarium viewing. This threshold augmentation was also increased after 10 min, 20 min and 30 min of FA-AAT. A remnant effect was noted up to 10 min after exposure. This short post-viewing time period could be useful in clinical practice to perform certain painful procedures in children, such as those involving needles, under improved conditions immediately after aquarium exposure.CONCLUSIONS: In the authors’ department, FA-AAT is now used as a nonpharmacological antinociceptive technique in association with a protocol of inhalated oxygen/nitrous oxide mixtures for needle-related procedures. Children and parents are invited to watch the aquarium during the 10 min to 20 min before venous punctures.

Resume L’objectif de l’etude a ete d’utiliser une nouvelle version de l’echelle des visages, transposition de la FPS-R sur ordinateur de poche de type PalmTM et d’en apprecier le bon usage et la validite aupres d’enfants douloureux. L’esprit et la forme originelle de cette echelle ont ete respectes sur le support electronique. 3 groupes homogenes de 30 enfants hospitalises (4 a 12 ans) ont auto-evalue leur douleur a 10 min d’intervalle, avec les deux outils, papier puis PDA, ou inversement, suivant une randomisation pre-definie. Un test de comprehension a ete effectue apres les deux mesures. Sur ce premier effectif de 92 enfants, le coefficient de correlation (r de Spearman) global entre les paires de scores est de 0,86 (p

C’est a partir de 2004, qu’un consensus international a permis de definir des criteres diagnostiques de la migraine de l’enfant [1]. Les premieres etudes epidemiologiques en population generale concernant les cephalees de l’enfant datent de 1990 [2].

Chronic daily headache (CDH) is relatively common among children. Although comorbid conditions have been extensively studied in adults, they have not been assessed in the pediatric CDH population. Accordingly, the authors assessed several conditions known to be associated with CDH in adult patients in children with either CDH or episodic headache. The influence of CDH or episodic headache on the number of school days missed was also assessed., BACKGROUND: Chronic daily headache (CDH) in children has been documented in general and clinical populations. Comorbid psychological conditions, risk factors and functional outcomes of CDH in children are not well understood. OBJECTIVES: To examine anxiety and depression, associated risk factors and school outcomes in a clinical population of youth with CDH compared with youth with episodic headache (EH). METHODS: Data regarding headache characteristics, anxiety, depression and missed school days were collected from 368 consecutive patients eight to 17 years of age, who presented with primary headache at a specialized pediatric headache centre. RESULTS: A total of 297 patients (81%) were diagnosed with EH and 71 were diagnosed with CDH. Among those with CDH, 78.9% presented with chronic tension-type headache and 21.1% with chronic migraine (CM). Children with CDH had a higher depression score than the standardized reference population. No difference was observed for anxiety or depression scores between children with CDH and those with EH. However, children with CM were more anxious and more depressed than those with chronic tension-type headache. Youth experiencing migraine with aura were three times as likely to have clinically significant anxiety scores. Headache frequency and history were not associated with psychopathological symptoms. Children with CDH missed school more often and for longer periods of time. CONCLUSIONS: These findings document the prevalence of anxiety, depression and school absenteeism in youth with CDH or EH. The present research also extends recent studies examining the impact of aura on psychiatric comorbidity and the debate on CM criteria.

Although migraine is the main chronic headache in childhood and adolescence, it remains extensively misdiagnosed. Schematically, migraine is a severe headache evolving by stereotyped attacks frequently associated with marked digestive symptoms (nausea, vomiting, abdominal pain). Throbbing pain, sensitivity to sound, and light (and sometimes odors) are frequent additional symptoms. The attack is sometimes preceded by a visual or sensory aura. Rest brings relief, and sleep often ends the attack. Childhood migraine prevalence varies between 5 and 10%. Migraine episodes are frequently triggered by several factors: emotional stress (school pressure, vexation, excitement, upset), hypoglycemia, lack or excess of sleep (weekend migraine), sensory stimulation (loud noise, bright light, strong odor, heat or cold, etc.), sympathetic stimulation (sport, physical exercise). Attack treatments must be given at an early stage, oral ibuprofen (10 mg/kg) being particularly recommended. If the oral route is not available because of nausea or vomiting, rectal or nasal routes have then to be used. Non-pharmacological treatments (biofeedback and interventions combining progressive muscle relaxation) have demonstrated good efficacy as prophylactic measures. Daily prophylactic pharmacological treatments are prescribed as the second line after failure of non-pharmacological treatments.

Headache is one of the most common physical complaints of children and adults. The authors have provided definitions of headache, a classification system, diagnostic evaluations appropriate for children, and treatment options for patients with acute and chronic headache. Also, this article has emphasized the importance of diagnosing and treating migraine headache, a painful malady that is extensively underestimated and misdiagnosed in the pediatric population and one that can be treated acutely and when appropriate prophylactically with great success. Lack of a specific biologic marker, specific investigation, or brain imaging reduce these clinical entities too often to a psychological illness. Nonpharmacologic treatments are pivotal to manage chronic headaches. Migraine therapy, if administered early and through the appropriate route, could provide important and rapid relief.

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.

All neonates in the Neonatal Intensive Care Unit (NICU) or during the first days of life undergo painful and stressful procedures. Epidemiologic studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Prevention is the first step of pain management, and practical guidelines should be used in the NICU. Assessment must be done with adequate tools that take into account the infant’s pathology and gestational age. Distinguishing between acute and prolonged pain is important for both assessment and treatment. The most common drugs that have been studied for the treatment of pain and stress are opioids, hypnosedatives, and NMDA receptor antagonists. Morphine and fentanyl are most frequently used for acute or prolonged pain in the NICU. They have potent analgesic effects and few immediate or long-term adverse effects. Midazolam is a commonly used hypnosedative, but its adverse effects limit its use. Drugs such as propofol and ketamine have been used for acute painful procedures; however, further research is needed to assess their long-term effects. Use of non-pharmacologic pain management techniques has increased in recent years. These methods are easy, inexpensive, and effective in helping newborns recover from painful procedures. Sweet solutions and non-nutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and facilitated tucking are the most commonly employed and evaluated non-pharmacologic methods. Hospitals should promote and improve parent involvement in pain management. In-service education and well organized hospital teams are crucial for successful implementation of pain protocols in newborns.

Resume L’anxiete preoperatoire est un malaise physique et psychologique dont l’apparition est consecutive a la possibilite d’une intervention chirurgicale. Lorsqu’elle est d’intensite faible a moderee, c’est une reponse adaptee a cette situation potentiellement anxiogene. Il a ete etabli que des niveaux importants d’anxiete preoperatoire augmentent le risque de complications postoperatoires, ainsi que la survenue de troubles emotionnels et comportementaux. Malgre ces consequences medicales et psychologiques parfois graves, il n’y a que tres peu de litterature destinee aux professionnels de sante francophones sur le sujet. L’objectif de cet article est d’effectuer une synthese de la notion d’anxiete preoperatoire, de ses manifestations cliniques, ainsi que de ses moyens d’evaluation et de prevention.

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.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.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.A total of 57 references were identified. Clinical guidelines have been defined for each invasive procedure.

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.

6% des enfants et adolescents presentent des douleurs chroniques avec repercussion sur leur vie. Les medecins sont souvent demunis et un recours a une structure specialisee douleur peut etre indique pour une prise en charge multidisciplinaire. Objectif decrire les patients consultant dans ces structures, leurs douleurs et la prise en charge proposee. Sujet / materiels et methode en 2013, une enquete prospective a ete menee 5 semaines dans 22 des 24 structures douleur enfants francaises. Resultats principaux 337 enfants inclus, d’âge moyen 11 ans, 57% de filles. Les douleurs etaient des cephalees 57%, des douleurs musculo-squelettiques 26%, des douleurs diffuses 12%, des douleurs abdominales 6%, des douleurs neuropathiques 1%. Elles duraient depuis 6 mois a 3 ans pour 52% et plus de 3 ans pour 23%. 1/4 des enfants avaient consulte aux urgences et 19% avaient ete hospitalises pour leurs douleurs. L’absenteisme scolaire etait de plus de 15 jours par semestre pour 1/3 d’entre eux. La consultation, souvent menee en binome medecin/psy est longue : en moyenne 70 minutes. La prise en charge proposee a ete medicale et psychologique pour 71%. Conclusion cette 1ere enquete francaise permet de bien decrire les douleurs chroniques des enfants et adolescents en France, et leur lourdeur.

In France, administration of premixed 50% nitrous oxide and oxygen for procedural sedation is under close supervision by the French Drug Agency before final approval for use. We have examined the frequency of adverse events in children sedated with 50% nitrous oxide and oxygen over a broad range of non-specialised facilities. A mean of 0.33% (SD 0.10) children had major adverse events. Thus, premixed 50% nitrous oxide and oxygen seems to be a safe option for procedural sedation in children.

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 older, respectively.Staff satisfaction regarding EMONO efficacy was as follows: very satisfied (56.7%), satisfied (31.3%), not satisfied (8.6%), and very unsatisfied (3.3%). Minor side effects were observed during 381 (37%) inhalations. These side effects were euphoria (20.1%), change in visual or auditory perception (7.0%), dreams (5.7%), nausea and vomiting (3.7%), deep sedation (2.1%), paresthesia (1.7%), dizziness (1.6%), restlessness (1.5%), nightmares and hallucinations (1.2%), and miscellaneous (1.9%). All side effects were transient and vanished within 5 minutes after removing the inhalation device. No serious side effects were noted.Conclusions.This survey shows that EMONO is used to provide analgesia in a great variety of procedures. Although analgesia obtained during procedures is good, this gas mixture is not efficacious in all patients. Therefore, physicians should quickly detect failures to switch to another analgesic approach. The best results are obtained in children 3 years of age or older. Although minor effects are frequent during EMONO inhalation, its use seems very safe because no single serious side effect was noted during this study. This helpful method is still underused, and it should be readily available in each emergency and pediatric department.

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.

Objectif Une premiere etude US (Triner WR 1997) a montre les benefices du MEOPA dans la crise migraineuse de l’adulte. Chez l’enfant aucune donnee n’etait disponible. Methode Deux etudes prospectives ont ete realisees en 2001 et 2003 aux urgences pediatriques Une fois la crise de migraine identifiee, 1 a 2 inhalations de 10 minutes de MEOPA ont ete faites. Resultats Cinquante-six enfants ont ete inclus en 2001, 29 en 2003. Dans 65 % des cas, l’inhalation de MEOPA a ete suffisante pour soulager la crise (EVA Aucun effet indesirable serieux n’a ete note. Pour 6 cas en 2001 et 1 cas en 2003, la cephalee a ete majoree durant l’inhalation. Tous ces effets ont cede tres rapidement a la fin de l’inhalation. Conclusion Ces 2 etudes pilotes suggerent fortement l’interet du MEOPA dans le traitement de la crise de migraine de l’enfant neanmoins, d’autres etudes sont necessaires pour en preciser l’efficacite (versus placebo) et les contre-indications (modifications du debit sanguin cerebral).

La douleur chez l’enfant a mis longtemps a etre prise en compte. Actuellement, les antalgiques et en particulier la morphine permettent de soulager les souffrances dans le cadre de protocoles qui impliquent l’enfant lui-meme.