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We present a case series of four paediatric patients who successfully tolerated sialendoscopy of the submandibular duct under local anaesthesia in the Royal Gwent Hospital Maxillofacial Department, Newport. Both diagnostic and interventional sialendoscopy procedures are reported in the case series, including basket retrieval and lithotripsy. These cases demonstrate the feasibility and effectiveness of both diagnostic and interventional sialendoscopy under local anaesthesia in the paediatric patient and propose that this may be considered a primary treatment option in cases of paediatric obstructive sialadenitis of the submandibular duct.

In Japan, declining birth rates and concentration of pediatric cases in fewer high-volume children's hospitals have reduced anesthesiologists' opportunities, particularly during training, to gain experience in pediatric anesthesia. There is no standardized national curriculum, and training relies largely on workplace-based learning. The Safer Anaesthesia From Education (SAFE) Paediatrics Course is a structured program originally developed for low- and middle-income countries; whether it can be contextually adapted and disseminated in a high-income country facing different training challenges has not been established. To describe the translation, contextual adaptation, early implementation, and initial national dissemination of the SAFE Paediatrics Course in Japan, including preliminary educational outcomes from a single-center resident training program. We conducted a two-phase descriptive educational project. Phase 1 comprised course translation, contextual adaptation, pilot testing of a multiple-choice question (MCQ) examination, and pilot delivery. Phase 2 comprised single-center implementation and evaluation at Saitama Children's Medical Center among anesthesia residents (October 2021-March 2023). Participants completed pre- and post-course MCQ tests and confidence ratings; a post-course survey assessed satisfaction. National dissemination was described using aggregated course-level data. Thirty residents participated in the single-center evaluation. MCQ scores increased from 37.87 to 41.67 out of 50 (mean increase 3.80; 95% CI: 2.64-4.96; p&#x2009;<&#x2009;0.001), and self-rated confidence increased. Satisfaction was high (17/20 respondents rated the course 4 or 5). Between October 2021 and January 2026, 28 courses were delivered across four geographical areas and national meeting-affiliated sessions, accounting for 359 participant attendances; many used condensed one-day or half-day formats. The SAFE Paediatrics Course was translated, contextually adapted, and implemented in Japan, with early dissemination across multiple geographical areas and flexible delivery formats. Preliminary single-center outcomes support its suitability as a structured pediatric anesthesia educational program in this setting. Further multicenter and longitudinal evaluation is warranted.

Acute pancreatitis is a rare postoperative complication in children, particularly following non-abdominal surgery. Its occurrence after paediatric oral and maxillofacial procedures performed under general anaesthesia is exceedingly uncommon and can be easily overlooked due to non-specific clinical manifestations. We report the case of a boy in early childhood who underwent uneventful marsupialisation of a mandibular odontogenic cyst with extraction of multiple deciduous teeth under total intravenous anaesthesia with propofol. Within hours of surgery, he developed diffuse abdominal pain. Laboratory investigations revealed markedly elevated serum amylase and lipase levels, while abdominal ultrasonography demonstrated a bulky, hypoechoic pancreas with peripancreatic fluid, confirming acute pancreatitis. The case was classified as mild acute pancreatitis per the revised Atlanta Classification. The child was managed conservatively with bowel rest, intravenous fluids, antibiotics and analgesia under multidisciplinary supervision. His symptoms resolved completely and follow-up imaging at 1&#x2009;month showed full recovery. This case highlights the importance of considering acute pancreatitis in the differential diagnosis of unexplained postoperative abdominal pain in children undergoing maxillofacial surgery and emphasises that early recognition and supportive care are key to achieving favourable outcomes.

Neuraxial anaesthesia is recommended as the preferred technique for caesarean section, and the proportion performed under general anaesthesia is increasingly regarded as a quality indicator. Previous national audits in the Czech Republic and Slovakia demonstrated a reduction in general anaesthesia rates between 2011 and 2015; however, contemporary population-level data are lacking. OBAAMA-COV was a prospective, cross-sectional national audit conducted in November 2022 across maternity units in the Czech Republic and Slovakia. Consecutive caesarean sections were recorded using a structured electronic registry. Population weighting based on official national statistics was applied to generate representative estimates of anaesthetic technique distributions and reported indications. The analyses were descriptive. A total of 2,270 caesarean sections were recorded from 94 centres. Population-weighted estimates corresponded to 2,068 procedures in the Czech Republic and 1,205 in Slovakia. Overall general anaesthesia rates were 33.9% and 31.3%, respectively. In elective procedures, general anaesthesia was used in 23.0% (95% CI 19.9-26.4) in the Czech Republic and 24.9% (20.6-29.7) in Slovakia; in emergency procedures, rates were 45.4% (42.1-48.8) and 36.8% (31.8-42.1), respectively. Maternal preference was the leading reported indication in elective cases (approximately 60-63% across audit cycles), whereas urgency predominated in emergency settings. Rapid sequence induction with tracheal intubation was used in most cases; difficult intubation occurred in approximately 2% of cases, and no aspiration was recorded. Umbilical arterial pH values were comparable between general anaesthesia and neuraxial techniques. These population-weighted data demonstrate a persistent divergence from contemporary European standards. General anaesthesia for caesarean section remains common in both countries, plateauing rather than declining since 2015. The continued reliance on general anaesthesia-driven by maternal preference in elective procedures and by urgency in acute settings-suggests an important contribution of organisational and sociocultural factors beyond strictly clinical indications. ClinicalTrials.gov (NCT04912791), registered June 2, 2021.

Postoperative pain is common in children, yet its relationship to age and sex remains underexplored. We hypothesise that postoperative pain intensity varies across age groups. The objective is to identify ages at which high pain with functional impairment is most prevalent and assess any sex difference in the association between age and postoperative pain. Cohort study. Data were extracted from the paediatric PAIN OUT registry, an international registry. Data were prospectively collected at hospitals in Germany, the Netherlands and Austria. The study includes 2005 patients aged 4 to 18&#x200a;years who underwent appendectomy, tonsillectomy, hernia repair, orthopaedic, or spinal fusion surgery. Postsurgical pain scores (Faces Pain Scale 0 to 10) were compared between surgical procedures, stratified by sex, and age. The association between the primary outcome, 'worst pain' score on the first day after surgery, and age and sex was analysed using regression models adjusted for confounding factors: surgery type, duration, perioperative opioid consumption, and use of regional anaesthesia. Postoperative pain intensity was high with 79% of children experiencing moderate to severe pain, increasing with age, peaking around 12&#x200a;years, particularly in girls. The regression model confirmed an age-related increase in pain intensity in females (interaction coefficient: 0.08, 95% confidence interval 0.02 to 0.15, P &#x200a;=&#x200a;0.017). Appendectomy and not receiving regional anaesthesia were associated with higher pain intensity. Higher mean oral morphine equivalent doses were given to patients aged 12&#x200a;years or older for appendectomy (0.57&#x200a;&#xb1;&#x200a;0.52 vs. 0.60&#x200a;&#xb1;&#x200a;0.66&#x200a;mg&#x200a;kg -1 , P &#x200a;=&#x200a;0.003) and spine surgery (2.1&#x200a;&#xb1;&#x200a;1.6 vs. 2.7&#x200a;&#xb1;&#x200a;2.4&#x200a;mg&#x200a;kg -1 , P &#x200a;=&#x200a;0.038), with comparable doses between the sexes. In this paediatric cohort, 79% experienced moderate to severe postoperative pain, with higher scores in children aged 12+ and a peak in girls around the onset of puberty. These findings emphasise the need for improved paediatric pain management with consideration for age and sex-related differences.

Hypoxaemia occurs in approximately 30% of children undergoing anaesthesia for flexible bronchoscopy. Nasal high-flow oxygen (NHF) can prolong safe apnoea time and be used in children with abnormal airways. During flexible bronchoscopy, there is limited evidence that NHF may confer advantages over the current standard practice in avoiding hypoxaemia. This study aimed to evaluate the feasibility of recruitment to a protocol investigating NHF during anaesthesia for flexible bronchoscopy, with the objective of reducing rescue oxygenation and hypoxaemia. The BUFFALO study was a bi-centre, unmasked, randomised, controlled, parallel-group pilot trial comparing NHF techniques with standard practice during anaesthesia. Children aged >37 weeks gestational age to 16 years presenting for elective bronchoscopy were randomised to NHF or standard-care oxygen post-induction of anaesthesia. Outcomes included the feasibility of recruitment, hypoxaemic events, rescue oxygenations, adherence to trial procedures, acceptability of the intervention, and completion rates of data collection methods. Of the 707 children screened, 89 children were eligible, 81 children were recruited, 43 to the NHF, and 38 to the standard care group. The feasibility outcomes were: proportion of eligible children recruited 91% (95%CI [85,97]), protocol adherence 93% (95%CI [87,98]), and completion rate 100%. The technique of using NHF during flexible bronchoscopies in children and the protocol for this trial were feasible in the two participating centres. However, respiratory physicians' hesitancy to use this technique in high-risk children and concerns about the potential for translocation of upper airway infectious material into the lower airways reduced the number of eligible patients.

To evaluate parental acceptance of behaviour guidance techniques (BGTs) used in paediatric dentistry in Greece, and to explore its association with parental and child demographics, previous dental experience, dental anxiety, educational level, and family income. A secondary purpose was to provide a contextual comparison with findings from a previous Greek study. A cross-sectional questionnaire-based study was conducted amongst parents accompanying their children to the Postgraduate Clinic of Paediatric Dentistry of Aristotle University of Thessaloniki and five private paediatric dental practices. Data were collected using a structured questionnaire, including demographical information, the Modified Corah Dental Anxiety Scale (MDAS) for parental dental anxiety, and a 0-10 rating scale assessing parental acceptance of 13 BGTs, following a standardised video-based presentation. Associations between acceptance scores and independent variables were assessed using nonparametric statistical tests. A total of 294 parents participated in this study (147 from the University clinic and 147 from private practice). Positive reinforcement (9.90&#x2009;&#xb1;&#x2009;0.38) and tell-show-do (9.77&#x2009;&#xb1;&#x2009;0.77) were the most accepted techniques, whereas general anaesthesia (5.5&#x2009;&#xb1;&#x2009;3.9) and passive restraint (4.5&#x2009;&#xb1;&#x2009;3.8) were the least accepted. Acceptance was not associated with parental or child age and gender, children's dental experience or parental dental anxiety (mean MDAS: 9.75&#x2009;&#xb1;&#x2009;4.67). Statistically significant associations were found between acceptance of more invasive and advanced BGTs and parental dental experience, educational level, and annual family income (p&#x2009;<&#x2009;0.05). Within the limitations of this study, communicative and non-invasive behaviour guidance techniques remain the most accepted amongst parents in Greece, whereas advanced and restrictive techniques are less preferred.

The Mission of Brave - Let's turn radiotherapy into an adventure! is a person-focused preparation and education programme developed to reduce anxiety and improve engagement among paediatric patients (aged 0-18) across seven Hungarian radiotherapy centres. From May 2023 to May 2026, 256 children participated in this nationwide initiative. The programme integrates storytelling, play-based education, and environmental transformation. Core elements include a themed gift box with a LEGO linear accelerator model, storybooks, interactive activities, personalised immobilisation mask decoration, comfort objects, and symbolic milestones. By framing radiotherapy as a heroic mission with the character 'Brave', the programme enhances understanding, reduces fear, and promotes cooperation through multidisciplinary staff collaboration. Notably, in 5 cases, improved procedural familiarity directly eliminated the need for general anaesthesia. Integrated into routine clinical preparation and supported by charitable donations, this programme provides a practical model for improving patient experience in paediatric radiation oncology.

Open pyeloplasty in the paediatric population involves extensive tissue dissection and manipulation, resulting in significant postoperative pain. Ultrasound-guided fascial plane blocks have emerged as an important component of multimodal analgesia in abdominal surgeries. This study compared the analgesic efficacy of ultrasound-guided Erector spinae plane block (ESP) and posterior transversus abdominis plane (pTAP) block in children undergoing open pyeloplasty. It is a prospective, randomised, double-blind study conducted at a single paediatric centre in a tertiary care hospital in Asia from January 2022 to June 2023. 40 ASA I-II children were randomised to receive either the ESP block (Group E) or the pTAP block (Group T). Both groups received 0.4 ml/kg, 0.2% ropivacaine with 1 mcg/kg dexmedetomidine. Children with an allergy to local anaesthetics, cardiac, renal or hepatic dysfunction and local site infection were excluded. The primary outcome was cumulative 24 h postoperative acetaminophen consumption. Secondary outcomes included the effects on intraoperative hemodynamics, perioperative opioid consumption, FLACC and Watcha scores, time to first rescue analgesia, and any block-related complications. Weight-normalised 24 h postoperative acetaminophen consumption was significantly lower in the ESP group (13.5 &#xb1; 4.7 mg/kg) compared to the pTAP group (25.4 &#xb1; 8.3 mg/kg), with a mean difference of -12 mg/kg (p < 0.001, 95%CI -16 to -7.6). The median time to first rescue analgesia was significantly longer in the ESP group (18 h [95% CI, 18-24]) than in the TAP group (9 h [95% CI, 6-12]), p < 0.001. Although FLACC scores were significantly lower in the ESP group at 30 min and 12 h postoperatively, the overall longitudinal analysis using a linear mixed-effects model showed no significant difference in the trend of FLACC scores over time between the two groups. There were no block-related complications. Ultrasound-guided ESPB provides better, longer-lasting analgesia than posterior TAP block in children undergoing open pyeloplasty. Hence, it may serve as an effective component of multimodal pain management in paediatric open pyeloplasty. CTRI REGISTRATION (CTRI/2022/04/041876) DATED 13/04/2022): https://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=67747&EncHid=42257.14515&modid=1&compid=19.

This randomized split-mouth clinical trial evaluated the effectiveness of 810-nm diode laser photobiomodulation therapy (PBMT) in accelerating reversal of maxillary and mandibular soft tissue local anaesthesia in children. Forty children aged 4-9 years requiring infiltration anesthesia in both arches were included in the study. Each participant received PBMT irradiation on one side and sham irradiation on the opposite side. Irradiation was performed 45&#xa0;min after the application of local anesthesia. The primary outcome was the time required for the return of normal soft tissue sensation. Secondary outcomes included the incidence of postoperative soft tissue trauma. Recovery time was significantly shorter in the PBMT group than in the sham group (p&#x2009;<&#x2009;0.001). At 20 and 30&#xa0;min, recovery rates were significantly higher in the PBMT group (p&#x2009;=&#x2009;0.002 and p&#x2009;=&#x2009;0.035, respectively). Soft tissue trauma incidence was lower in the PBMT group (p&#x2009;=&#x2009;0.020). Comparable recovery trends were observed in both maxillary and mandibular procedures. PBMT using an 810-nm diode laser appears to be a safe, non-invasive, and effective adjunct for reducing the duration of soft tissue local anaesthesia and associated trauma in paediatric dental patients. *This study was registered on ClinicalTrials.gov (Protocol ID: NCT06841120), 2025-21-01, retrospectively registered.

This review integrates recent literature on paediatric laryngotracheal surgery, focusing on surgical techniques, anaesthetic management and ventilation strategies in the shared-airway setting. Its scope includes common airway pathologies, evolving reconstructive options and contemporary perioperative approaches, aiming to provide a practical, multidisciplinary framework for clinicians. Recent evidence highlights a shift toward lesion-specific reconstruction, including expanded endoscopic techniques, posterior cricoid split with rib grafting and refined indications for single-stage reconstruction versus cricotracheal resection. Anaesthetic practice is moving toward adaptive ventilation strategies - spontaneous ventilation, high-flow nasal oxygen-assisted apnoea, supraglottic jet ventilation and controlled ventilation - selected according to physiology and surgical phase. Emphasis on first-attempt airway success, preoxygenation and multidisciplinary coordination reflects growing recognition of the high-risk nature of these procedures. Paediatric laryngotracheal surgery demands meticulous planning, flexible airway strategies and close surgeon-anaesthetist collaboration. Individualised ventilation, careful oxygenation and postoperative vigilance remain central to optimising outcomes. The evolving trend toward personalised, physiology-protective management underscores the need for teams proficient in multiple airway techniques.

Post-intubation tracheal stenosis (PITS) can remain clinically silent until a physiological stressor precipitates life-threatening airway failure. This case report describes a 15-year-old male, a survivor of traumatic brain injury requiring prolonged endotracheal intubation, who presented in active convulsive status epilepticus with a Glasgow Coma Scale score of 4 and oxygen saturation of 43%. Sequential endotracheal intubation with three tube sizes failed, establishing a cannot intubate, cannot oxygenate (CICO) scenario. Emergency flexible bronchoscopy, performed with a laryngeal mask airway as a ventilatory bridge, revealed fully mobile vocal cords but a pinpoint subglottic lumen through which the bronchoscope could not advance, consistent with Myer-Cotton Grade III-IV PITS. Critical respiratory acidosis was confirmed: pH 6.95, partial pressure of carbon dioxide (pCO2) 135 mmHg. Emergency surgical tracheostomy under local anaesthesia restored ventilation. CT of the neck confirmed circumferential tracheal wall thickening extending 2.3 cm below the subglottis. The patient was weaned from mechanical ventilation and discharged on hospital day 11 with planned outpatient tracheal reconstruction. This case introduces the triple jeopardy airway crisis: the convergence of active status epilepticus, occult mechanical airway obstruction, and critical respiratory acidosis, and illustrates that successful CICO management in this setting demands anatomical contextualisation beyond algorithmic adherence.

An increasing number of children are being admitted to hospitals for dental general anaesthesia (GA). This study investigated the effects of a chronic disease management (CDM) protocol on rates of dental treatment under GA for Early Childhood Caries (ECC). A 24-month study was conducted in New South Wales, Australia. Children aged <&#x2009;72&#x2009;months with ECC were managed utilising a CDM protocol. Rates of treatment completed in the chair vs. GA were compared to historical controls. The effect of silver fluoride treatment on avoiding the need for GA in the prospective group was also analysed. GA was avoided and treatment completed in the chair for 47% of the children in the prospective group (who were 9.6 times more likely to avoid a GA) compared to 15% in the retrospective control group. For participants in the prospective cohort who were initially referred for GA, silver fluoride application was associated with significantly increased odds of avoiding GA and completing treatment in the chair compared with those who did not receive silver fluoride (OR 5.51, 95% CI: 2.09-14.57). The CDM protocol was effective in reducing the number of dental treatments under GA for ECC in select public dental clinics. Implementation of a CDM protocol in public dentistry has resulted in a seismic shift in the management of caries in young children. Prospective patients referred for treatment under GA were nine times more likely to have their treatment completed in the dental chair and avoid a GA compared to historical controls. Silver fluoride played a vital role in the CDM protocol. Patients that received silver fluoride treatment were five times more likely to avoid a GA. The CDM protocol was highly effective in incorporating disease management visits within the existing appointment framework avoiding the need for additional appointments overall.

High-flow nasal oxygen (HFNO) has become an increasingly important component of contemporary airway management, extending beyond its origins as a therapy for hypoxaemic respiratory failure to a versatile perioperative tool used across operating theatres, non-operating-room anaesthesia (NORA), and critical care settings. By delivering heated, humidified oxygen at high flow rates, HFNO provides a range of physiological benefits including reliable oxygen delivery, anatomical dead-space washout, low-level positive airway pressure, and facilitation of apnoeic oxygenation. This narrative review explores the physiological mechanisms underpinning HFNO and examines its evolving role in modern anaesthetic practice. The evidence supporting its use for preoxygenation, apnoeic oxygenation, postoperative respiratory support, procedural sedation, tubeless airway surgery, and management of the physiologically difficult airway is reviewed. Particular attention is given to high-risk populations, including patients living with obesity, obstetric patients, and children, as well as applications in a range of NORA environments. The review also examines key limitations and safety considerations, including hypercapnia, aspiration risk, airway obstruction, airway-fire hazards, human factors, and emerging concerns regarding environmental sustainability. While HFNO can improve oxygenation and increase the margin of safety during periods of physiological vulnerability, it should not be viewed as a substitute for definitive airway management or vigilant monitoring. HFNO represents a significant advance in physiology-centred airway management. Its greatest value lies not in routine application, but in thoughtful integration into broader airway safety strategies where meaningful physiological or patient-centred benefit is anticipated.

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Quantitative neuromuscular monitoring in children remains challenging, particularly in weight and age categories without equipment certification. The study compared the precision of kinemyography and electromyography in children <5 yr of age. Sixty-four children were stratified into neonates (&#x2264;44 weeks postmenstrual age), infants (44-58 weeks postmenstrual age), toddlers (>58 weeks postmenstrual age to &#x2264;2 yr), and children (2-5 yr). Kinemyography and electromyography were applied to contralateral arms. Primary endpoints were precision of train-of-four ratios before rocuronium administration and after assumed complete recovery (i.e. after sugammadex administration). Precision was quantified using the repeatability coefficient, indicating the range within which a repeated train-of-four ratio is with 95% probability. A low repeatability coefficient indicates high precision. Median repeatability coefficients were 0.06 [IQR 0.03-0.10] for kinemyography and 0.06 [0.05-0.09] for electromyography (median difference 0.00 [95% confidence interval, CI -0.01 to 0.01]) at baseline and 0.04 [0.02-0.07] and 0.04 [0.03-0.06] after recovery (median difference 0.00 [-0.01 to 0.01]). Kinemyography precision was worse in non-certified use (<5 kg: 0.08 [0.05-0.11], &#x2265;5 kg: 0.04 [0.02-0.06]; median difference 0.04 [0.02-0.05]), whereas electromyography performed similarly regardless of its certification (neonates 0.05 [0.03-0.11], others 0.06 [0.03-0.09]; median difference -0.01 [-0.04 to 0.05]). Train-of-four ratios <0.9 were more frequent in kinemyography than in electromyography (33% vs 16%, P<0.05). Neither kinemyography nor electromyography was inferior to the other in terms of precision. Unlike kinemyography, electromyography remained precise even when applied below recommended age or weight limits. The importance of baseline values before rocuronium is underlined by the frequently measured train-of-four ratios of <0.9. ClinicalTrials.gov; NCT06062290 (registered August 15th, 2023).

Lipid emulsion has several established clinical uses, including parenteral nutrition, treatment of local anaesthetic systemic toxicity and as an energy source in metabolic crises, such as maple syrup urine disease. In toxicological settings, it acts via a 'lipid sink' mechanism, sequestering lipophilic drugs and reducing their bioavailability. This raises the possibility that the pharmacokinetics of commonly used anaesthetic agents may be affected in patients with a high intravascular lipid load. We report the peri-operative management of a 14-year-old child with maple syrup urine disease receiving a high-dose lipid emulsion infusion during a metabolic crisis, who required general anaesthesia and intubation to facilitate transfer to a specialist paediatric centre. During induction of anaesthesia, fentanyl appeared to have a minimal sedating effect. Ketamine was avoided due to concerns regarding unpredictable efficacy in the setting of lipid loading. The patient also developed significant hypotension during maintenance with sevoflurane at one minimum alveolar concentration, raising the possibility of altered anaesthetic potency. A review of the literature revealed a lack of evidence examining the pharmacodynamics of anaesthetic drugs in lipid-loaded patients. As the use of lipid emulsion increases, further research is required to guide safe and effective anaesthetic practice in this setting.