Analgesia en Niños

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doi: 10.1136/adc.2008.137174

2008 2008 93: 995-997 originally published online February 27,Arch Dis Child

M Anderson and E Collins QUESTION 2

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(2670 articles)Pain (anaesthesia) (2719 articles)Pain (palliative care)

(30030 articles)Pain (neurology)

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groups (for example, mencap and scope)have sections on their website aboutdolphin therapy or swimming with dol-phins. Scope state that ‘‘dolphin therapy does not claim to cure any specific

condition but it may help alleviate somesymptoms associated with some condi-tions’’. They do however conclude‘‘research is on-going but there is notcurrently clear scientific evidence of last-ing benefits. Dolphin therapy is compara-tively expensive and not funded via any UK statutory agencies’’.

Since John Lilly first studied dolphin–human communication in the 1960s,much of the study by researchers in thisfield has been practice based and uncon-trolled ‘‘making it impossible to deter-

mine whether their results were due tospecific effects of DAT or a host of otherpotentially confounding factors’’.3

In 2003 Humphries looked at a practicebased research synthesis focusing on theeffectiveness of DAT in children(6 yearsof age with disabilities, in order todetermine the intervention’s implicationfor practice.1 She found six papers thatmet her selection criteria.4–9 The childreninvolved in the studies had a range of disabilities including autism, developmen-tal delay, speech disorders and traumaticbrain injury, with only two papers speci-fically including children with cerebralpalsy. Some studies included direct obser-vation of the children’s behaviour, othersused videotaped observations and oneinvolved a parent survey. Key resultsincluded acquisition of skills, cognitivefunctioning and improvement in psycho-emotional status. Criticisms of study design included small sample size, lack of a control group and respondent andinvestigator bias. Humphries concludedthat better designed and better controlledresearch is needed to determine whether

DAT is truly an effective interventionthat should be promoted to parents and

practitioners worldwide. She also notedthat the cost of these therapies is oftenhigh and that there is not enoughevidence available currently to supportthe use of this practice.

After reviewing 20 years of research in2005, Dr Karsten Brensing concluded‘‘there is still no proof that DAT is more

successful than other animal assistedtherapies’’.10

Several hypotheses have been proposedto explain how DAT works. One is thatdolphins emit healing energy vibrations;another speculation is that the ultrasoundfrom the echolocation clicks of dolphinsheals by stimulating the endocrine sys-tem. Neither of these theories has beensubstantiated.

DAT has become an increasingly pop-ular intervention for children with dis-abilities. Many parents believe it can have

a significant positive effect on the ‘‘cog-nitive, physical or social–emotional beha-viours’’ of their disabled child.

As the popularity of DAT has grown,claims of the therapeutic benefit havealso grown. Despite much media cover-age and support groups discussing itspotential benefits, we could find noevidence to date to support the benefitof swimming with dolphins for childrenwith cerebral palsy.

A Baverstock, Community Child Health Department,

Bath NHS House, Newbridge Hill, Bath BA1 3QE, UK;[email protected]

F Finlay , Community Child Health Department, BathNHS House, Newbridge Hill, Bath BA1 3QE, UK

Competing interests: None.

Arch Dis Child 2008;93:994–995.doi:10.1136/adc.2007.126573

REFERENCES1. Humphries TL. Effectiveness of dolphin-assisted

therapy as a behavioural intervention for youngchildren with disabilities. Bridges 2003;1(6):1–9.

2. Antonioli C, Reveley MA. Randomised controlled trialof animal facilitated therapy with dolphins in the

treatment of depression. BMJ 2005;331:1231.3. Marino L, Lilienfield SO. Dolphin-assisted therapy:

flawed data, flawed conclusions. Anthrozoos1998;11:194–200.

4. Lukina LN. Influence of dolphin-assisted therapysessions on the functional state of children withpsychoneurological symptoms of diseases. Hum

Physiol 1999;25:676–9.5. Nathanson DE. Using Atlantic bottlenose dolphins to

increase cognition of mentally retarded children. In:Lovibond PH, Wilson PH, eds. Clinical and abnormal

psychology . Amsterdam: North-Holland, 1989:233–42.6. Nathanson DE. Long-term effectiveness of dolphin-

assisted therapy for children with severe disabilities. Anthrozoos 1998;11:22–32.

7. Nathanson DE, de Castro D, Friend H, et al .Effectiveness of short-term dolphin assisted therapy

for children with severe disabilities. Anthrozoos1997;10:90–100.

8. Nathanson DE, de Faria S. Cognitive improvement ofchildren in water with and without dolphins.

Anthrozoos 1993;6:17–29.9. Servais V. Some comments on context embodiment

in zootherapy: the case of the Autidolfijn project. Anthrozoos 1999;12:5–15.

10. Brensing K. Expert statement on ‘‘Swim with thedolphin programs and dolphin-assisted therapy’’,2005. Agreement on the Conservation of Cetaceansof the Black Sea, Mediterranean Sea and contiguousAtlantic area: Third Meeting of the Scientific

Committee, Cairo, Egypt, 2005

QUESTION 2

ANALGESIA FOR CHILDREN WITH ACUTE

ABDOMINAL PAIN AND DIAGNOSTIC

ACCURACY

A 9-year-old boy presents with severe rightiliac fossa pain. You contact the surgicalteam who are currently in theatre and willnot be able to attend for at least 20 min. You wonder if administering morphine to

the boy will hinder or delay diagnosis.

STRUCTURED CLINICAL QUESTIONIn children with acute abdominal pain[patient] does analgesia before surgicalconsultation [intervention] affect surgicaldiagnostic accuracy [outcome]?

SEARCH STRATEGY AND OUTCOME

StrategyMedline and Embase were searched usingthe Dialog Datastar interface.

MEDLINE (1950–date) search terms:

(abdominal ADJ pain OR acute ADJabdomen) AND (analges$ OR pain ADJrelief) AND diagnosis AND LG= EN AND HUMAN = YES AND (CHILD#OR ADOLESCENT.DE. OR INFANT#)

EMBASE (1974–date) search terms:(abdominal ADJ pain OR acute ADJ abdo-men) AND (analges$ OR pain ADJ relief) AND diagnosis AND LG = EN ANDHUMAN = YES AND CHILD = YES

The BestBETs website was searched.

Outcome

MEDLINE yielded 56 papers and EMBASE yielded 100 papers. BestBETs yielded 1 BET,but although the clinical scenario involvedthe assessment of a child, all of the evidencerelated to studies performed in adults.

Clinical bottom line

c There is limited evidence from one smallstudy in adults with depression that dolphintherapy is effective in alleviating symptomsof mild to moderate depression. (Grade A)

c Dolphin therapy is comparativelyexpensive. Prices vary but a week’s

therapy in Florida can cost aroundUS$2000 not including travel andaccommodation.

c There is no conclusive scientific evidenceto support the benefit of swimming withdolphins for children with cerebral palsy,although many do report positive effects.

Clinical bottom line

c Surgical diagnostic accuracy is not affectedby pre-assessment analgesia. (Grade B)

c Early analgesia in children with suspectedsurgical abdominal pain is effective;administration should not be withheld

pending surgical consultation. (Grade B)

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Table 2 Analgesia for children with acute abdominal pain and diagnostic accuracy

Author, dateand country Patient group

Study type(level of evidence) Outcomes Key results Study weaknesses

Kim et al 60 children aged 5–18 years Randomised, Pain score Median difference in Small sample size. Post-

(2002), with abdominal pain for double-blind, reduction of pain score hoc power calculation

USA1 ,5 days scoring >5 on a placebo- between groups of two performed but not related

VAS. 0.1 mg/kg morphine controlled points (p =0.002) to the original question

iv vs same volume 0.9% trial Change in mean Paediatric emergency physicians

NaCl iv. Patients examined ( level 2b) number of areas of Morphine: 0.9 (95% CI 0.1 to 1.8)

before and after tenderness to palpation Placebo: 0.1 (95% CI 20.6 to 0.7)

administration of study drug before and after Surgeons

by paediatric emergency study drug Morphine: 0.1 (95% CI 20.6 to 0.7)

physicians and surgeons Placebo: 0.3 (95% CI 20.1 to 0.6)

Change in mean Paediatric emergency physicians

number of areas of Morphine: 1.0 (95% CI 0.1 to 1.9)

tenderness to Placebo: 0.0 (95% CI 20.3 to 0.4)

percussion before and Surgeons

after s tudy drug Morphine: 0 .2 (95% CI 20.1 to 0.6)

Placebo: 20.2 (95% CI 20.7 to 0.4)

Dif ference in Paediatric emergency phys ic ians

diagnostic accuracy Before study drug:

(true surgical causes 1.8% (95% CI 0.1 to 2.0)

and true non-surgical After study drug:causes as a proportion 5.4% (95% CI 20.1 to 0.3)

of all results) between Surgeons

morphine and placebo Before study drug:

groups 11.6% (95% CI 0.1 to 2.0)

After study drug:

11.8% (95% CI 0.1 to 2.0)

Green et 108 children aged 5–16 years Double-blind, Pain score using colour Mean pain score reduction No power calculation

al (2005), with abdominal pain of randomised, analogue scale with morphine 2.2 vs 1.2

Canada2 ,48 h duration of possible placebo- with placebo (p =0.015)

surgical origin. 0.05 mg/kg controlled trial Physician confidence in Morphine group: 68.9% (before)

morphine iv vs same volume (level 2b) diagnosis (0–100%) vs 69.5% (after) (effect size: 1.2%;

0.9% NaCl iv. Patients before and after study 95% CI 22.9% to 5.3%)

examined before and after drug Placebo group: 65.5% (before)administration of study vs 70.9% (after) (effect size: 5.3%;

drug by paediatric 95% CI 2.7% to 7.9%)

emergency physician and Surgeon confidence in Morphine group: 73.8%

afterwards only by diagnosis (0–100%) Placebo group: 73.6%

paediatric surgeon after study drug (effect size: 0.01%;

95% CI 20.39% to 0.40%)

Appendici tis at Morphine group: 24/25

laparotomy in those Placebo group: 22/24

children undergoing (p= 0.25)

surgical intervention

Kokki et 63 children aged 4–15 years Randomised, Mean s ummed pain Oxycodone group: 22 (SD 18) Small number of patients .

al (2005), with abdominal pain scori ng doubl e-blind intensity difference Pl acebo gro up: 9 (SD 12) Powered to detect

Finland3 >5 out of 10 on a VAS. placebo- over 7 observations at Mean difference: 13 significant change in pain

0.1 mg/kg buccal controlled trial half-hourly intervals (95% CI 2 to 24; p = 0 .04) scores but not diagnostic

oxycodone vs same volume (level 2b) Diagnostic accuracy Oxycodone group: accuracy

buccal 0.9% NaCl. Patients (true surgical causes Before analgesia 72%

examined before and after and true non-surgical After analgesia 88% (p = 0 .12)

administration of study drug causes as a proportion Placebo group:

of all results ) Before analgesia 84%

After analgesia 84%

(p value not reported)

Bailey et 90 children aged 8–18 years Randomised, Decreas e in pa in Morphine group: 24 (SD 23) mm Sample s ize required to

al (2007), with presumptive double- intensity on 100 mm Placebo group: 20 (SD 18 mm detect significant

Canada appendicitis and pain scoring blind placebo- VAS after study drug Mean difference: 4 mm reduction in pain

>5 out of 10 on a verbal controlled trial administration (95% CI 25 to 12 mm) (estimated as 220 mm)

Continued

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After removal of duplicates, 134abstracts were scanned. Four papers werefound to be relevant to the three-partquestion (see table 2).

COMMENTARY

Classic teaching in general surgery hassuggested that administration of analgesiain children with acute abdominal painshould be deferred until after a definitivesurgical treatment plan has been formu-lated. Theoretically, analgesia may maskpain and lessen examination findings thatwould normally suggest a surgical causefor abdominal pain.

All but one of the studies found thatopioid analgesia was effective at reducing

pain scores in children with acute abdom-inal pain. Bailey et al4 state that morphinewas not more effective than placebo indiminishing pain. This study suffers frombeing significantly underpowered regard-ing this outcome, but this does not fully explain the result, which appears to bedue to a high placebo response comparedto the other studies rather than a lack of response to morphine. The reasons forsuch a high response are likely to becomplex and beyond the scope of thiscommentary.

The studies identified all report thatadministration of analgesia to childrenwith acute abdominal pain did notsignificantly interfere with diagnosis.Diagnostic accuracy was defined in twostudies as true surgical and true non-surgical diagnoses as a proportion of allresults. One study detected no difference,3

while the other1 noted a difference whenchildren were examined by one subgroupof doctors, although the confidence inter-vals are borderline, and the authors’other measure of diagnostic accuracy (reduction in mean number of areas of

abdominal tenderness) was unaffectedby the administration of analgesia. One

study 2 used the doctors’ estimation of confidence in diagnosis as their measureof diagnostic accuracy. The remainingstudy 4 used the time between arrival inthe emergency department and the

surgical decision. Other proxy measuresof diagnostic accuracy, such as differ-ences in time to operating theatre andperforation rates, where recorded, arealso reported as being unaffected.

These results are in keeping with whatis known in adult patients; a recentCochrane review5 of this topic concludedthat the use of opioid analgesics inpatients with acute abdominal pain doesnot delay treatment decisions. None of the studies identified included childrenless than 5 years old. In infants and

preschool children, acute abdomen isuncommon, examination findings may be non-specific and as a result diagnosismay be difficult. Generalising findingsfrom older children to this age groupmay therefore be detrimental.

The clinical assessors were reported asblinded to whether the children hadreceived analgesia or placebo. However,as the same assessor was responsible forexamining the child before and afteradministration of the study drug, nomechanism existed to prevent biasintroduced by the assessor rememberingthe previous clinical findings. Only inthe study by Green et al2 were thechildren examined after administrationof medication by another assessor (apaediatric surgeon) who was naive tothe initial examination findings andwhose confidence in diagnosis was thesame for both the analgesia and theplacebo groups.

The studies all suffer from being under-powered to detect true differences indiagnostic ability. Post-hoc power calcula-tions performed on the papers by Green et

al2

and Kokki et al3

indicate that in orderto attain a power of 80% over 1000

patients would need to be recruited intoeach arm of a trial. This would be asignificant undertaking and subjectingseveral thousand children in pain toplacebo analgesia to identify a difference

in diagnostic accuracy that may have littleclinical impact is ethically suspect.Certainly, none of the studies aboveidentified major morbidity or mortality as a result of early treatment withanalgesia.

Since such a trial is therefore very unlikely to be performed, what remainsis to make an informed decision based onthe current evidence, and with thepatient’s interests foremost. Taking theseinto account, children with acute abdom-inal pain should be treated promptly and

adequately with analgesia unless futurestudies suggest evidence of harm.

M Anderson, Academic Division of Child Health,University of Nottingham, Derbyshire Children’s Hospital,Derby, UK; [email protected]

E Collins, University of Nottingham, Nottingham, UK

Competing interests: None.

Arch Dis Child 2008;93:995–997.doi:10.1136/adc.2008.137174

REFERENCES1. Kim MK, Strait RT, Sato TT, et al .

A randomized clinical trial of analgesia in childrenwith acute abdominal pain. Acad Emerg Med 2002;9:281–7.

2. Green R, Bulloch B, Kabani A, et al . Early analgesia forchildren with acute abdominal pain. Pediatrics2005;116:978–83.

3. Kokki H, Lintula H, Vanamo K, et al . Oxycodonevs placebo in children with undifferentiatedabdominal pain. Arch Pediatr Adolesc Med 2005;159:320–5.

4. Bailey B, Bergeron S, Gravel J, et al . Efficacy andimpact of intravenous morphine before surgicalconsultation in children with right lower quadrant painsuggestive of appendicitis: a randomized controlledtrial. Ann Emerg Med 2007;50:371–8.

5. Manterola C, Astudillo P, Losada H, et al . Analgesia in

patients with acute abdominal pain. Cochrane Database Syst Rev 2007;(3):CD005660.

Table 2 Continued

Author, dateand country Patient group

Study type(level of evidence) Outcomes Key results Study weaknesses

numeric scale. 0.1 mg/kg (level 2b) Difference between Morphine group: 269 min was calculated as 152.

iv morphine vs similar time of arrival Placebo group: 307 min Sample size required to

looking placebo. Patients in ED and time of Mean difference: 234 min detect difference of 1 h

examined before and after surgical decision for (95% CI 2105 to 40 min) in time between arrival

administration of study drug disposition of patient and surgical disposition

was calculated as 184.Study terminated early

due to slow enrolment

and interim analysis

showing no difference

ED, emergency department; VAS, visual analogue scale.

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