Key words: Pain, Drug dosages, Association therapy, Pre-emptive treatment, Non-pharmacological therapeutic strategies
SUMMARY: The paper deals with pain in children. In the first part the most relevant physio-pathological aspects and the changing patterns of pain according to age are described. The relevance of the maturation of the central nervous system in the perception of pain and in the evaluation of symptoms is discussed in detail. The age related epidemiology of pain is discussed in the second part of the paper, highlighting the most frequent and clinically relevant pain causes in the different periods of child growth. Finally, the basic golden rules of pain management are discussed from a pragmatical point of view highlighting the importance of adequate drug dosages, association therapy, pre-emptive treatment and non-pharmacological therapeutic strategies.
Some specific issues on pain in paediatrics: summary and review of the present knowledge and practice - Medico e Bambino 2010;29:289-301
Franco Panizon1, Egidio Barbi2
1Professore Emerito, Dipartimento di Scienze della Riproduzione e dello Sviluppo, Università di Trieste
2Clinica Pediatrica, IRCCS “Burlo Garofolo”, Trieste
Key words: Neonatal pain, Analgesia, Care
SUMMARY: Neonatal pain is still today inadequately treated. This flaw is due to several reasons, among which the difficulty to consider newborns as patients like others and to understand their language. Newborns feel pain and it is our duty to prevent, recognize and treat it. More than 30 scales have been developed to evaluate pain, but a gold standard has not been found. We have good therapeutic instruments for pain treatment. It is necessary to use adequate analgesia also for minor invasive procedures: in the last few years the use of non-pharmacological analgesia has made big progress, e.g. instillation of sweet solution or performing sensorial saturation. However, in neonatal analgesia, attention should be paid not only to the use of analgesia, but also to doctors’ and parents’ suffering.
Neonatal pain - Medico e Bambino 2010;29:289-301
Carlo Valerio Bellieni, Lorenzo Iantorno, Giuseppe Buonocore
Dipartimento di Pediatria, Ostetricia e Medicina della Riproduzione, Università di Siena
OBJECTIVE: To compare the efficacy of oral sweet solutions to water or no treatment in infants aged 1–12 months during immunisation.
METHODS: Randomised controlled trials (RCTs) were retrieved through internet searches or manual searches of reference lists. Search terms included newborn, infant, pain, sucrose and alternative names for sweet solutions. Summary estimates with 95% CIs were calculated and included relative risk (RR), risk difference (RD) and number needed to treat to benefit (NNTB) for dichotomous outcomes, and weighted mean differences (WMD) for continuous outcomes. Where pooling of results was not possible, a narrative summary of study results is presented.
RESULTS: Of the 695 studies identified, 14 RCTs with 1674 injections met the inclusion criteria. Sucrose or glucose, compared to water or no treatment decreased crying during or following immunisation in 13 of the 14 studies. Infants receiving 30% glucose (three trials, 243 infants) had a decreased RR in crying incidence following immunisation (typical RR 0.80, 95% CI 0.69 to 0.93; RD −0.17, 95% CI −0.29 to −0.05; NNTB 6, 95% CI 3 to 20). With sucrose or glucose, there was a 10% WMD reduction in proportion of crying time (95% CI −18 to −2) and a 12 s reduction in crying duration (95% CI −23 to −0.7 s). An optimal dose of sucrose or glucose could not be ascertained due to the varied volumes and concentrations used.
CONCLUSIONS: OInfants aged 1–12 months administered sucrose or glucose before immunisation had moderately reduced incidence and duration of crying. Healthcare professionals should consider using sucrose or glucose before and during immunisation.
Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review - Arch Dis Child 2010;95:406-413 doi:10.1136/adc.2009.174227; [Full Text PDF]
Denise Harrison,Bonnie Stevens,Mariana Bueno,Janet Yamada,Thomasin Adams-Webber,Joseph Beyene,Arne Ohlsson
OBJECTIVE: After prolonged opioid exposure, children develop opioidinduced
hyperalgesia, tolerance, and withdrawal. Strategies for prevention
and management should be based on the mechanisms of opioid
tolerance and withdrawal.
METHODS: Relevant manuscripts published in the English language were searched in Medline by using search terms “opioid,” “opiate,” “sedation,” “analgesia,” “child,” “infant-newborn,” “tolerance,” “dependency,” “withdrawal,” “analgesic,” “receptor,” and “individual opioid drugs.” Clinical and preclinical studies were reviewed for data synthesis.
RESULTS: Mechanisms of opioid-induced hyperalgesia and tolerance suggest important drug- and patient-related risk factors that lead to tolerance and withdrawal. Opioid tolerance occurs earlier in the younger age groups, develops commonly during critical illness, and results more frequently from prolonged intravenous infusions of short-acting opioids. Treatment options include slowly tapering opioid doses, switching to longer-acting opioids, or specifically treating the symptoms of opioid withdrawal. Novel therapies may also include blocking the mechanisms of opioid tolerance, which would enhance the safety and effectiveness of opioid analgesia.
CONCLUSIONS: Opioid tolerance and withdrawal occur frequently in critically ill children. Novel insights into opioid receptor physiology and cellular biochemical changes will inform scientific approaches for the use of opioid analgesia and the prevention of opioid tolerance and withdrawal.
Tolerance and Withdrawal From Prolonged Opioid Use in Critically Ill Children - Pediatrics 2010;125;e1208-e1225;
Kanwaljeet J. S. Anand, Douglas F. Willson, John Berger, Rick Harrison, Kathleen L.Meert, Jerry Zimmerman, Joseph Carcillo, Christopher J. L. Newth, Parthak Prodhan,J. Michael Dean, Carol Nicholson and for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network
OBJECTIVE: The purpose of this controlled study was to provide a description of children's postoperative pain, including pain intensity and analgesic consumption.
METHODS: Participants included 261 children, 2 to 12 years of age, undergoing routine tonsillectomy and adenoidectomy surgery. Baseline and demographic data were collected before surgery, and a standardized approach to anesthesia and surgical procedures was used. Pain and analgesic consumption were recorded for 2 weeks at home.
RESULTS: On the first day at home, although parents rated 86% of children as experiencing significant overall pain, 24% of children received 0 or just 1 medication dose throughout the entire day. On day 3 after surgery, although 67% of children were rated by parents as experiencing significant overall pain, 41% received 0 or 1 medication dose throughout the entire day.
CONCLUSIONS: We conclude that a large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.
STUDY OBJECTIVE: We
compare the treatment of pain in children with arm fractures by
ibuprofen 10 mg/kg versus acetaminophen with codeine 1 mg/kg/dose
METHODS: This was a randomized, double-blind, clinical trial of children during the first 3 days after discharge from the emergency department (ED). The primary outcome was failure of the oral study medication, defined as use of the rescue medication. Pain medication use, pain scores, functional outcomes, adverse effects, and satisfaction were also assessed.
RESULTS: Three hundred thirty-six children were randomized to treatment, 169 to ibuprofen and 167 to acetaminophen with codeine; 244 patients were analyzed. Both groups used a median of 4 doses (interquartile range 2, 6.5). The proportion of treatment failures for ibuprofen (20.3%) was lower than for acetaminophen with codeine (31.0%), though not statistically significant (difference=10.7%; 95% confidence interval -0.2 to 21.6). The proportion of children who had any function (play, sleep, eating, school) affected by pain when pain was analyzed by day after injury was significantly lower for the ibuprofen group. Significantly more children receiving acetaminophen with codeine reported adverse effects and did not want to use it for future fractures.
CONCLUSION: Ibuprofen was at least as effective as acetaminophen with codeine for outpatient analgesia for children with arm fractures. There was no significant difference in analgesic failure or pain scores, but children receiving ibuprofen had better functional outcomes. Children receiving ibuprofen had significantly fewer adverse effects, and both children and parents were more satisfied with ibuprofen. Ibuprofen is preferable to acetaminophen with codeine for outpatient treatment of children with uncomplicated arm fractures.
Se ogni anno in Italia 90 mila malati terminali non vengono curati, o lo sono parzialmente, per la sofferenza fisica (22 milioni di dosi di morfina annui bastano per curarne 60 mila su 150 mila), ancor peggio è la situazione per quei 10-15 milioni di italiani che soffrono di dolore cronico non causato da tumori. Mal di schiena al primo posto. Un classico. La mattina ci si sveglia senza riuscire a muoversi, anzi a distendere la schiena. Fitte atroci, piegati dal dolore. Telefonata in ufficio per avvertire dell'assenza: «Colpo della strega». Poi al medico di base. Un antinfiammatorio prescritto al telefono. Poi tutto passa... Le cause possono essere diverse, ma si calcola che almeno il 90 per cento della popolazione mondiale almeno una volta nella vita abbia provato questa lancinante sofferenza. E 9 volte su dieci passa da solo nel giro di qualche giorno. Quindi niente esami, nessuna diagnosi, causa ignota. Un dato che, con la creazione di servizi multispecialistici (Pain center) in grado di affrontare il dolore come malattia, è subito sceso a circa il 70 per cento. Almeno è questa l'esperienza di New York, dove il mal di schiena è nell'hit parade dei costi sociali come giorni di lavoro persi, costi sanitari, assistenza domiciliare...
Skin-to-skin contact, or kangaroo mother care (KMC) has been shown to be efficacious in diminishing pain response to heel lance in full term and moderately preterm neonates. The purpose of this study was to determine if KMC would also be efficacious in very preterm neonates.
Preterm neonates (n = 61) between 28 0/7 and 31 6/7 weeks gestational age in three Level III NICU's in Canada comprised the sample. A single-blind randomized crossover design was employed. In the experimental condition, the infant was held in KMC for 15 minutes prior to and throughout heel lance procedure. In the control condition, the infant was in prone position swaddled in a blanket in the incubator. The primary outcome was the Premature Infant Pain Profile (PIPP), which is comprised of three facial actions, maximum heart rate, minimum oxygen saturation levels from baseline in 30-second blocks from heel lance. The secondary outcome was time to recover, defined as heart rate return to baseline. Continuous video, heart rate and oxygen saturation monitoring were recorded with event markers during the procedure and were subsequently analyzed. Repeated measures analysis-of-variance was employed to generate results.
PIPP scores at 90 seconds post lance were significantly lower in the KMC condition (8.871 (95%CI 7.852–9.889) versus 10.677 (95%CI 9.563–11.792) p < .001) and non-significant mean differences ranging from 1.2 to1.8. favoring KMC condition at 30, 60 and 120 seconds. Time to recovery was significantly shorter, by a minute(123 seconds (95%CI 103–142) versus 193 seconds (95%CI 158–227). Facial actions were highly significantly lower across all points in time reaching a two-fold difference by 120 seconds post-lance and heart rate was significantly lower across the first 90 seconds in the KMC condition.
Very preterm neonates appear to have endogenous mechanisms elicited through skin-to-skin maternal contact that decrease pain response, but not as powerfully as in older preterm neonates. The shorter recovery time in KMC is clinically important in helping maintain homeostasis.
(Current Controlled Trials) ISRCTN63551708
The aim of this study was to investigate the degree to which Swedish neonatal units have adopted the national guidelines for prevention and treatment of pain in newborn infants. Method: A survey was sent to all units in Sweden that provide neonatal care. For a list of potentially painful procedures, compiled from the national neonatal pain guidelines, the units were asked if they would use pharmacological and/or behavioural interventions, and in each case to specify the treatment. Results: The response rate was 80.4%. Eighty-eight percent of the units had written guidelines for pain management, and 59% of these had been updated within the last 2 years. For almost every presented case, all units reported that they used either pharmacological or behavioural treatment or both. The survey showed a wide variation in morphine and paracetamol dosing and the absence of a paracetamol loading dose in a fourth of the units. Conclusions: This study suggests that a majority of Swedish neonatal units have adopted pain management guidelines in concordance with the Swedish national guidelines, and kept them up-to-date. For most painful situations a variety of behavioural and pharmacological interventions are used, often in combination.
Pain management in Swedish neonatal units - a national survey
Mats Eriksson, Maria Gradin
Acta Paediatrica 2008;97(7):870-874.
La sensazione che in Italia la prevenzione del dolore da procedure e il trattamento del dolore acuto fisico in ospedale non siano adeguatamente trattati, ha indotto gli Autori a promuovere un’indagine conoscitiva tesa a comprendere quale sia lo stato della prevenzione e del trattamento del dolore acuto nel bambino nel nostro Paese e quale sia la sensibilità dei medici e delle infermiere che a qualunque titolo hanno in cura i bambini, dal neonato sano all’adolescente. È stato inviato un questionario ai responsabili di 200 reparti di pediatria largamente rappresentativi di tutte le regioni italiane. I risultati si riferiscono ai 110 reparti che hanno risposto al questionario. In generale la prevenzione del dolore da procedure è poco attuata e, negli ospedali in cui è praticata, lo è in maniera scarsamente aderente alle linee-guida internazionali. Solo nel 17% dei reparti sono presenti protocolli per la terapia del dolore. La sedazione nelle procedure diagnostiche endoscopiche in gastroenterologia è, invece, più diffusamente e meglio attuata. Il dolore fisico acuto è trattato in maniera discretamente adeguata, ma gli oppioidi trovano pochissimo spazio soprattutto nel dolore post-chirurgico. Si ritiene, pertanto, necessario migliorare la sensibilità dei pediatri e delle infermiere all’uso delle pratiche antidolore anche attraverso l’approntamento di linee-guida nazionali e l’inclusione di programmi di formazione specifici nelle Scuole di Spe cia - lizzazione in Pediatria e negli ospedali.
Sensibilità dei pediatri e delle infermiere
alla prevenzione e terapia del dolore in ospedale
L. De Seta, F. Parizzi, G. Patrucco, L. Peratoner, M. Pocecco, C. Rossetti
Gruppo ospedaliero dell’Associazione Culturale Pediatri
Nonostante sempre maggiori evidenze che il dolore acuto e ripetitivo è causa di alterazioni fisiologiche, comportamentali, ormonali ed endocrine destabilizzanti con effetti deleteri a breve e lungo termine, ancora frequentemente i neonati ricoverati nelle Terapie Intensive Neonatali (TIN) sono esposti precocemente a stimoli dolorosi non controllati per procedure diagnostiche, terapeutiche e chirurgiche.
Raccomandazioni per la prevenzione ed il trattamento del dolore nel neonato
Lago P Ancora G, Bellini C, et al.
Gruppo di Studio di Analgesia e Sedazione, Società Italiana di Neonatologia
OBJECTIVES: To characterize the magnitude of the placebo response in trials of migraine therapy in children and adolescents, and to identify its determinants. STUDY DESIGN: MEDLINE and CENTRAL were searched through November 2006 for randomized controlled trials or controlled clinical trials of pediatric acute migraine pharmacologic treatment that included a placebo comparator group. The main outcomes were headache relief and pain-free response, and effect estimates for risk differences were calculated whenever possible. The influence of placebo response determinants was studied using subgroup analysis. A total of 13 trials (1324 participants in the placebo groups) were included in the analysis. RESULTS: The pooled placebo responses for pain relief and pain-free at 2 hours were 46% (range, 38% to 53%) and 21% (range, 17% to 26%). Parallel studies conducted in North American centers demonstrated a significantly higher placebo response, as did trials that used 4-point pain scales. Other placebo determinants did not influence the effect estimate, although insufficient data were available to study some of them. CONCLUSIONS: There is a widely variable placebo response in pediatric migraine trials, supporting the continued use of placebo groups and suggesting the need for more research into the placebo effect in the pediatric population.
The placebo response in studies of acute migraine
Fernandes R, Ferreira JJ, Sampaio C
J Pediatr 2008;152(4):527-33, 533.e1. Epub 2007 Dec 3
BACKGROUND Chronic abdominal pain (CAP) is common in childhood and often causes significant disruption to daily life. It is most often due to a nonorganic/functional gastrointestinal disorder.
OBJECTIVE This article presents information to assist in differentiating between nonorganic and organic causes of CAP. It stresses the importance of functional abdominal pain as a common clinical entity which needs active diagnosis and management.
DISCUSSION Chronic abdominal pain is pain that occurs continuously or recurrently over a period of time. A thorough history and examination together with an event diary, recognition of ‘alarm’ symptoms and signs and appropriate investigation will assist in identifying patients with organic disease. A diagnosis of functional abdominal pain allows both the physician and family to focus on understanding the brain-gut interaction, avoid unnecessary investigations and implement appropriate pain management strategies.
Chronic abdominal pain in children
Leonie Gray MBBS, FRACP, is Senior Paediatrician VMO, Rockhampton Hospital, Queensland.
Australian Family Physician 2008;37(6):398–400
BACKGROUND: Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. It is unclear whether the diagnosis includes children with different aetiologies for their pain. For the majority no organic cause for their pain can be found on physical examination or investigation. Although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended. OBJECTIVES: To determine the effectiveness of dietary interventions for recurrent abdominal pain in school-age children. SEARCH STRATEGY: The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched . Where appropriate, search filters were employed. In addition, researchers working in this area were asked to identify relevant studies. SELECTION CRITERIA: Randomised or quasi-randomised studies of any dietary treatment versus placebo or no treatment in school-age children with a diagnosis of RAP or functional gastrointestinal disorder based on the Rome II criteria. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trials for inclusion, assessed quality and extracted data. Where appropriate studies were pooled using a random effects meta-analysis. MAIN RESULTS: Seven trials were included in this review. Two trials, including 83 participants, compared fibre supplements with placebo (Christensen 1982, Feldman 1985), with data from one study reported in two papers (Christensen 1982, Christensen 1986). The pooled odds ratio for improvement in the frequency of abdominal pain was 1.16 (95% CI 0.45-2.87).Two trials, including 90 participants (Lebenthal 1981, Dearlove 1983) compared lactose-containing with lactose-free diets. Neither reported data in a form which could be used in the meta-analysis and the former trial had a loss to follow-up of 45%. We were not able to obtain further data for either trial.Three trials (Bausserman 2005, Gavronska 2007, Young 1997) comparing supplementation with Lactobacillus with placebo met the inclusion criteria but only two (Bausserman 2005, Gavronska 2007), including a total of 168 children, provided analysable data. The pooled odds ratio for improvement of symptoms was 1.17 (95% CI 0.62, 2.21). AUTHORS' CONCLUSIONS: There is a lack of high quality evidence on the effectiveness of dietary interventions. This review provides no evidence that fibre supplements, lactose free diets or lactobacillus supplementation are effective in the management of children with RAP.
Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood.
Huertas-Ceballos A, Logan S, Bennett C, Macarthur C
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003019
BACKGROUND: Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority no organic cause for their pain can be found on physical examination or investigation and although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended. OBJECTIVES: To determine the effectiveness of medication for recurrent abdominal pain in school-age children. SEARCH STRATEGY: The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched with appropriate filters SELECTION CRITERIA: Studies on school age children with RAP (Apley or the Rome II criteria for gastrointestinal diseases) allocated by random or quasi-random methods to a drug treatment vs. placebo/ no treatment were included. DATA COLLECTION AND ANALYSIS: References identified by the searches were screened against the inclusion criteria by two independent reviewers. Data was extracted and analysed using RevMan 4.2.10. MAIN RESULTS: Three trials met the inclusion criteria. Symon et al report a cross-over trial comparing pizotifen and placebo in 16 children with "abdominal migraine". Data before cross-over was not available. Results for 14 children showed Mean fewer days in pain of 8.21 (95% CI 2.93, 13.48) while taking the active drug.Kline et al compared peppermint oil capsules with placebo in a randomised trial in 50 children with RAP and IBS. 42 children completed the study. OR for improvement was 3.33 (95% CI 0.93-12.1)See et al compared famotidine with placebo in a randomised cross-over trial in 25 children with RAP and dyspepsia. OR for improvement before cross-over was 11 (95%CI 1.6, 75.5). AUTHORS' CONCLUSIONS: This review provides weak evidence of benefit on medication in children with RAP. The lack of clear evidence of effectiveness for any of the recommended drugs suggests that there is little reason for their use outside of clinical trials. Clinicians may choose to prescribe drugs in children with severe symptoms that have not responded to simple management. However, if using drugs as a "therapeutic trial", clinicians should be aware that, RAP is a fluctuating condition and any "response" may reflect the natural history of the condition or a placebo effect rather than drug efficacy.
Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood
Huertas-Ceballos A, Logan S, Bennett C, Macarthur C
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003017
BACKGROUND: Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority of such children, no organic cause for their pain can be found on physical examination or investigation. Although most children are managed by reassurance and simple measures, a large range of psychosocial interventions including cognitive and behavioural treatments and family therapy have been recommended. OBJECTIVES: To determine the effectiveness of psychosocial interventions for recurrent abdominal pain or IBS in school-age children. SEARCH STRATEGY: The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2006), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched with appropriate filters. SELECTION CRITERIA: Any study in which the majority of participants were school-age children fulfilling standard criteria for RAP (Apley or the Rome II criteria for functional gastrointestinal diseases) , randomly allocated to any psychosocial treatment compared to standard care or waiting list, were selected. DATA COLLECTION AND ANALYSIS: References identified by the searches were independently screened against the inclusion criteria by two reviewers. Data were extracted and analysed using RevMan 4.2.10. MAIN RESULTS: Six randomised trials (including a total of 167 participants) of cognitive behavioural interventions were identified, with data reported in ten papers. Five studies reported statistically significant improvements in pain, measured in a variety of ways, in children randomised to receive interventions based on cognitive behavioural therapy compared to children on wait lists or receiving standard medical care (Duarte 2006; Humphreys 1998; Robins 2005; Sanders 1989; Sanders 1994). The remaining trial (Hicks 2003) included a wider group of children with recurrent pain and too few with only RAP to provide interpretable data. AUTHORS' CONCLUSIONS: The included trials were small, with methodological weaknesses and a number failed to give appropriate detail regarding numbers of children assessed. In spite of these methodological weaknesses and the clinical heterogeneity, the consistency and magnitude of the effects reported provides some evidence that cognitive behavioural therapy may be a useful intervention for children with recurrent abdominal pain although most children, particularly in primary care, will improve with reassurance and time.
Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood
Huertas-Ceballos A, Logan S, Bennett C, Macarthur C
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003014
Vaccine-related pain: randomised controlled trial of two injection techniques
Moshe Ipp, Anna Taddio, Jonathan Sam, Morton Gladbach, Patricia C Parkin
Arch Dis Child 2007;92(12):1105-8
Riduzione del dolore legato alle vaccinazioni
Appunti di Terapia Pagine Elettroniche, Settembre 2007
I farmaci nel trattamento del dolore: dall’uso off-label alla razionalità della prescrizione
Presentazioni PPT Pagine Elettroniche, Aprile 2007
Mi sono fatto male nascendo
Presentazioni PPT Pagine Elettroniche, Marzo 2007
Il dolore che nasce dalla psiche:
patologia somatoforme, da inganno e
sindrome di Munchausen by proxy
Presentazioni PPT Pagine Elettroniche, Febbraio 2007
Il dolore che nasce dalla psiche:
la patologia somatoforme e da inganno
Presentazioni PPT Pagine Elettroniche, Gennaio 2007
La cefalea: tra la psiche ed evidenze farmacologiche di trattamento
Presentazioni PPT Pagine Elettroniche, Dicembre 2006
Il dolore che porta alla diagnosi di tumore
Presentazioni PPT Pagine Elettroniche, Novembre 2006
Trattare il dolore addominale con i farmaci? Un vecchio mito da sfatare
D. Radzik, G. Pelizzo
Presentazioni PPT Pagine Elettroniche, Ottobre 2006
È ragionevole trattare il dolore addominale
acuto con i farmaci analgesici?
D. Radzik, C. Zaramella
Farmacoriflessioni Medico e Bambino 2006;25(8):519-5240
Il trattamento sintomatico della febbre e del dolore nella pratica ambulatoriale
F. Marchetti, J. Bua, M. Maschio, E. Barbi
Farmacoriflessioni Medico e Bambino 2006;25(1):49-50
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