Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
World Journal of Pediatrics
Published in: World Journal of Pediatrics 5/2019

01-10-2019 | Intellectual Disability | Review Article

Sedation and analgesia in children with cerebral palsy: a narrative review

Authors: Ingrid Rabach, Francesca Peri, Marta Minute, Emanuela Aru, Marianna Lucafò, Alberto Di Mascio, Giorgio Cozzi, Egidio Barbi

Published in: World Journal of Pediatrics | Issue 5/2019

Login to get access

Abstract

Background

Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications.

Data sources

We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as ‘cerebral palsy and children and pain’ or ‘sedation and cerebral palsy and children’.

Results

While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation.

Conclusions

Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.
Literature
1.
American Academy of Pediatrics; American Academy of Pediatric Dentistry, Work Group on Sedation, Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118:2587–602.
2.
Sacchetti A, Senula G, Strickland J, Dubin R. Procedural sedation in the community emergency department: initial results of the ProSCED registry. Acad Emerg Med. 2007;14:41–6 (Epub 2006 Aug 31).PubMed
3.
Mace SE, EMSC Panel (Writing Committee) on Critical Issues in the Sedation of Pediatric Patients in the Emergency, et al. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008;51:378–99 (399.e1-57).PubMed
4.
Coté CJ, Wilson S. Guidelines for monitoring anda management of pediatric patients before, during and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatrics. 2016;138:e20161212.PubMed
5.
Grunwell JR, McCracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014;30:381–7.PubMed
6.
Mazurek MS. Sedation and analgesia for procedures outside the operating room. Semin Pediatr Surg. 2004;13:166–73.PubMed
7.
Ramaiah R, Bhananker S. Pediatric procedural sedation and analgesia outside the operating room: anticipating, avoiding and managing complications. Expert Rev Neurother. 2011;11:755–63.PubMed
8.
Po’ C, Agosto C, Farina MI, Catalano I, Coccato F, Lazzarin P, Benini F. Procedural pain in children: education and management. The approach of an Italian pediatric pain center. Eur J Pediatr. 2012;171:1175–83.PubMed
9.
Burkitt CC, Breau LM, Zabalia M. Parental assessment of pain coping in individuals with intellectual and developmental disabilities. Res Dev Disabil. 2011;32:1564–71.PubMed
10.
Barbi E, Badina L, Massaro M, Pisciotta G, Ventura A. Paediatricians’ attitudes toward pain in children with severe cognitive impairment. A regional survey. Pediatr Med Chir. 2014;36:94.PubMed
11.
Weissman-Fogel I, Roth A, Natan-Raav K. Lotan M Pain experience of adults with intellectual disabilities–caregiver reports. J Intellect Disabil Res. 2015;59:914–24.PubMed
12.
Kingsnorth S, et al. Chronic pain assessment tools for cerebral palsy: a systematic review. Pediatrics. 2015;136:e947–60.PubMed
13.
Novak I, Hines M, Goldsmith S, Barclay R. Clinical prognostic messages from a systematic review on cerebral palsy. Pediatrics. 2012;130:e1285–312.PubMed
14.
Massaro M, Pastore S, Ventura A, Barbi E. Pain in cognitively impaired children: a focus for general pediatricians. Eur J Pediatr. 2013;172:9–14.PubMed
15.
Butler MG, Hayes BG, Hathaway MM, Begleiter ML. Specific genetic diseases at risk for sedation/anesthesia complications. Anesth Analg. 2000;91:837–55.PubMedPubMedCentral
16.
Sewell MD, Eastwood DM, Wimalasundera N. Managing common symptoms of cerebral palsy in children. BMJ. 2014;25:g5474.
17.
Colver A, Fairhurst C, Pharoah PO. Cerebral palsy. Lancet. 2014;383:1240–9.PubMed
18.
Fairhurst C. Cerebral palsy: the whys and hows. Arch Dis Child Educ Pract Ed. 2012;97:122–31.PubMed
19.
Fahey MC, Maclennan AH, Kretzschmar D, Gecz J, Kruer MC. The genetic basis of cerebral palsy. Dev Med Child Neurol. 2017;59:462–9.PubMed
20.
Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006;28:183–91.PubMed
21.
Breau LM, Camfield CS, McGrath PJ, Finley GA. Risk factors for pain in children with severe cognitive impairments. Dev Med Child Neurol. 2004;46:364–71.PubMed
22.
Breau LM, Camfield CS, McGrath PJ, Finley GA. The incidence of pain in children with severe cognitive impairments. Arch Pediatr Adolesc Med. 2003;157:1219–26.PubMed
23.
Parkinson KN, Gibson L, Dickinson HO, Colver AF. Pain in children with cerebral palsy: a cross-sectional multicentre European study. Acta Paediatr. 2010;99:446–51.PubMed
24.
Penner M, Xie WY, Binepal N, Switzer L, Fehlings D. Characteristics of pain in children and youth with cerebral palsy. Pediatrics. 2013;132:e407–13.PubMed
25.
Nolan J, Chalkiadis GA, Low J, Olesch CA, Brown TC. Anaesthesia and pain management in cerebral palsy. Anaesthesia. 2000;55:32–41.PubMed
26.
Krauss BS, Calligaris L, Green SM, Barbi E. Current concepts in management of pain in children in the emergency department. Lancet. 2016;387:83–92.PubMed
27.
Hennequin M, Morin C, Feine JS. Pain expression and stimulus localisation in individuals with Down’s syndrome. Lancet. 2000;356:1882–7.PubMed
28.
Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviors. Pain. 2002;99:281–8.PubMed
29.
Swiggum M, Hamilton ML, Gleeson P, Roddey T, Mitchell K. Pain assessment and management in children with neurologic impairment: a survey of pediatric physical therapists. Pediatr Phys Ther. 2010;22:330–5.PubMed
30.
Voepel-Lewis T, Malviya S, Tait AR. Validity of parent ratings as proxy measures of pain in children with cognitive impairment. Pain Manag Nurs. 2005;6:168–74.PubMed
31.
Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006;16:258–65.PubMed
32.
Tyler DC, Tu A, Douthit J, Chapman CR. Toward validation of pain measurement tools for children: a pilot study. Pain. 1993;52:301–9.PubMed
33.
Solodiuk J, Curley MA. Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS). J Pediatr Nurs. 2003;18:295–9.PubMed
34.
Hunt A, Goldman A, Seers K, Crichton N, Mastroyannopoulou K, Moffat V, Oulton K, Brady M. Clinical validation of the paediatric pain profile. Dev Med Child Neurol. 2004;46:9–18.PubMed
35.
Collignon P, Giusiano B. Validation of a pain evaluation scale for patients with severe cerebral palsy. Eur J Pain. 2001;5:433–42.PubMed
36.
Breau LM, Finley GA, McGrath PJ, Camfield CS. Validation of the non-communicating children’s pain checklist-postoperative version. Anesthesiology. 2002;96:528–35.PubMed
37.
Solodiuk JC. Parent described pain responses in nonverbal children with intellectual disability. Int J Nurs Stud. 2013;50:1033–44. CrossRefPubMed
38.
Voepel-Lewis T, Malviya S, Tait AR, Merkel S, Foster R, Krane EJ, Davis PJ. A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anesth Analg. 2008;106:72–8 (table of contents).PubMed
39.
Crosta QR, Ward TM, Walker AJ, Peters LM. A review of pain measures for hospitalized children with cognitive impairment. J Spec Pediatr Nurs. 2014;19:109–18. CrossRefPubMedPubMedCentral
40.
Chen-Lim ML, Zarnowsky C, Green R, Shaffer S, Holtzer B, Ely E. Optimizing the assessment of pain in children who are cognitively impaired through the quality improvement process. J Pediatr Nurs. 2012;27:750–9.PubMed
41.
Massaro M, Ronfani L, Ferrara G, Badina L, Giorgi R, D'Osualdo F, et al. A comparison of three scales for measuring pain in children with cognitive impairment. Acta Paediatr. 2014;103:e495–500.PubMed
42.
Riquelme I, Montoya P. Developmental changes in somatosensory processing in cerebral palsy and healthy individuals. Clin Neurophysiol. 2010;121:1314–20.PubMed
43.
Schreiber S, Cozzi G, Rutigliano R, Assandro P, Tubaro M, Cortellazzo Wiel L, et al. Analgesia by cooling vibration during venipuncture in children with cognitive impairment. Acta Paediatr. 2016;105:e12–6.PubMed
44.
Slifer KJ, Hankinson JC, Zettler MA, Frutchey RA, Hendricks MC, Ward CM, et al. Distraction, exposure therapy, counterconditioning, and topical anesthetic for acute pain management during needle sticks in children with intellectual and developmental disabilities. Clin Pediatr (Phila). 2011;50:688–97.
45.
Hansen LK, Kibaek M, Martinussen T, Kragh L, Hejl M. Effect of a clown’s presence at botulinum toxin injections in children: a randomized, prospective study. J Pain Res. 2011;4:297–300.PubMedPubMedCentral
46.
Ben-Pazi H, Cohen A, Kroyzer N, Lotem-Ophir R, Shvili Y, Winter G, et al. Clown-care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections—a quasi-randomized controlled crossover study. PLoS One. 2017;12:e0175028.PubMedPubMedCentral
47.
Pascolo P, Peri F, Montico M, Funaro M, Parrino R, Vanadia F, et al. Needle-related pain and distress management during needle-related procedures in children with and without intellectual disability. Eur J Pediatr. 2018;177:1753–60.PubMed
48.
Yoshikawa F, Tamaki Y, Okumura H, Miwa Z, Ishikawa M, Shimoyama K, et al. Risk factors with intravenous sedation for patients with disabilities. Anesth Prog. 2013;60:153–61.PubMedPubMedCentral
49.
Cote CJ, Wilson S. Guideline for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatr Dent. 2016;38:77–106.
50.
Mason KP. Pediatric sedation outside of the operating room. A multispecialty international collaboration. Berlin: Springer; 2012.
51.
Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg. 1991;72:282–8.PubMed
52.
Zamunér AR, Cunha AB, da Silva E, Negri AP, Tudella E, Moreno MA. The influence of motor impairment on autonomic heart rate modulation among children with cerebral palsy. Res Dev Disabil. 2011;32:217–21.PubMed
53.
Riker RR, Fraser GL. Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit. Pharmacotherapy. 2005;25:8S–18S.PubMed
54.
Lam F, Bhutta AT, Tobias JD, Gossett JM, Morales L, Gupta P. Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart disease. Pediatr Cardiol. 2012;33:1069–77.PubMed
55.
Mikesell Christine E, Atkinson David E, Rachman Bonnie R, Prolonged QT. Syndrome and sedation. A case report and a review of the literature. Pediatr Emer Care. 2011;27:129–31.
56.
Grunwell JR, Marupudi NK, Gupta RV, Travers CD, Mccracken CE, Williamson JL, Stockwell JA, Fortenberry JD, Couloures K, Cravero J, Kamat PP. Outcomes following implementation of pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies. Paediatr Anaesth. 2016;26:628–36.PubMedPubMedCentral
57.
Dahlseng MO, Finbråten AK, Júlíusson PB, Skranes J, Andersen G, Vik T. Feeding problems, growth and nutritional status in children with cerebral palsy. Acta Paediatr. 2012;101:92–8.PubMed
58.
Mtaweh H, Bayır H, Kochanek PM, Bell MJ. Effect of a single dose of propofol and lack of dextrose administration in a child with mitochondrial disease: a case report. J Child Neurol. 2014;29:NP40–6.PubMed
59.
Oberlander TF, O’Donnell ME. Beliefs about pain among professionals working with children with significant neurologic impairment. Dev Med Child Neurol. 2001;43:138–40.PubMed
60.
Misurac JM, Knoderer CA, Leiser JD, Nailescu C, Wilson AC, Andreoli SP. Nonsteroidal anti-inflammatory drugs are an important cause of acute kidney injury in children. J Pediatr. 2013;162:1153–9.PubMed
61.
Marchetti F, Gerarduzzi T, Ventura A. Proton pump inhibitors in children: a review. Dig Liver Dis. 2003;35:738–46.PubMed
62.
Marzuillo P, Guarino S, Barbi E. Paracetamol: a focus for the general pediatrician. Eur J Pediatr. 2014;173:415–25.PubMed
63.
Kannikeswaran N, Sethuraman U, Sivaswamy L, Chen X, Mahajan PV. Children with and without developmental disabilities: sedation medication requirements and adverse events related to sedation. Pediatr Emerg Care. 2012;28:1036–40.PubMed
64.
Kim EJ, Jo YY, Kil HK. Optimal sedative dose of propofol to start MRI in children with cerebral palsy. Korean J Anesthesiol. 2011;61:216–9.PubMedPubMedCentral
65.
Kannikeswaran N, Mahajan PV, Sethuraman U, Groebe A, Chen X. Sedation medication received and adverse events related to sedation for brain MRI in children with and without developmental disabilities. Paediatr Anaesth. 2009;19:250–6.PubMed
66.
Cortellazzi P, Lamperti M, Minati L, Falcone C, Pantaleoni C, Caldiroli D. Sedation of neurologically impaired children undergoing MRI: a sequential approach. Paediatr Anaesth. 2007;17:630–6.PubMed
67.
Malviya S, Voepel-Lewis T, Tait AR, Reynolds PI, Gujar SK, Gebarski SS, et al. Pentobarbital vs chloral hydrate for sedation of children undergoing MRI: efficacy and recovery characteristics. Paediatr Anaesth. 2004;14:589–95.PubMed
68.
Collado V, Faulks D, Nicolas E, Hennequin M. Conscious sedation procedures using intravenous midazolam for dental care in patients with different cognitive profiles: a prospective study of effectiveness and safety. PLoS One. 2013;8:e71240.PubMedPubMedCentral
69.
Faulks D, Hennequin M, Albecker-Grappe S, Manière MC, Tardieu C, Berthet A, et al. Sedation with 50% nitrous oxide/oxygen for outpatient dental treatment in individuals with intellectual disability. Dev Med Child Neurol. 2007;49:621–5.PubMed
70.
Chaushu S, Gozal D, Becker A. Intravenous sedation: an adjunct to enable orthodontic treatment for children with disabilities. Eur J Orthod. 2002;24:81–9.PubMed
71.
Vaile L, Finlay F. Is injection of botulinum toxin type A effective in the treatment of drooling in children with cerebral palsy? Arch Dis Child. 2006;91:862–3.PubMedPubMedCentral
72.
Pavone V, Testa G, Restivo DA, Cannavò L, Condorelli G, Portinaro NM, et al. Botulinum toxin treatment for limb spasticity in childhood cerebral palsy. Front Pharmacol. 2016;19:29.
73.
Chow C, Choong CT. Ketamine-based procedural sedation and analgesia for botulinum toxin A injections in children with cerebral palsy. Eur J Paediatr Neurol. 2016;20:319–22.PubMed
74.
Forrester M, Srinivasan J, Mihrshahi S, Waugh M, O'Flaherty S, Rice J, et al. Conscious sedation or general anaesthetic for intramuscular botulinum toxin injections in children—a two centre cross-sectional prospective. Eur J Paediatr Neurol. 2012;16:215–7.PubMed
75.
Brochard S, Blajan V, Lempereur M, Garlantezec R, Houx L, Le Moine P, et al. Determining the technical and clinical factors associated with pain for children undergoing botulinum toxin injections under nitrous oxide and anesthetic cream. Eur J Paediatr Neurol. 2011;15:310–5.PubMed
76.
Gubbay A, Langdon K. Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injections in children. Dev Med Child Neurol. 2009;51:491–2 (author reply 492).PubMed
77.
Kumar R, Sneade C, Littler K. Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injections in children. Dev Med Child Neurol. 2009;51:838–9.PubMed
78.
Zier JL, Rivard PF, Krach LE, Wendorf HR. Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injections in children. Dev Med Child Neurol. 2008;50:854–8.PubMed
79.
Bakheit AM. Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres. Eur J Neurol. 2003;10:415.PubMed
80.
Nilsson S, Brunsson I, Askljung B, Påhlman M, Himmelmann K. A rectally administered combination of midazolam and ketamine was easy, effective and feasible for procedural pain in children with cerebral palsy. Acta Paediatr. 2017;106:458–62.PubMed
Metadata
Title
Sedation and analgesia in children with cerebral palsy: a narrative review
Authors
Ingrid Rabach
Francesca Peri
Marta Minute
Emanuela Aru
Marianna Lucafò
Alberto Di Mascio
Giorgio Cozzi
Egidio Barbi
Publication date
01-10-2019
Publisher
Springer Singapore
Published in
World Journal of Pediatrics / Issue 5/2019
Print ISSN: 1708-8569
Electronic ISSN: 1867-0687
DOI
https://doi.org/10.1007/s12519-019-00264-0

Other articles of this Issue 5/2019

World Journal of Pediatrics 5/2019 Go to the issue

Review Article

A negative regulator of synaptic development: MDGA and its links to neurodevelopmental disorders

Original Article

Establishment of an efficient reverse genetic system of Mumps virus S79 from cloned DNA

Original Article

Management of Wilms tumor with intravenous thrombus in children: a single center experience

Meta-analysis

Fluoroquinolones-resistant Shigella species in Iranian children: a meta-analysis

Original Article

Impact of dyslipidemia on estimated glomerular filtration rate in apparently healthy children and adolescents: the CASPIAN-V study

Brief Report

Attenuated MuV-S79 as vector stably expressing foreign gene