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QUESTION 2
M Anderson and E Collins
Arch Dis Child 2008 93: 995-997 originally published online February 27,
2008

doi: 10.1136/adc.2008.137174

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References

This article cites 4 articles, 2 of which can be accessed free at:

http://adc.bmj.com/content/93/11/995.full.html#ref-list-1

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Archimedes
Clinical bottom line
c

There is limited evidence from one small

study in adults with depression that dolphin
therapy is effective in alleviating symptoms
of mild to moderate depression. (Grade A)
Dolphin therapy is comparatively
expensive. Prices vary but a weeks
therapy in Florida can cost around
US$2000 not including travel and
accommodation.
There is no conclusive scientific evidence
to support the benefit of swimming with
dolphins for children with cerebral palsy,
although many do report positive effects.

groups (for example, mencap and scope)

have sections on their website about
dolphin therapy or swimming with dolphins. Scope state that dolphin therapy
does not claim to cure any specific
condition but it may help alleviate some
symptoms associated with some conditions. They do however conclude
research is on-going but there is not
currently clear scientific evidence of lasting benefits. Dolphin therapy is comparatively expensive and not funded via any
UK statutory agencies.
Since John Lilly first studied dolphin
human communication in the 1960s,
much of the study by researchers in this
field has been practice based and uncontrolled making it impossible to determine whether their results were due to
specific effects of DAT or a host of other
potentially confounding factors.3
In 2003 Humphries looked at a practice
based research synthesis focusing on the
effectiveness of DAT in children (6 years
of age with disabilities, in order to
determine the interventions implication
for practice.1 She found six papers that
met her selection criteria.49 The children
involved in the studies had a range of
disabilities including autism, developmental delay, speech disorders and traumatic
brain injury, with only two papers specifically including children with cerebral
palsy. Some studies included direct observation of the childrens behaviour, others
used videotaped observations and one
involved a parent survey. Key results
included acquisition of skills, cognitive
functioning and improvement in psychoemotional status. Criticisms of study
design included small sample size, lack of
a control group and respondent and
investigator bias. Humphries concluded
that better designed and better controlled
research is needed to determine whether
DAT is truly an effective intervention
that should be promoted to parents and
Arch Dis Child November 2008 Vol 93 No 11

practitioners worldwide. She also noted

that the cost of these therapies is often
high and that there is not enough
evidence available currently to support
the use of this practice.
After reviewing 20 years of research in
2005, Dr Karsten Brensing concluded
there is still no proof that DAT is more
successful than other animal assisted
therapies.10
Several hypotheses have been proposed
to explain how DAT works. One is that
dolphins emit healing energy vibrations;
another speculation is that the ultrasound
from the echolocation clicks of dolphins
heals by stimulating the endocrine system. Neither of these theories has been
substantiated.
DAT has become an increasingly popular intervention for children with disabilities. Many parents believe it can have
a significant positive effect on the cognitive, physical or socialemotional behaviours of their disabled child.
As the popularity of DAT has grown,
claims of the therapeutic benefit have
also grown. Despite much media coverage and support groups discussing its
potential benefits, we could find no
evidence to date to support the benefit
of swimming with dolphins for children
with cerebral palsy.

A Baverstock, Community Child Health Department,

Bath NHS House, Newbridge Hill, Bath BA1 3QE, UK;
annabav@hotmail.com
F Finlay, Community Child Health Department, Bath
NHS House, Newbridge Hill, Bath BA1 3QE, UK
Competing interests: None.
Arch Dis Child 2008;93:994995.
doi:10.1136/adc.2007.126573

REFERENCES
1.

2.

3.

4.

5.

6.

7.

Humphries TL. Effectiveness of dolphin-assisted

therapy as a behavioural intervention for young
children with disabilities. Bridges 2003;1(6):19.
Antonioli C, Reveley MA. Randomised controlled trial
of animal facilitated therapy with dolphins in the
treatment of depression. BMJ 2005;331:1231.
Marino L, Lilienfield SO. Dolphin-assisted therapy:
flawed data, flawed conclusions. Anthrozoos
1998;11:194200.
Lukina LN. Influence of dolphin-assisted therapy
sessions on the functional state of children with
psychoneurological symptoms of diseases. Hum
Physiol 1999;25:6769.
Nathanson DE. Using Atlantic bottlenose dolphins to
increase cognition of mentally retarded children. In:
Lovibond PH, Wilson PH, eds. Clinical and abnormal
psychology. Amsterdam: North-Holland, 1989:23342.
Nathanson DE. Long-term effectiveness of dolphinassisted therapy for children with severe disabilities.
Anthrozoos 1998;11:2232.
Nathanson DE, de Castro D, Friend H, et al.
Effectiveness of short-term dolphin assisted therapy
for children with severe disabilities. Anthrozoos
1997;10:90100.

8.
9.
10.

Nathanson DE, de Faria S. Cognitive improvement of

children in water with and without dolphins.
Anthrozoos 1993;6:1729.
Servais V. Some comments on context embodiment
in zootherapy: the case of the Autidolfijn project.
Anthrozoos 1999;12:515.
Brensing K. Expert statement on Swim with the
dolphin programs and dolphin-assisted therapy,
2005. Agreement on the Conservation of Cetaceans
of the Black Sea, Mediterranean Sea and contiguous
Atlantic area: Third Meeting of the Scientific
Committee, Cairo, Egypt, 2005

QUESTION 2
ANALGESIA FOR CHILDREN WITH ACUTE
ABDOMINAL PAIN AND DIAGNOSTIC
ACCURACY
A 9-year-old boy presents with severe right
iliac fossa pain. You contact the surgical
team who are currently in theatre and will
not be able to attend for at least 20 min.
You wonder if administering morphine to
the boy will hinder or delay diagnosis.

STRUCTURED CLINICAL QUESTION

In children with acute abdominal pain
[patient] does analgesia before surgical
consultation [intervention] affect surgical
diagnostic accuracy [outcome]?

SEARCH STRATEGY AND OUTCOME

Strategy
Medline and Embase were searched using
the Dialog Datastar interface.
MEDLINE (1950date) search terms:
(abdominal ADJ pain OR acute ADJ
abdomen) AND (analges$ OR pain ADJ
relief) AND diagnosis AND LG = EN
AND HUMAN = YES AND (CHILD#
OR ADOLESCENT.DE. OR INFANT#)
EMBASE (1974date) search terms:
(abdominal ADJ pain OR acute ADJ abdomen) AND (analges$ OR pain ADJ relief)
AND diagnosis AND LG = EN AND
HUMAN = YES AND CHILD = YES
The BestBETs website was searched.

Outcome
MEDLINE yielded 56 papers and EMBASE
yielded 100 papers. BestBETs yielded 1 BET,
but although the clinical scenario involved
the assessment of a child, all of the evidence
related to studies performed in adults.

Clinical bottom line

c
c

Surgical diagnostic accuracy is not affected

by pre-assessment analgesia. (Grade B)
Early analgesia in children with suspected
surgical abdominal pain is effective;
administration should not be withheld
pending surgical consultation. (Grade B)

995

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Archimedes
Table 2 Analgesia for children with acute abdominal pain and diagnostic accuracy
Author, date
and country Patient group

Study type
(level of evidence) Outcomes

Kim et al
(2002),
USA1

Randomised,
double-blind,
placebocontrolled
trial
(level 2b)

60 children aged 518 years

with abdominal pain for
,5 days scoring >5 on a
VAS. 0.1 mg/kg morphine
iv vs same volume 0.9%
NaCl iv. Patients examined
before and after
administration of study drug
by paediatric emergency
physicians and surgeons

Pain score

Change in mean
number of areas of
tenderness to palpation
before and after
study drug
Change in mean
number of areas of
tenderness to
percussion before and
after study drug
Difference in
diagnostic accuracy
(true surgical causes
and true non-surgical
causes as a proportion
of all results) between
morphine and placebo
groups

Green et
al (2005),
Canada2

108 children aged 516 years

with abdominal pain of
,48 h duration of possible
surgical origin. 0.05 mg/kg
morphine iv vs same volume
0.9% NaCl iv. Patients
examined before and after
administration of study
drug by paediatric
emergency physician and
afterwards only by
paediatric surgeon

Double-blind,
randomised,
placebocontrolled trial
(level 2b)

Pain score using colour

analogue scale
Physician confidence in
diagnosis (0100%)
before and after study
drug

Surgeon confidence in
diagnosis (0100%)
after study drug
Appendicitis at
laparotomy in those
children undergoing
surgical intervention

Key results

Study weaknesses

Median difference in
reduction of pain score
between groups of two
points (p = 0.002)
Paediatric emergency physicians
Morphine: 0.9 (95% CI 0.1 to 1.8)
Placebo: 0.1 (95% CI 20.6 to 0.7)
Surgeons
Morphine: 0.1 (95% CI 20.6 to 0.7)
Placebo: 0.3 (95% CI 20.1 to 0.6)
Paediatric emergency physicians
Morphine: 1.0 (95% CI 0.1 to 1.9)
Placebo: 0.0 (95% CI 20.3 to 0.4)
Surgeons
Morphine: 0.2 (95% CI 20.1 to 0.6)
Placebo: 20.2 (95% CI 20.7 to 0.4)
Paediatric emergency physicians
Before study drug:
1.8% (95% CI 0.1 to 2.0)
After study drug:
5.4% (95% CI 20.1 to 0.3)
Surgeons
Before study drug:
11.6% (95% CI 0.1 to 2.0)
After study drug:
11.8% (95% CI 0.1 to 2.0)

Small sample size. Posthoc power calculation

performed but not related
to the original question

Mean pain score reduction

with morphine 2.2 vs 1.2
with placebo (p = 0.015)
Morphine group: 68.9% (before)
vs 69.5% (after) (effect size: 1.2%;
95% CI 22.9% to 5.3%)
Placebo group: 65.5% (before)
vs 70.9% (after) (effect size: 5.3%;
95% CI 2.7% to 7.9%)
Morphine group: 73.8%
Placebo group: 73.6%
(effect size: 0.01%;
95% CI 20.39% to 0.40%)
Morphine group: 24/25
Placebo group: 22/24
(p = 0.25)

No power calculation

Kokki et
al (2005),
Finland3

63 children aged 415 years

with abdominal pain scoring
>5 out of 10 on a VAS.
0.1 mg/kg buccal
oxycodone vs same volume
buccal 0.9% NaCl. Patients
examined before and after
administration of study drug

Randomised,
double-blind
placebocontrolled trial
(level 2b)

Mean summed pain

intensity difference
over 7 observations at
half-hourly intervals
Diagnostic accuracy
(true surgical causes
and true non-surgical
causes as a proportion
of all results)

Oxycodone group: 22 (SD 18)

Placebo group: 9 (SD 12)
Mean difference: 13
(95% CI 2 to 24; p = 0.04)
Oxycodone group:
Before analgesia 72%
After analgesia 88% (p = 0.12)
Placebo group:
Before analgesia 84%
After analgesia 84%
(p value not reported)

Small number of patients.

Powered to detect
significant change in pain
scores but not diagnostic
accuracy

Bailey et
al (2007),
Canada

90 children aged 818 years

with presumptive
appendicitis and pain scoring
>5 out of 10 on a verbal

Randomised,
doubleblind placebocontrolled trial

Decrease in pain
intensity on 100 mm
VAS after study drug
administration

Morphine group: 24 (SD 23) mm

Placebo group: 20 (SD 18 mm
Mean difference: 4 mm
(95% CI 25 to 12 mm)

Sample size required to

detect significant
reduction in pain
(estimated as 220 mm)
Continued

996

Arch Dis Child November 2008 Vol 93 No 11

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Archimedes
Table 2 Continued
Author, date
and country Patient group
numeric scale. 0.1 mg/kg
iv morphine vs similar
looking placebo. Patients
examined before and after
administration of study drug

Study type
(level of evidence) Outcomes
(level 2b)

Difference between
time of arrival
in ED and time of
surgical decision for
disposition of patient

Key results

Study weaknesses

Morphine group: 269 min

Placebo group: 307 min
Mean difference: 234 min
(95% CI 2105 to 40 min)

was calculated as 152.

Sample size required to
detect difference of 1 h
in time between arrival
and surgical disposition
was calculated as 184.
Study terminated early
due to slow enrolment
and interim analysis
showing no difference

ED, emergency department; VAS, visual analogue scale.

After removal of duplicates, 134

abstracts were scanned. Four papers were
found to be relevant to the three-part
question (see table 2).

COMMENTARY
Classic teaching in general surgery has
suggested that administration of analgesia
in children with acute abdominal pain
should be deferred until after a definitive
surgical treatment plan has been formulated. Theoretically, analgesia may mask
pain and lessen examination findings that
would normally suggest a surgical cause
for abdominal pain.
All but one of the studies found that
opioid analgesia was effective at reducing
pain scores in children with acute abdominal pain. Bailey et al4 state that morphine
was not more effective than placebo in
diminishing pain. This study suffers from
being significantly underpowered regarding this outcome, but this does not fully
explain the result, which appears to be
due to a high placebo response compared
to the other studies rather than a lack of
response to morphine. The reasons for
such a high response are likely to be
complex and beyond the scope of this
commentary.
The studies identified all report that
administration of analgesia to children
with acute abdominal pain did not
significantly interfere with diagnosis.
Diagnostic accuracy was defined in two
studies as true surgical and true nonsurgical diagnoses as a proportion of all
results. One study detected no difference,3
while the other1 noted a difference when
children were examined by one subgroup
of doctors, although the confidence intervals are borderline, and the authors
other measure of diagnostic accuracy
(reduction in mean number of areas of
abdominal tenderness) was unaffected
by the administration of analgesia. One
Arch Dis Child November 2008 Vol 93 No 11

study2 used the doctors estimation of

confidence in diagnosis as their measure
of diagnostic accuracy. The remaining
study4 used the time between arrival in
the emergency department and the
surgical decision. Other proxy measures
of diagnostic accuracy, such as differences in time to operating theatre and
perforation rates, where recorded, are
also reported as being unaffected.
These results are in keeping with what
is known in adult patients; a recent
Cochrane review5 of this topic concluded
that the use of opioid analgesics in
patients with acute abdominal pain does
not delay treatment decisions. None of
the studies identified included children
less than 5 years old. In infants and
preschool children, acute abdomen is
uncommon, examination findings may
be non-specific and as a result diagnosis
may be difficult. Generalising findings
from older children to this age group
may therefore be detrimental.
The clinical assessors were reported as
blinded to whether the children had
received analgesia or placebo. However,
as the same assessor was responsible for
examining the child before and after
administration of the study drug, no
mechanism existed to prevent bias
introduced by the assessor remembering
the previous clinical findings. Only in
the study by Green et al2 were the
children examined after administration
of medication by another assessor (a
paediatric surgeon) who was naive to
the initial examination findings and
whose confidence in diagnosis was the
same for both the analgesia and the
placebo groups.
The studies all suffer from being underpowered to detect true differences in
diagnostic ability. Post-hoc power calculations performed on the papers by Green et
al2 and Kokki et al3 indicate that in order
to attain a power of 80% over 1000

patients would need to be recruited into

each arm of a trial. This would be a
significant undertaking and subjecting
several thousand children in pain to
placebo analgesia to identify a difference
in diagnostic accuracy that may have little
clinical impact is ethically suspect.
Certainly, none of the studies above
identified major morbidity or mortality
as a result of early treatment with
analgesia.
Since such a trial is therefore very
unlikely to be performed, what remains
is to make an informed decision based on
the current evidence, and with the
patients interests foremost. Taking these
into account, children with acute abdominal pain should be treated promptly and
adequately with analgesia unless future
studies suggest evidence of harm.

M Anderson, Academic Division of Child Health,

University of Nottingham, Derbyshire Childrens Hospital,
Derby, UK; mark.anderson@nottingham.ac.uk
E Collins, University of Nottingham, Nottingham, UK
Competing interests: None.
Arch Dis Child 2008;93:995997.
doi:10.1136/adc.2008.137174

REFERENCES
1.

2.

3.

4.

5.

Kim MK, Strait RT, Sato TT, et al.

A randomized clinical trial of analgesia in children
with acute abdominal pain. Acad Emerg Med
2002;9:2817.
Green R, Bulloch B, Kabani A, et al. Early analgesia for
children with acute abdominal pain. Pediatrics
2005;116:97883.
Kokki H, Lintula H, Vanamo K, et al. Oxycodone
vs placebo in children with undifferentiated
abdominal pain. Arch Pediatr Adolesc Med
2005;159:3205.
Bailey B, Bergeron S, Gravel J, et al. Efficacy and
impact of intravenous morphine before surgical
consultation in children with right lower quadrant pain
suggestive of appendicitis: a randomized controlled
trial. Ann Emerg Med 2007;50:3718.
Manterola C, Astudillo P, Losada H, et al. Analgesia in
patients with acute abdominal pain. Cochrane
Database Syst Rev 2007;(3):CD005660.

997