Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children

Prodrug strategies for enhancing the percutaneous absorption of drugs

The transdermal application of drugs has attracted increasing interest over the last decade or so, due to the advantages it offers, compared to other delivery methods. The development of an efficient means of transdermal delivery can increase drug concentrations, while reducing their systemic distribution, thereby avoiding certain limitations of oral administration. The efficient barrier function of the skin, however, limits the use of most drugs as transdermal agents. This limitation has led to the development of various strategies to enhance drug-skin permeation, including the use of penetration enhancers. This method unfortunately has certain proven disadvantages, such as the increased absorption of unwanted components, besides the drug, which may induce skin damage and irritancy. The prodrug approach to increase the skin’s permeability to drugs represents a very promising alternative to penetration enhancers. The concept involves the chemical modification of a drug into a bioreversible entity that changes both its pharmaceutical and pharmacokinetic characteristics to enhance its delivery through the skin. In this review; we report on the in vitro attempts and successes over the last decade by using the prodrug strategy for the percutaneous delivery of pharmacological molecules.

The postoperative management of pain from intracranial surgery in pediatric neurosurgical patients

Pain following intracranial surgery has historically been undertreated because of the concern that opioids, the analgesics most commonly used to treat moderate-to-severe pain, will interfere with the neurologic examination and adversely affect postoperative outcome. Over the past decade, accumulating evidence, primarily in adult patients, has revealed that moderate-to-severe pain is common in neurosurgical patients following surgery. Using the neurophysiology of pain as a blueprint, we have highlighted some of the drugs and drug families used in multimodal pain management. This analgesic method minimizes opioid-induced adverse side effects by maximizing pain control with smaller doses of opioids supplemented with neural blockade and nonopioid analgesics, such nonsteroidal antiinflammatory drugs, local anesthetics, corticosteroids, N-methyl-D-aspartate (NMDA) antagonists, α2 -adrenergic agonists, and/or anticonvulsants (gabapentin and pregabalin).

Comparison of benzydamine hydrochloride and Salvia officinalis as an adjuvant local treatment to systemic nonsteroidal anti-inflammatory drug in controlling pain after tonsillectomy, adenoidectomy, or both: an open-label, single-blind, randomized clinical trial

BACKGROUND

Benzydamine hydrochloride (BNZD) is a nonsteroidal anti-inflammatory drug (NSAID) used in an oral rinse formulation as an adjuvant to other NSAIDs in controlling postoperative pain after tonsillectomy, adenoidectomy, or both. Salvia officinalis (SO) is a topically applied herbal preparation frequently used for the same indication. Pain, bleeding, and infection are the most common postoperative complications of tonsillectomy.

OBJECTIVE

The aim of this study was to compare the efficacy and tolerability of BNDZ with those of SO as adjuvant treatments in controlling postoperative pain.

METHODS

This open-label, single-blind, randomized clinical trial was conducted at the Department of Otorhinolaryngology, Clinical Hospital Center "Dr. Dragiša Mišović-Dedinje" (Belgrade, Serbia and Montenegro). Pediatric and adult patients undergoing tonsillectomy, adenoidectomy, or both were enrolled. Patients were randomized to receive BNZD or SO, in addition to ibuprofen 20 mg/kg·d (children) or diclofenac 100 mg/d (adults). The primary end point was the proportion of patients with mild or no pain on postoperative days 1, 2, 4, and 7. Secondary end points were the incidences of infection, hemorrhage, and other adverse events.

RESULTS

A total of 420 patients were enrolled (217 females, 203 males; 278 children, 142 adults; mean [SD] age, 6.2 [2.1] years [children] and 24.1 [9.8] years [adults] [range, 3-45 years]). One hundred thirty-eight children received BNZD; 140 received SO (both in addition to ibuprofen 20 mg/kg·d). Seventy-two adults received BNZD; 70 received SO (both in addition to diclofenac 100 mg/d). A significantly lower proportion of children treated with adjuvant BNZD experienced moderate or severe pain than those treated with SO at each time point (P < 0.01 at days 1 and 4; P < 0.001 at days 2 and 7). In children, the risk for postoperative infection was similar between BNZD and SO (absolute risk reduction [ARR], 6.9%; 95% CI, 6.4%-7.6%); however, the risk was reduced in adults (ARR, 19.0%; 95% CI, 16.5%-21.9%; P = 0.008).

CONCLUSIONS

In this clinical trial of children and adults who underwent tonsillectomy, adenoidectomy, or both, BNZD, as an adjuvant to an NSAID, was more effective than SO in controlling postoperative pain and infection. The pain-reducing effect of BNZD was of quick onset and persisted for 1 week after surgery. The safety profile of BNZD was comparable to that of SO, with the exception of postoperative infection in adults, for which BNZD was more efficacious. In particular, the use of BNZD was not associated with a high risk for early postoperative hemorrhage.

Anaesthesiological and intensive care management in craniovertebral junction surgery

The main factors of modern perioperative care of the craniovertebral junction surgery include a comprehensive approach to the patients, including a thorough cardiorespiratory, neurophysiological, and metabolic assessment, intraoperative monitoring of spinal cord function, safe airway management, and judicious use of fluids and blood transfusions. Admission in PICU shortly after the CVJ surgery is mandatory to ensure haemodynamic and respiratory stability and to recognize postoperative complications. Anticipating complications in order to achieve an early treatment and adverse event prophylaxis can contribute to reduced morbidity and mortality and increased patients' safety. Multidisciplinary management of perioperative patient care and careful pain control is mandatory in order to improve the outcomes.

Sedation and analgesia in critically ill children

The interplay of pain, discomfort, and fear can cause agitation in critically ill children. Therefore, sedation and analgesia are essential components in the intensive care unit setting and are best managed with a multidisciplinary team approach. No one standard approach exists to assess and manage pain and anxiety. Many tools are available for the assessment of pain and sedation, but each tool has its advantages and disadvantages. Clinicians should consider adopting a validated tool for routine continuous assessment. Multiple pharmacological therapies are available to manage pain, anxiety, fear, and agitation. Dosing of these agents can be influenced by age-related pharmacokinetic and pharmacodynamic changes. Agents should be selected on the basis of the child's disease state, desired level of sedation, and cardiac and respiratory status.

Rheological characterization of an acetaminophen jelly

The aim of this study was to prepare an inclusion complex of acetaminophen and β-cyclodextrin (molar ratio of 1:1). A jelly with inclusion complexes formed by kneading was prepared. The formation of inclusion complexes was assessed by powder X-ray diffraction patterns and Fourier transform-infrared spectroscopy. Jellies were prepared with xanthan gum, gelatin, and κ-carrageenan. The concentration of each jelling agent was 0.5, 1.0, and 1.5% w/v. Viscoelasticity and dissolution characteristics were determined and osmometry was performed. PGWater(™), a commercial jelly for fluid replacement, served as a reference for viscoelastic characteristics and dissolution. Powder X-ray diffraction measurement revealed a different diffraction pattern for the kneading than for acetaminophen and β-cyclodextrin. Fourier transform-infrared spectroscopy revealed an absorption peak (at around 1655 cm(-1)) due to the carbonyl group and benzene ring (at around 1610 cm(-1)) of acetaminophen. In contrast, the kneaded mixture (1:1) had a shift in the absorption peak due to the carbonyl group (at around 1650 cm(-1)) in acetaminophen's molecular structure, and the formation of an inclusion complex was noted. The viscosity of xanthan gum-1.0, gelatin-1.5, and carrageenan-0.5 resembled the viscoelasticity of PGWater(™). The acetaminophen in gelatin-1.0 and carrageenan-0.5 had dissolution behavior similar to that of commercial acetaminophen preparations. The osmolality of jellies prepared in different concentrations ranged from about 20-50 mOsm/kg. Results suggested that carrageenan-0.5 could serve as a useful jelly vehicle for acetaminophen.

Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. However, as they inhibit platelet aggregation and prolong bleeding time they could cause increased perioperative bleeding. The overall risk remains unclear. This review was originally published in 2005 and was updated in 2010 and in 2012.

OBJECTIVES

The primary objective of this review was to assess the effects of NSAIDs on bleeding with paediatric tonsillectomy. Our secondary outcome was to establish whether NSAIDs affect the incidence of other postoperative complications when compared to other forms of analgesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); MEDLINE (inception until October 2012); EMBASE (inception until October 2012); Current Problems (produced by the UK Medicines Control Agency), MedWatch (produced by the US Food and Drug Administration) and the Australian Adverse Drug Reactions Bulletins (to May 2010). The original search was performed in August 2004. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

We included randomized controlled trials assessing NSAIDs in children, up to and including 16 years of age, undergoing elective tonsillectomy or adenotonsillectomy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted the data. We contacted study authors for additional information, where necessary.

MAIN RESULTS

We included 15 studies that involved 1101 children in this updated review. One study was added as a result of our 2012 search, another previously included study was removed due to lack of randomization. Fourteen included studies compared NSAIDs with other analgesics or placebo and reported on bleeding requiring surgical intervention. The use of NSAIDs was associated with a non-significant increase in the risk of bleeding requiring surgical intervention: Peto odds ratio (OR) 1.69 (95% confidence interval (CI) 0.71 to 4.01). Ten studies involving 365 children reported perioperative bleeding requiring non-surgical intervention. NSAIDs did not significantly alter the number of perioperative bleeding events requiring non-surgical intervention: Peto OR 0.99 (95% CI 0.41 to 2.40) but the confidence intervals did not exclude an increased risk. Thirteen studies involving 1021 children reported postoperative vomiting. There was less vomiting when NSAIDs were used as part of the analgesic regime than when NSAIDs were not used: Mantel Haenszel (M-H) risk ratio (RR) 0.72 (95% CI 0.61 to 0.85).

AUTHORS' CONCLUSIONS

There is insufficient evidence to exclude an increased risk of bleeding when NSAIDs are used in paediatric tonsillectomy. They do however confer the benefit of a reduction in vomiting.

Ketorolac administration does not delay early fracture healing in a juvenile rat model: a pilot study

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at controlling pain in children, especially in the treatment of fractures. Adult animal and adult clinical studies demonstrate conflicting evidence for the inhibitory relationship between NSAIDs and fracture healing. Published pediatric orthopaedic clinical studies do not demonstrate an inhibitory effect of ketorolac on bone healing. Little is known about the effects of any NSAID on bone formation in juvenile animals. This study investigates the effects of the NSAID ketorolac on fracture healing in a juvenile rat model.

METHODS

Unilateral surgically induced and stabilized tibial shaft fractures were created in 45 juvenile (3 to 4 wk old) male Sprague-Dawley rats. Either ketorolac (5 mg/kg; n=24) or saline (0.9% normal saline; n=21) was then administered to the rats 6 d/wk by intraperitoneal injections. Animals were then randomly assigned into time groups and euthanized at 7 days (n=8 ketorolac, n=7 saline), 14 days (n=8 ketorolac, n=7 saline), or 21 days (n=8 ketorolac, n=7 saline) postfracture. Biomechanical analysis was performed using a custom-designed 4-point bending loading apparatus. Statistics for tibial stiffness and strength data were performed using software package Systat 11. Specimens were also evaluated histologically using hematoxylin and eosin staining.

RESULTS

Strength and stiffness of all fractured tibiae increased over time from day 7 to day 21 regardless of treatment type. No statistical difference was found between the fractured tibiae strength or stiffness in the ketorolac or control-treated specimens at the same time point. In addition, the quality of the fracture callus was similar in both groups at each of the time points.

CONCLUSIONS

In this study of a juvenile rat model with a stabilized tibia fracture, fracture callus strength, stiffness, and histologic characteristics were not affected by the administration of ketorolac during the first 21 days of fracture healing.

CLINICAL RELEVANCE

The absence of inhibitory effects of ketorolac on early juvenile rat fracture healing supports the clinical practice of utilizing NSAIDs for analgesia in children with long bone fractures.

Stability of diclofenac sodium oral suspensions packaged in amber polyvinyl chloride bottles

BACKGROUND

Prescribing of diclofenac for children usually involves a dose different from commercially available strengths. This drug is available only as tablets, which can be divided only so many times before the dose obtained becomes inaccurate. In addition, children may have difficulty swallowing tablets. For these reasons, a compounding formula for a liquid dosage form is essential to ensure effective delivery of the drug to pediatric patients.

OBJECTIVES

To develop a compounding formula for diclofenac sodium and to determine the extended physical and chemical stability of this compound when stored in amber polyvinyl chloride (PVC) prescription bottles under refrigeration and at room temperature.

METHODS

A suspension of diclofenac sodium (10 mg/mL) was prepared from commercially available diclofenac sodium tablets, with Ora-Blend as the suspending and flavouring agent. The suspension was packaged in 60-mL amber PVC prescription bottles and stored at either room temperature (23°C) or under refrigeration (5°C). Samples were collected on days 0, 7, 14, 21, 27, 56, and 93. Chemical stability was determined using a validated stability-indicating high-performance liquid chromatography method. At each sampling time, the suspensions were checked for changes in appearance (i.e., colour, layering, caking, ease of resuspension), odour, and pH.

RESULTS

The diclofenac sodium suspensions were very stable, retaining at least 99.5% of the original concentration for up to 93 days, regardless of storage temperature. There were no apparent changes in the physical appearance of the suspensions, nor were there any substantial changes in odour or pH.

CONCLUSIONS

Suspensions of diclofenac sodium (10 mg/mL) were quantitatively stable but difficult to prepare because of the enteric coating of the tablets. Therefore, it is recommended that diclofenac powder be used for the preparation of suspensions. For pediatric use, palatability is a consideration, and a masking agent should be added before administration. An expiry date of up to 93 days is suggested.

Stability of celecoxib oral suspension

BACKGROUND

Celecoxib is a selective cyclo-oxygenase 2 inhibitor that relieves pain without affecting platelet function, causing gastrointestinal toxic effects, or increasing the risk of bleeding.

OBJECTIVES

To develop a suspension formulation for oral celecoxib and to determine its physical and chemical stability when packaged in amber polyvinyl chloride (PVC) bottles and stored with refrigeration (5°C) and at room temperature (23°C).

METHODS

The contents of celecoxib capsules were used to prepare a single suspension, with Ora-Blend used as the suspending and flavouring agent. The suspension (10 mg/mL) was then packaged in amber PVC bottles and stored at either 5°C or 23°C. Samples were collected on days 0, 7, 14, 21, 27, 56, and 93. Chemical stability was determined using a validated stability-indicating high-performance liquid chromatography method. At each sampling time, the suspensions were checked visually for changes in appearance (i.e., colour, layering, caking, and ease of resuspension), odour, and pH.

RESULTS

All of the suspensions were stable for at least 93 days, regardless of storage conditions. There were no apparent changes in physical appearance, nor were there any substantial changes in odour or pH.

CONCLUSIONS

Suspensions of celecoxib (10 mg/mL in Ora-Blend) packaged in amber PVC bottles were stable for up to 93 days when stored at 5°C or 23°C. A 3-month expiry date has been established for this oral suspension on the basis of physical compatibility and chemical stability.

Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center

A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.

Effect of pre-operative rectal diclofenac suppository on post-operative analgesic requirement in cleft palate repair: A randomised clinical trial

BACKGROUND

Opioid analgesics used for analgesia are associated with sedation, respiratory depression and post-operative nausea and vomiting. Non-steroidal anti-inflammatory drugs such as diclofenac are a safe and effective alternative with opioid-sparing effect.

OBJECTIVE

To evaluate the effectiveness of pre-operative rectal diclofenac suppository (1 mg/kg) in cleft palate repair for post-operative analgesia and reduction in post-operative opioid requirements.

STUDY DESIGN

A randomized clinical trial.

METHODS

After obtaining approval from the institutional ethical committee, 60 children were allocated by a computer-generated randomisation into two groups of 30 each; group D (Diclofenac group) and group C (Conventional group). Children in group D and group C were similar in all aspects except for the fact that group D children received 1 mg/kg diclofenac suppository after induction. Pain was evaluated using modification of the objective pain scale by Hannallah and colleagues for 6 h post-operatively by an anaesthesiology resident or nursing staff who was blinded to the group. If the pain score was more than 3, rescue analgesic I.V. fentanyl 0.5 μgm/kg was administered. The pain scores at different intervals, number of doses and quantity of rescue analgesic required were noted.

RESULTS

We observed that pre-operative rectal diclofenac provided effective analgesia in the immediate post-operative period, as evidenced by reduced pain scores and reduced opioid requirement (P=0.00002). There was no evidence of any increased perioperative bleeding in the diclofenac group.

CONCLUSION

Pre-operative rectal diclofenac reduces opioid consumption and provides good post-operative analgesia.

Preemptive analgesic effects of midazolam and diclofenac in rat model

The aim of the present study was to investigate the preemptive analgesic effects of intraperitoneally administrated midazolam and diclofenac, before acute and inflammatory induced pain in rat model. One hundred twenty-eight (n=8 in each group) male Sprague Dawley rats were included in the study. Paw movements in response to thermal stimulation or paw flinching in response to formalin injection were compared after midazolam (0.1, 1, 5 and 10 mg/kg) and diclofenac (10 mg/kg), intraperitoneal administration. Saline was used as a control. Preemptive analgesic effect was significant in both tests when diclofenac and midazolam was administrated before the pain stimuli (p<0.01 and p<0.001). Intraperitoneal injection of midazolam in doses 5 and 10 mg/kg, increase the response time in hot plate test and decrease the number of flinches in formalin test (p<0.01 vs. p<0.001). ED50 of midazolam (with diclofenac) in hot plate test was 2.02 mg/kg (CI95% =-3.47-5.03 mg); and, 0.9 mg/kg (CI95% =-0.87-4.09 mg) in phase I and 0.7 mg/kg (CI95% = 0.48-6.63 mg) in phase II, in formalin test.Intraperitoneally administered midazolam and diclofenac had preemptive analgesic effects on acute thermal, and inflammatory induced pain in rats.

Dose variations associated with formulations of NSAID prescriptions for children: a descriptive analysis of electronic health records in the UK

BACKGROUND

NSAIDs, particularly ibuprofen, are commonly prescribed for children but there is limited published research on real-life prescribed doses for this class of drugs.

OBJECTIVE

The aim of the study was to investigate if variations in NSAID doses prescribed to children can be explained by patient age, indication, dosage form, type of NSAID or year of prescription.

STUDY DESIGN

Recorded daily doses for drugs within the 'Anti-rheumatics, non-steroidal plain' anatomical classification were studied. First prescriptions of a distinct NSAID substance within 13-month time periods in a patient's history were included. To enable grouping and comparison of NSAIDs, doses were analysed as prescribed daily doses (PDDs) relative to the adult defined daily dose, stated as the relative PDD (rPDD) in this study. Multiple regression analysis was performed with the rPDD as the response variable, and age, indication, dosage form, NSAID substance and year of prescription as the explanatory variables.

SETTING

Prescriptions from the Intercontinental Medical Statistics (IMS) Health Disease Analyzer database containing electronic health records of general practitioners in the UK issued from 1988 to December 2005.

PATIENTS

Data for children aged 2-11 years with NSAID prescriptions including daily dose information.

RESULTS

A total of 21 473 first prescriptions for 19 695 patients were studied. The vast majority of prescriptions were for ibuprofen (n = 20 855), which were therefore analysed separately. The other NSAID prescriptions were grouped (n = 618), containing diclofenac, indometacin, mefenamic acid, naproxen and piroxicam ('NSAID group'). The rPDD varied considerably with dosage form in both the ibuprofen and NSAID groups. In particular, tablets/capsules were prescribed at higher doses than liquid dosage forms. In the NSAID group, naproxen was prescribed at noticeably higher doses. The rPDD varied only slightly with age in both groups. Prescriptions indicated for rheumatic disease were associated with lower doses than other indications in the NSAID group. The rPDD was not influenced by year of prescription.

CONCLUSIONS

This study shows a correlation between higher prescribed NSAID doses and tablet/capsule formulation, and highlights the need for careful choice of dose formulation when prescribing medicines for children.

Safety of ketorolac in surgical neonates and infants 0 to 3 months old

BACKGROUND

Ketorolac is a nonsteroidal antiinflammatory drug widely used as an adjunct to postoperative pain control in adult and pediatric patients. Minimal safety data exist regarding the use of ketorolac in neonates.

METHODS

The charts of 57 postsurgical neonates between 0 and 3 months of age were retrospectively reviewed for bleeding events associated with ketorolac. Data included gestational age (GA), corrected gestational age (CGA) at the time of ketorolac, serum creatinine, platelet count, urine output (in milliliters per kilogram per hour), concomitant medications, enteral feeds, number of ketorolac doses, and surgical procedure performed.

RESULTS

Of 57 patients, 10 (17.2%) demonstrated a bleeding event. Mean CGA and serum creatinine for those with bleeding events was 39.4 weeks (P = .69) and 0.64 mg/dL (P = .03), respectively. Patients with a bleeding event received ketorolac at a mean of 20.7 days of life with 70% receiving the drug at less than 14 days of age, whereas those without a bleeding event received ketorolac at a mean of 31.9 days (P = .04). Bleeding events correlated with glomerular filtration rate of less than 30 mL/min/1.73 m(2) or concomitant medications in all but 1 patient.

CONCLUSIONS

Infants younger than 21 days and less than 37 weeks CGA are at significantly increased risk for bleeding events and should not be candidates for ketorolac therapy.

Plasma and cerebrospinal fluid pharmacokinetics of flurbiprofen in children

AIMS

This study was designed to characterize paediatric pharmacokinetics and central nervous system exposure of flurbiprofen.

METHODS

The pharmacokinetics of flurbiprofen were studied in 64 healthy children aged 3 months to 13 years, undergoing surgery with spinal anaesthesia. Children were administered preoperatively a single dose of flurbiprofen intravenously as prodrug (n= 27) or by mouth as syrup (n= 37). A single cerebrospinal fluid (CSF) sample (n= 60) was collected at the induction of anaesthesia, and plasma samples (n= 304) before, during and after the operation (up to 20 h after administration). A population pharmacokinetic model was built using the NONMEM software package.

RESULTS

Flurbiprofen concentrations in plasma were well described by a three compartment model. The apparent bioavailability of oral flurbiprofen syrup was 81%. The estimated clearance (CL) was 0.96l h(-1) 70 kg(-1) . Age did not affect the clearance after weight had been included as a covariate. The estimated volume of distribution at steady state (V(ss) ) was 8.1 l 70 kg(-1) . Flurbiprofen permeated into the CSF, reaching concentrations that were seven-fold higher compared with unbound plasma concentrations.

CONCLUSIONS

Flurbiprofen pharmacokinetics can be described using only weight as a covariate in children above 6months, while more research is needed in neonates and in younger infants.

Treatment of acute pediatric pain

Pediatric neurologists frequently treat acute pain in children. A broad range of medication options is available including nonsteroidal anti-inflammatory drugs, opioids, and other analgesic adjuvants, such as antidepressants and antiepileptics. This article reviews the physiology underlying the experience of pain and compares the pharmacologic mechanisms and properties of these medications, providing a framework for developing effective multimodal medical treatment approaches to pain in children.

Ketoprofen pharmacokinetics, efficacy, and tolerability in pediatric patients

The NSAID ketoprofen is used widely in the management of inflammatory and musculoskeletal conditions, pain, and fever in children and adults. Pharmacokinetic studies show that drug exposure after a single intravenous dose is similar in children and adults (after dose normalization), and thus similar mg/kg bodyweight dosing may be used in children and adults. Ketoprofen crosses the blood-brain barrier and therefore has the potential to cause central analgesic effects. Ketoprofen has been investigated in children for the treatment of pain and fever, peri- and postoperative pain, and inflammatory pain conditions. The results of four clinical trials in febrile conditions with the oral syrup formulation indicate that ketoprofen is as effective as acetaminophen (paracetamol) and ibuprofen, allowing children to rapidly return to daily activities with improvements in sleep quality and appetite. Studies of ketoprofen in the management of postoperative pain indicate that ketoprofen is a highly effective analgesic when administered perioperatively for a variety of surgical types, by a variety of routes, and whether given preoperatively or postoperatively. For adenoidectomy, intravenous ketoprofen provided superior postoperative analgesic efficacy compared with placebo. Analgesic efficacy was similar with intravenous, intramuscular, or rectal routes of administration, but oral administration just before surgery was inferior to intravenous administration in this setting. In patients undergoing a tonsillectomy, intravenous ketoprofen was superior to intravenous tramadol in terms of the need for postoperative rescue analgesia, but did not remove the need for rescue opioid therapy in these patients. Intravenous ketoprofen had superior postoperative analgesic efficacy to placebo when given as an adjuvant to epidural sufentanil analgesia after major surgery. Oral ketoprofen has shown efficacy in the treatment of juvenile rheumatoid arthritis. Ketoprofen is generally well tolerated in pediatric patients. Most of the adverse events reported are mild and transient, and are similar to those observed with other NSAIDs. Long-term tolerability has not yet been fully established in children, but data from three studies in >900 children indicate that oral ketoprofen is well tolerated when administered for up to 3 weeks after surgery. In conclusion, ketoprofen is effective and well tolerated in children for the control of post-surgical pain and for the control of pain and fever in inflammatory conditions.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

Ketoprofen versus paracetamol (acetaminophen) or ibuprofen in the management of fever: results of two randomized, double-blind, double-dummy, parallel-group, repeated-dose, multicentre, phase III studies in children

Fever is a common symptom in children and one of the major concerns of parents of younger and preschool-age children. To compare the efficacy and safety of ketoprofen with that of paracetamol (acetaminophen) and ibuprofen in the treatment of febrile conditions in children. Two prospective, randomized, double-blind, double-dummy, repeated-dose, multicentre, phase III studies with two parallel groups in each study were conducted in primary-care outpatient clinics. Children aged 6 months to 6 years presenting with a febrile condition and an oral body temperature of > or =38.8 degrees C or rectal temperature of > or =39 degrees C were eligible for inclusion. Patients were randomized to receive either ketoprofen syrup 0.5 mg/kg, ibuprofen suspension 5 mg/kg or paracetamol suspension 15 mg/kg every 6 hours by the oral route. The primary outcome measure was the change in temperature at 3 hours (H3), compared with baseline (H0). All three treatments provided similar mean maximum decreases of 1.4-1.5 degrees C in body temperature at H3 compared with H0. Use of ketoprofen was not associated with any increased risk of adverse events compared with the two reference compounds. Ketoprofen 0.5 mg/kg appeared to be equivalent to the standard antipyretic doses of the reference products ibuprofen 5 mg/kg and paracetamol 15 mg/kg. Ketoprofen at the 0.5 mg/kg dose should be an effective and safe option for symptomatic management of fever in children.

Dose-finding studies of ketoprofen in the management of fever in children: report on two randomized, single-blind, comparator-controlled, single-dose, multicentre, phase II studies

BACKGROUND

Ketoprofen is a highly effective NSAID with antipyretic and analgesic properties for the symptomatic management of pain and fever in both adults and children.

OBJECTIVE

To compare three dose levels of ketoprofen with paracetamol (acetaminophen) in the management of fever in children.

METHODS

Two prospective, randomized, single-blind, comparator-controlled, single-dose, multicentre, phase II studies with four parallel groups in each study were conducted in primary-care outpatient clinics. Children aged 6-24 months and 2-6 years presenting with a febrile condition (rectal body temperature > or =39 degrees C) were included in the studies. Patients were treated with either ketoprofen syrup 0.25 mg/kg, 0.5 mg/kg or 1 mg/kg, or paracetamol drinkable solution 15 mg/kg, both administered orally. The primary outcome measure was the maximal reduction in body temperature before re-medication compared with baseline during the 6-hour study period.

RESULTS

In the ketoprofen groups, the mean maximal temperature decreases in the younger/older age groups were 1.6/1.6 degrees C, 2.0/1.9 degrees C and 1.9/2.2 degrees C with doses of 0.25 mg/kg, 0.5 mg/kg and 1 mg/kg of ketoprofen, respectively, compared with 1.8/1.8 degrees C with paracetamol 15 mg/kg. In the older children, ketoprofen provided antipyretic efficacy in a dose-dependent manner.

CONCLUSION

Ketoprofen was found to have a significant antipyretic efficacy in children. The lowest dose of ketoprofen syrup that provided a meaningful antipyretic effect in both groups was 0.5 mg/kg. At this dose the antipyretic efficacy was equal to that of paracetamol 15 mg/kg. Based on these data, a dose of 0.5 mg/kg of ketoprofen was selected for future evaluation in phase III studies in the symptomatic management of fever in children.

Pharmacologic management of acute pediatric pain

The accurate assessment and effective treatment of acute pain in children in the hospital setting is a high priority. During the past 2 to 3 decades, pediatric pain management has gained tremendous knowledge with respect to the understanding of developmental neurobiology, developmental pharmacology the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. A wide range of medications is available to treat a variety of pain types. This article provides an overview of the most common analgesic medications and techniques used to treat acute pain in children.

Safety of intravenous use of ketorolac in infants following cardiothoracic surgery

OBJECTIVES

To evaluate the impact of intravenous ketorolac on renal function and haematologic values in patients less than six months old following cardiothoracic surgery.

BACKGROUND

Ketorolac is a potent nonsteroidal anti-inflammatory drug indicated for short term management of moderate to severe post-operative pain. Little data is available related to its safety in infants less than six months of age.

METHODS

This was a retrospective, case-control chart review of 19 patients aged less than six months of age with biventricular circulations who received intravenous ketorolac following cardiothoracic surgery. They were compared with 19 age-matched control patients. Those with functionally univentricular anatomy were excluded due to their higher risk for renal impairment following surgery. Student's t-test was used to compare the incidence of renal impairment and haematologic complications between the groups, as well as the number of analgesic doses administered. Charts were reviewed for number of blood transfusions.

RESULTS

Patients receiving intravenous ketorolac had no statistically significant changes in pre-operative versus post-treatment renal function or haematologic effects compared to the control group. No statistically significant differences were detected for number of post-operative blood transfusions or additional analgesic administration between groups.

CONCLUSIONS

Intravenous ketorolac appears to be safe when used in infants less than six months of age with biventricular circulations following cardiothoracic surgery. Ketorolac as used in these patients does not decrease the use of standard analgesic therapy.

Selective and nonselective nonsteroidal anti-inflammatory drugs in perianesthesia pain management

Despite advances in pain management techniques, there remains room for further improvement in optimizing postoperative patient comfort. Although nonsteroidal anti-inflammatory drugs (NSAIDs) that are more selective in the inhibition of the cyclooxygenase (COX) enzyme have become more popular over recent years, the use of traditional nonselective NSAIDs remains efficacious in reducing postoperative pain. Both nonselective and selective NSAIDs have an important role in perianesthesia pain management. This article reviews the benefits and risks of both nonselective NSAIDs and COX-2 NSAIDs in the perianesthesia period.

Combined regional and general anesthesia for ambulatory peripheral orthopedic surgery in children

Pediatric orthopedic surgery is rarely done in an outpatient setting because of the postoperative pain. The purpose of this study was to evaluate the children's comfort and parents' satisfaction after ambulatory peripheral pediatric orthopedic surgery performed under general anesthesia combined with regional anesthesia (RA). Sixty consecutive children were enrolled in this prospective study. All children fulfilled inclusion criteria for outpatient and for RA and parents received proper information regarding their child postoperative care. Postoperative pain control was sustained for 48 h using routine paracetamol, ibuprofen, and oral tramadol if needed. A telephone survey was conducted on day 1 and day 2 to evaluate pain scores, limb motor function, occurrence of postoperative nausea and vomiting, and feeding, sleep or play disturbance. The parents were also asked about their overall satisfaction rate and the choice of ambulatory mode versus inpatient admission in case of future orthopedic procedure. A total of 34 soft tissue procedures and 26 bony procedures were performed. 63.3% recovered motor function before discharge from the postanesthesia care unit. Low pain scores and good postoperative comfort were observed. Parents' satisfaction was greater than eight out of 10 in 88.3% of the cases, and 85% of the parents would choose ambulatory surgery in case of a second procedure. RA used with level I or II analgesics is compatible with ambulatory peripheral pediatric orthopedic surgery. Resulting good analgesia and postoperative comfort render the ambulatory mode to be favored by the parents.

Diclofenac readily penetrates the cerebrospinal fluid in children

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Diclofenac, a nonselective nonsteroidal anti-inflammatory drug,, exerts analgesic action both in the peripheral tissues and in the central nervous system by inhibiting cyclooxygenase enzymes COX-1/2, but central nervous system penetration of diclofenac has not been evaluated in humans.

WHAT THIS STUDY ADDS

Diclofenac penetrates the cerebrospinal fluid rapidly, and after a single intravenous dose of 1 mg kg(-1), sufficient concentrations to inhibit COX-1/2 are sustained for up to 4 h.

AIMS

The primary aim was to study the cerebrospinal fluid (CSF) penetration of intravenous diclofenac in children. The secondary aim was to evaluate the plasma diclofenac concentration at the onset of wound pain after inguinal surgery in children.

METHODS

A total of 31 children (24 boys) aged 3 months to 12 years received a single intravenous injection of diclofenac 1 mg kg(-1). Paired CSF and blood samples were obtained 5 min to 22 h (median 69 min) later. In children having inguinal surgery a second blood sample was obtained at the time that the children felt wound pain for the first time after surgery. Diclofenac concentrations in CSF, plasma and protein free plasma were measured by gas chromatography with mass spectrometric detection.

RESULTS

In the 28 CSF samples obtained at 5 min to 3 h 43 min after injection, diclofenac concentrations ranged between 0.5 and 4.7 microg l(-1). At 5.5 h the CSF concentration was 0.1 microg l(-1), and no diclofenac was detected in the two CSF samples obtained at 22 h. The median of plasma diclofenac concentration at the time when pain returned after inguinal surgery was 104 microg l(-1) (range 70-272 microg l(-1)). No serious or unexpected adverse effects were reported.

CONCLUSIONS

Diclofenac penetrates the CSF rapidly, and a sufficient concentration to inhibit cyclooxygenase enzymes is sustained for up to 4 h.

Current concepts in pain management: pharmacologic options for the pediatric, geriatric, hepatic and renal failure patient

This article provides a review for current practice. Strict guidelines are not available on some topics, and they may never be drafted because pain is such a unique individual experience. It is recommended to coordinate care with other medical specialties when patients present with organ dysfunctions or are at the extremes of age. More data are required in the field of pain management, particularly with regard to renal and hepatic dysfunction. In turn, these data serve as a foundation for physicians making practice decisions based on current evidence. Until this is achieved, clinicians must rely on anecdotal evidence and the experiences of others to treat a complex issue: pain.

Cerebrospinal fluid distribution of ibuprofen after intravenous administration in children

BACKGROUND

Ibuprofen is the most commonly used nonsteroidal, antipyretic, antiinflammatory analgesic in children. Nonsteroidal, antipyretic, antiinflammatory analgesics act in both the peripheral tissues and the central nervous system. The central nervous system penetration of ibuprofen has been described in adults but not in children.

OBJECTIVES

Our goals were to investigate the cerebrospinal fluid penetration of ibuprofen in children and evaluate the analgesic plasma concentration of ibuprofen after inguinal surgery in children.

MATERIALS AND METHODS

A total 36 healthy children (25 boys) aged 3 months to 12 years received a single intravenous injection of ibuprofen (10 mg/kg). A paired cerebrospinal fluid and blood sample was obtained 10 minutes to 8 hours after the injection. In children having inguinal surgery, a second blood sample was obtained at the time that the child first had wound pain.

RESULTS

The ibuprofen level was determined in all cerebrospinal fluid and plasma samples. Cerebrospinal fluid concentrations ranged between 15 and 541 microg/L, and the highest concentrations were measured 30 to 38 minutes after dosing. In all cerebrospinal fluid samples collected after 30 minutes, ibuprofen concentration exceeded that of unbound plasma. The plasma analgesic concentrations after inguinal surgery ranged between 10 and 25 mg/L.

CONCLUSIONS

Ibuprofen penetrates the cerebrospinal fluid readily, with peak concentrations attained 30 to 40 minutes after intravenous injection of a 10 mg/kg dose. The plasma analgesic concentration after inguinal surgery with spinal anesthesia is 10 to 25 mg/L.

The time course of inflammatory cytokine secretion in a rat model of postoperative pain does not coincide with the onset of mechanical hyperalgesia

We characterized the time course of inflammatory cytokine release at the site of injury and in plasma after surgery on the rat tail. Anesthetized Sprague–Dawley rats had a 20 mm long incision made through the skin and fascia of their tails. Control rats were anesthetized, but no incision was made. Blood and tissue samples were taken 2 h and 1, 2, 4, and 8 days after surgery and analysed by ELISA for interleukin-1β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and cytokine-induced neutrophil chemoattractant-1 (CINC-1). In another group of rats, daily behavioral measurements were made of the rats’ responses to a blunt noxious mechanical stimulus (4 Newtons) applied to their tails. Primary hyperalgesia developed within 2 h of surgery and lasted for 6 days. The tissue concentrations of IL-1β, IL-6, and CINC-1 increased within 24 h of surgery, and TNF-α concentration increased within 48 h of surgery. Thereafter, cytokine concentrations remained elevated for 4 (IL-1β and IL-6) to 8 days (CINC-1, TNF-α) after surgery. Control animals did not develop hyperalgesia and no changes in cytokines concentrations were detected. Thus, in our model of postoperative pain, secretion of inflammatory cytokines IL-1β, IL-6, TNF-α, and CINC-1 was not essential for the initiation of postoperative hyperalgesia.

Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery

OBJECTIVE

The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery, to relate previous experiences of surgery/tonsillitis with anxiety and pain, and to compare the children's, parent's and nurse's rating of pain.

METHOD

Ninety-two children (5-15 years) with sleep-disordered breathing (SDB) and with or without recurrent tonsillitis were randomized to partial tonsil resection/tonsillotomy (TT) or full tonsillectomy (TE).

MEASURES

Parents: Child Behavior Checklist (CBCL). Children: State-Trait-Anxiety Inventory for Children (STAIC) and seven-point Faces Pain Scale (FPS). Parents/staff: seven-point Verbal Pain Rating Scale (VPRS). Pain relievers were opoids, paracetamol and diclophenac.

RESULTS

These children with SDB scored significantly higher on CBCL than did normative groups, but no connection was observed between CBCL rating and experience of pain. There was no relation between pre-operative anxiety and pain. The post-operative anxiety level (STAIC) correlated with pain. The TE-group scored higher on STAIC after surgery. Previous experience of surgery or tonsillitis did not influence post-operative pain. The TE-group rated higher experience of pain despite more medication. The nurses scored pain lower than the parents/children and under-medicated.

CONCLUSION

SDB may influence children's behavior, but with no relation to post-operative pain. The surgical method predicts pain better than does the child's behavior rating. The nurses underestimated the pain experienced by the child.

Lack of influence of body mass index on efficacy and tolerance of acemetacin in short-term treatment of musculoskeletal diseases

Dose adjustments of NSAIDs according to body weight may be reasonable for an optimal efficacy/tolerance profile in the therapy of musculoskeletal disorders, but are unusual in adults. In this post hoc analysis of a prospective, one-arm clinical study of a short-term treatment with acemetacin, a total of 406 patients with pain because of various musculoskeletal diseases with or without joint inflammation was evaluated for the influence of body mass index (BMI) on the reduction of pain at rest, pain at movement and for mobility restriction between visits one and three (primary outcome parameters). No association was found between BMI and the efficacy of acemetacin regarding the primary outcome parameters and no influence of BMI on the occurrence of adverse events was observed. Dose adjustment of acemetacin according to BMI thus appears not necessary in a short-term treatment of musculoskeletal disorders, but prospective controlled trials are needed to confirm these results.

Evaluation of alternative strategies to optimize ketorolac transdermal delivery

In the present study, 2 alternative strategies to optimize ketorolac transdermal delivery, namely, prodrugs (polyoxyethylene glycol ester derivatives, I-IV) and nanostructured lipid carriers (NLC) were investigated. The synthesized prodrugs were chemically stable and easily degraded to the parent drug in human plasma. Ketorolac-loaded NLC with high drug content could be successfully prepared. The obtained products formulated into gels showed a different trend of drug permeation through human stratum corneum and epidermis. Particularly, skin permeation of ester prodrugs was significantly enhanced, apart from ester IV, compared with ketorolac, while the results of drug release from NLC outlined that these carriers were ineffective in increasing ketorolac percutaneous absorption owing to a high degree of mutual interaction between the drug and carrier lipid matrix. Polyoxyethylene glycol esterification confirmed to be a suitable approach to enhance ketorolac transdermal delivery, while NLC seemed more appropriate for sustained release owing to the possible formation of a drug reservoir into the skin.

Report of an Anaphylactoid and an Anaphylactic Reaction to Ketorolac in Two Pediatric Surgical Patients

Ketorolac is a potent analgesic drug that has been restricted in dosage and use because of its potential adverse effects. The diagnostic and ethical challenges of 2 children who had unpredictable adverse drug reactions to ketorolac are reported. Case 1: A 3-year-old boy received ketorolac 1 mg/kg for prevention of postoperative pain at the end of an orthopedic surgical procedure. Ten minutes later, he had bilateral palpebral edema, erythema in thorax, hypotension, and tachycardia. The adverse event was classified as a mixed reaction probably related to ketorolac. Case 2: A 7-year-old girl, who had previously received ketorolac in 2 different surgical procedures, underwent a third orthopedic surgery. She received ketorolac 1 mg/kg as pre-emptive analgesia at 1.5 hours of anesthetic time (approximately 1 hour of surgical time). The patient developed palpebral edema 5 minutes later in addition to erythema in thorax, hypotension, tachycardia, tachypnea, oxygen desaturation, and wheezing. The adverse event was classified as a systemic reaction probably related to ketorolac. The 2 patients were successfully treated with symptomatic therapy. Although rare in its frequency, ketorolac administration may be associated to anaphylactic and anaphylactoid reactions in children with or without history of previous exposure. Because ketorolac is off-licensed for pediatric patients, it should be administered only after the risks and benefits have been discussed with the child's parents in the preanesthetic consultation.

Analgesia and local anesthesia during invasive procedures in the neonate

BACKGROUND

Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area.

OBJECTIVE

The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates.

METHODS

Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded.

RESULTS

The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.

Ketoprofen and tramadol for analgesia during early recovery after tonsillectomy in children

BACKGROUND

Pain following tonsillectomy is often intense. Nonsteroidal anti-inflammatory drugs and opioids are effective, but both can cause adverse effects. Tramadol may be a viable alternative for post-tonsillectomy pain. This study was designed to compare the analgesic effects of ketoprofen and tramadol during the early recovery period after tonsillectomy.

METHODS

Forty-five ASA class I children (9-15 years) were randomized to receive either saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)) after induction of anesthesia. Upon completion of surgery, the study treatment was continued as a 6 h intravenous (i.v.) infusion of another dose of saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)). Postoperatively, each patient received rescue analgesia with patient-controlled analgesia (PCA) device programmed to deliver 0.5 microg.kg(-1) bolus doses of fentanyl. Postoperative pain was assessed using Visual Analog Scale (VAS) during swallowing. Intraoperative blood loss was measured.

RESULTS

The total number of requests of PCA-fentanyl was significantly less in ketoprofen group compared with tramadol and placebo groups (P = 0.035 and P = 0.049, respectively, in pairwise comparisons) and the VAS scores for pain were significantly lower in ketoprofen group compared with tramadol (P = 0.044) or placebo groups (P = 0.018) during the first six postoperative hours. Measured intraoperative blood loss was greater in ketoprofen-treated patients than in those receiving placebo (P = 0.029).

CONCLUSION

A dose of 4 mg.kg(-1) of i.v. ketoprofen provided good pain relief with moderate supplemental PCA-fentanyl requirements during the first six postoperative hours after tonsillectomy in children whereas the effects of 2 mg.kg(-1) of i.v. tramadol did not differ from those of placebo.

Current management of pediatric postoperative pain

Pain is a common complaint in children after surgery. Four out of five children require analgesia even after minor surgery, and after more extensive surgery, significant postoperative pain may last for weeks. Severe pain during, and after surgery may aggravate long-lasting negative effects to the body and mind. In order to prevent harmful effects, all children should be provided with effective analgesia. Pain management should be safe and easy to administer. Postoperative pain management in children has improved substantially during the last 5 years. Recent trials indicate that children may undergo major surgery with minimal untoward effects when effective proactive pain management is provided. This review will focus on new clinical strategies on pain management in children. Since most pediatric surgery is performed as a day-case or short-stay basic recommendations for parental guidance and pain management after discharge are also presented.

Summary proceedings from the neonatal pain-control group

Recent advances in neurobiology and clinical medicine have established that the fetus and newborn may experience acute, established, and chronic pain. They respond to such noxious stimuli by a series of complex biochemical, physiologic, and behavioral alterations. Studies have concluded that controlling pain experience is beneficial with respect to short-term and perhaps long-term outcomes. Yet, pain-control measures are adopted infrequently because of unresolved scientific issues and lack of appreciation for the need for control of pain and its long-term sequelae during the critical phases of neurologic maturation in the preterm and term newborn. The neonatal pain-control group, as part of the Newborn Drug Development Initiative (NDDI) Workshop I, addressed these concerns. The specific issues addressed were (1) management of pain associated with invasive procedures, (2) provision of sedation and analgesia during mechanical ventilation, and (3) mitigation of pain and stress responses during and after surgery in the newborn infant. The cross-cutting themes addressed within each category included (1) clinical-trial designs, (2) drug prioritization, (3) ethical constraints, (4) gaps in our knowledge, and (5) future research needs. This article provides a summary of the discussions and deliberations. Full-length articles on procedural pain, sedation and analgesia for ventilated infants, perioperative pain, and study designs for neonatal pain research were published in Clinical Therapeutics (June 2005).