Franca Benini

In recent years the emergence of new types of patient, clinical situations, technological frontiers and "health" objectives have changed considerably the needs of ill children, this also concerns pediatric palliative care (PPC). In Italy, despite the introduction of legislation (Law 38/2010) stipulating the right of children and families to access appropriate services for pain control and pediatric palliative care, the availability of these services is still limited. The aim of this study is to highlight, through a review of the existing data and published literature, the critical issues that obstacle the planning and development of PPC services in Italy. Four main areas identified were: socio-cultural setting; types of patients and nature of diseases requiring PPC; training for PPC providers; regulatory and political issues. This type of analysis can provide the rational for advancing proposals and developing supportive, corrective and implementation strategies.

We report our clinical experience on the effect of Scrambler Therapy (ST) for a child with acute mixed pain refractory to pharmacological treatment. ST, recently proposed as an alternative treatment for chronic neuropathic pain in adults, is a noninvasive approach to relieve pain, by changing pain perception at brain level. It is safe and has no side effects. Further research is needed to assess its efficacy for acute pain and for paediatric population.

Pediatric palliative care represents the ideal response to life-limiting and life-threatening diseases and requires a specific and multidisciplinary training. This study aims at evaluating in Italy the training programs offered in pain therapy and pediatric palliative care, the exposure, and the personal experience concerning end-of-life care management. The data have been obtained through a survey addressed to all the residents specializing in pediatrics in Italy. Three hundred forty-eight of 1,200 residents from 33 of the 41 schools of pediatrics existing in Italy responded to the questionnaire. One hundred seventy-four of them (50 %) declared they received training in end-of-life care at least once: 146 during their graduation course of medicine, 84 during the pediatric residency, and 54 in both occasions. Sixty percent of respondents were present at one death at least, with an increasing percentage in the last years of residency (91.5 % in the fifth year) but only 12 % were directly involved in the management (36.2 % in the fifth year); 5.7 % managed at least one communication of death; 12.6 % followed sedo-analgesia protocols. Only 11 % of residents felt ready to face end-of-life care management. Conclusion: The training in end-of-life care in Italy is not currently satisfactory. Further efforts are therefore required to create a comprehensive and multidisciplinary training.

Codeine is a mild opioid widely used as an analgesic in various age groups, including various pediatric settings. It is a prodrug that owes its analgesic effect almost entirely to the principal metabolite: morphine. The genetic polymorphisms can contribute to making the pharmacokinetics of codeine hard to predict and this it is particularly important in the pediatric population because infants and children have greater susceptibility to the side-effects of morphine. In recent years there have been several reports in the literature on the risks relating to the use of codeine. In August 2012, the American Food and Drugs Administration began to revise its recommendations for the safe use of codeine and in February 2013, established that codeine should not be used for postoperative pain control in children undergoing adenoidectomy and/or tonsillectomy and did restrict the use of this drug in the pediatric population. In June 2013, the European Medicine Agency opted the same decision. In July 2013, the Agenzia Italiana del Farmaco prohibit the use of medicines containing codeine for patients under 12 years old and recommended a limited use of the drug, in many other situations. Complying with these recommendations naturally means changing habits and treatment strategies well established in pediatric practice, but other drugs, tools and techniques available enable us to continue to assure an adequate pain control in pediatric patients, irrespective of their age and situation. The article proposes same alternatives of pain control drugs.

Background: Pain experienced by children in emergency departments (EDs) is often poorly assessed and treated. Although local protocols and strategies are important to ensure appropriate staff behaviours, few studies have focussed on pain management policies at hospital or department level. This study aimed at describing the policies and reported practices of pain assessment and treatment in a national sample of Italian pediatric EDs, and identifying the assocoated structural and organisational factors. Methods: A structured questionnaire was mailed to all the 14 Italian pediatric and maternal and child hospitals and to 5 general hospitals with separate pediatric emergency room. There were no refusals. Information collected included the frequency and mode of pain assessment, presence of written pain management protocols, use of local anaesthetic (EMLA cream) before venipuncture, and role of parents. General data on the hospital and ED were also recorded. Multiple Correspondence Analysis was used to explore the multivariable associations between the characteristics of hospitals and EDs and their pain management policies and practices. Results: Routine pain assessment both at triage and in the emergency room was carried out only by 26% of surveyed EDs. About one third did not use algometric scales, and almost half (47.4%) did not have local protocols for pain treatment. Only 3 routinely reassessed pain after treatment, and only 2 used EMLA. All EDs allowed parents’ presence and most (17, 89.9%) allowed them to stay when painful procedures were carried out. Eleven hospitals (57.9%) allowed parents to hold their child during blood sampling. Pediatric and maternal and child hospitals, those located in the North of Italy, equipped with medico-surgical-traumatological ED and short stay observation, and providing full assessment triage over 24 hours were more likely to report appropriate policies for pain management both at triage and in ER. A nurses to admissions ratio ≥ median was associated with better pain management at triage. Conclusions: Despite availability of national and international guidelines, pediatric pain management is still sub-optimal in Italian emergency departments. Multifaceted strategies including development of local policies, staff educational programs, and parental involvement in pain assessment should be carried out and periodically reinforced.

Pain management should be warranted for all children in every situation. Italian legislation proposes a model for pain assistance based on specialized tertiary centers which provide direct clinical management for complex cases and assure continuous cooperation with hospitals and family pediatricians for managing painful conditions every day. The Procedural Pain Service of the University of Padua Department of Pediatrics applies such model for procedural pain management. We describe activities of Service since January 1, 2006 on two levels: education and training for territorial services and sedation–analgesia when required for invasive and painful procedures. Since 2006 to date, the Service team produced an internal protocol for procedural sedation, developed two master courses, and organized a training program for procedural pain management in the territorial context. Procedural sedation–analgesia service provided overall 10,832 sedations to perform 14,264 procedures for 3,815 patients, median age of 6 years old. The most frequently performed procedures were lumbar puncture and bone marrow aspiration, followed by gastroscopy and bronchoscopy. Most frequently administered drug combinations were local analgesia + intravenous midazolam alone or midazolam and propofol or midazolam and propofol and ketamine; most frequently used non-pharmacological methods were distraction using cartoons and bubbles. Minor adverse events were recorded in 281 cases (2.5%), the most common being desaturation (2.1%). In conclusion, our model functions on two integrated levels, and it can be considered generally applicable as a solution for pain management.

Background: Beliefs of caregivers about patient's pain have been shown to influence assessment and treatment of children's pain, now considered an essential part of cancer treatment. Painful procedures in hematology-oncology are frequently referred by children as the most painful experiences during illness. Aim of this study was to evaluate professionals' beliefs about painfulness of invasive procedures repeatedly performed in Pediatric Hemato-Oncology Units.Methods: Physicians, nurses, psychologists and directors working in Hemato-Oncology Units of the Italian Association of Pediatric Hematology-Oncology (AIEOP) were involved in a wide-nation survey. The survey was based on an anonymous questionnaire investigating beliefs of operators about painfulness of invasive procedures (lumbar puncture, bone marrow aspirate and bone marrow biopsy) and level of pain management.Results: Twenty-four directors, 120 physicians, 248 nurses and 22 psychologists responded to the questionnaire. The score assigned to the procedural pain on a 0-10 scale was higher than 5 in 77% of the operators for lumbar puncture, 97.5% for bone marrow aspiration, and 99.5% for bone marrow biopsy. The scores assigned by nurses differed statistically from those of the physicians and directors for the pain caused by lumbar puncture and bone marrow aspiration. Measures adopted for procedural pain control were generally considered good.Conclusions: Invasive diagnostic-therapeutic procedures performed in Italian Pediatric Hemato-Oncology Units are considered painful by all the caregivers involved. Pain management is generally considered good. Aprioristically opinions about pain depend on invasiveness of the procedure and on the professional role.

Introduction: Medical and technological progress allows newborns, children and teenagers suffering from life-limiting and life-threatening illness to survive, but not necessarily to recover. Data on the number of children eligible for pediatric palliative care [PPC] and their needs are useful for health care planning. The main aim of this study was to ascertain the prevalence and the course of children eligible for pediatric palliative care in Italy. Methods: The data source considered was the hospital discharge records (HDR), containing information on the children's diagnosis, their personal and clinical details, hospital admissions, procedures and discharge. The list of diseases eligible for PPC was based on the ICD IX CM list, according to ACT criteria. All records of hospital admissions in Italy for the years 2001–2003 were processed. The first step was to identify hospital admissions involving individuals 0–17 years old with at least one of the selected life-limiting and life-threatening illnesses. The main features of these hospital admissions were described in terms of duration, frequency, and discharge arrangements, estimating the number of patients eligible for PPC and the number of deaths occurring in hospital. Results: The total number of hospital admissions concerning patients aged 0–17 years amounted to 3,578,649. Our restrictive criteria identified 323,415 hospital admissions in 3 years relating to diseases eligible for pediatric palliative care, which involved approximately 12,000 children. The most common diseases fell respectively into the following sectors: perinatal, neurological, neoplastic and congenital diseases. The number of days spent in hospital for diseases eligible for PPC ranged from 556,075 days/year to 591,983, and concerned 35,000 children every year. Conclusions: Our data agree with other international surveys on the prevalence and typology of pediatric patients. The HDR could be useful for the estimation of the cases eligible for pediatric palliative care and for monitoring of deaths in hospital.