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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.