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In June 2013, the European Medicine Agency (EMA) prohibited the use of medicines containing codeine for patients under 12 years of age. The EMA recommendations impose a change in the management of moderate-severe pain in children. Tramadol, an opioid-related analgesic with an intermediate analgesic potency between NSAIDs and major opioids, is a possible substitute for codeine in children. It shows less respiratory depression and sedation as well as other adverse effects of opioids and also has no clinically relevant effects on heart rate and blood pressure. It acts like a weak or partial agonist with no affinity for opioid receptors and its central analgesic effects are partially reversed by naloxone. According to the available evidence, tramadol appears to be efficacious in the management of moderate-severe pain in children and safe both in inpatients and outpatients with no case of paediatric respiratory depression at therapeutic dosage being currently reported in the literature. Nevertheless, it may be appropriate to limit the use of tramadol to monitored settings for children with specific risk factors (adeno-tonsillectomy, sleep apnoea, obesity, renal impairments and the neonatal period), subject to further safety evidence. This review takes into consideration the available evidence on the pharmacokinetic and pharmacodynamic efficacy and safety profile of tramadol.

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We present the case of two twin brothers with surfactant protein C deficiency who were treated with hydroxychloroquine for three years, with apparent success. The exact physiopathology of this disease is not known and there is no specific treatment for it. There is merely news from a few previous descriptions in the literature about the use of hydroxychloroquine for surfactant protein C deficiency with satisfactory results. Two years after the treatment was withdrawn, the twins were evaluated once again: they presented no new infections, growth and general state were normal and chest CT showed a notable additional reduction in the interstitial pneumopathy. These data seem to cast some doubt on the efficacy of hydroxychloroquine, and they suggest that the clinical improvement was simply the natural evolution of the disease.

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Background: Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications. Data sources: We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as ‘cerebral palsy and children and pain’ or ‘sedation and cerebral palsy and children’. Results: While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation. Conclusions: Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.

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A 16-year-old boy presented because of the occurrence of a nonpruritic rash involving mainly the trunk. He had a fever and sore throat the previous week, for which he began antibiotic therapy (amoxicillin-clavulanate) for 7 days, without any improvement. As a result, at 2 days before admission to the emergency department, therapy had been switched to ciprofloxacin. On physical examination, he was febrile (38 C) but in good general condition. He had pharyngitis with laterocervical lymphadenopathy and a morbilliform rash involving the neck and both arms, with spread to the entire trunk (Figure 1), sparing a rectangular area at the left side (Figure 2), where up to 4 days earlier he had applied an anti-inflammatory patch (diclofenac) for back pain. The diagnosis of infectious mononucleosis was confirmed a few days later on the basis of Epstein-Barr virus–specific IgM and IgG antibodies.