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In the past, management of pain in neonates was regarded as unnecessary, with the belief that neonates have an immature nervous system and do not perceive pain. Later studies confirmed that neonates certainly do feel pain, though they lack the inhibitory mechanisms that modulate excruciating stimuli, unlike in older children. Repeated painful encounters experienced in the newborn period are associated with poor cognitive and motor development by 1 year of age. Pain in preverbal infants and children is also poorly recognized and often undertreated. Neonates and preverbal children cannot verbally communicate their pain and discomfort but express them through specific behavioral, physiological, and biochemical responses. Several pain measurement tools have been developed for young children as surrogate measures of pain. To achieve optimum postoperative or procedural pain relief, easily understandable tools and a multimodal treatment module should be tailor-made for each health-care facility that cares for neonates and young infants. The aim of this advisory is to outline key concepts of pain assessment in neonates and preverbal children and suggest a rational approach to its management by all anesthesiologists, pediatricians, nursing staff, and other medical personnel caring for these children. The Indian Association of Paediatric Anaesthesia (IAPA) convened an online meeting in April 2020 to formulate the advisory on pain management in neonates and preverbal children under the chairmanship of Dr. Elsa Varghese, President IAPA, and members of the guideline committee. After several such meetings and revisions using feedback from IAPA members, the final guidelines were released in October 2020 on the IAPA website. Recommendations: Pain relief should generally be accomplished with a combination of nonpharmacologic approaches and pharmacologic techniques in a stepwise tiered manner by escalating type and dose of analgesia with anticipated increases in procedural pain. Nonpharmacological distraction measures may be sufficient for minor needle procedures like vaccination and venipuncture and may be offered as a first step and to complement other pain management remedies. An interdisciplinary approach involving pharmacologic, cognitive-behavioral, psychologic, and physical treatments should be employed whenever feasible.

Background and Aims: In the cleft lip and palate, the laryngoscope blade often tends to lodge inside midline clefts, causing reduced manoeuvrability and tissue trauma. The paraglossal technique avoids the midline and offers better Cormack Lehane (CL) grades. We aimed to assess the first-pass intubation rate in performing the left paraglossal laryngoscopy with a curved-blade videolaryngoscope (VLS) versus direct laryngoscope (DLS) in children with cleft palate and evaluate the time taken for successful endotracheal intubation (TTI) and Intubation Difficulty Score (IDS) with both devices. Methods: This randomised controlled trial included 60 patients with cleft palate, between 3 months and 6 years. Patients were randomised into group V (VLS) (n = 30) and group D (DLS) (n = 30). Left paraglossal laryngoscopy was done with VLS or DLS, and the first-pass intubation, TTI, CL grade and IDS were recorded. Results: First-pass intubation (primary outcome) was successful in all cases in group V and in 29 (96%) cases in group D (P = 0.923). Amongst the secondary outcomes, the IDS of the majority in both groups was 1–4 (slight difficulty) (P = 0.98) and the mean TTI In group D was 34.6 s (SD = 19.0) (95% CI: 27.5–41.7) versus 39.8 s (SD = 5.2) (95% CI: 37.8–41.7) in group V (P = 0.151). Conclusions: There was no significant difference in the use of a VLS over a DLS in performing the left paraglossal laryngoscopy in terms of first-pass intubation rate, CL Grade, IDS and TTI. Further studies with different VLS may be done to improve the ease of this technique.