**6. Conclusion**

156 Complementary Pediatrics

There are a number of strategies adopted by oncologists to minimize the adverse effects of cancer therapy such as dose reduction, and other preventive treatment options. For example, leucovorin has been used for years to minimize the mucositis resulting from use of 5-FU (Lalla and Peterson, 2005). These are the province of oncologists and are not discussed further here. There has been a range of interventions developed for prophylaxis of oral mucositis but a more rational approach may be warranted. Indeed, there are very few randomized controlled double-blind trials (RCTs) assessing most of the interventions. A recent Cochrane review (Worthington, 2011) concluded that *cryotherapy (ice chips) and Keratinocyte Growth Factor (Palifermin ®) have shown some evidence of benefit in the prevention of mucositis. There is weaker less reliable evidence of a benefit associated with aloe vera, amifostine, intravenous glutamine supplementation, granulocyte-colony stimulating factor, honey, laser, polymixin/tobramycin/amphotericin (PTA) lozenges and sucralfate. There is no evidence that chlorhexidine is more effective that placebo and this intervention should not be used in the* 

The outcomes from studies testing GM-CSF, benzydamine hydrochloride or amifostine are mixed. (Mascarin et al, 1999; Tejedor et al, 2000). *Benzydamine HCl has been shown in single centre studies and in a multicentre double blind randomized placebo controlled trial in radiation therapy to reduce the intensity and duration of mucosal damage as well as to delay the need to use systemic pain-relievers including opioids* (Epstein et al., 1989, 2001)*.* Benzydamine was not effective however, in patients receiving accelerated radiotherapy doses of more than 220 cGy. A preliminary study indicated that the severity of oral mucositis, both objective and subjective, in HSCT patients may be reduced by 0.1% topical tretinoin cream which has antiinflammatory activity, administered daily from the beginning of the HCST conditioning until marrow engraftment (Cohen et al., 1997). Local antimicrobials containing amphotericin, polymixin and tobramycin may have some activity (Bondi et al., 1997). *Small single centre trials show that the incidence, severity and duration of radiochemotherapy-induced mucositis can be significantly reduced by oral rinsing with povidone iodine performed in addition to the standard prophylaxis scheme* (Adamietz et al. 1998). Mixed results have been seen with oral glutamine, which is involved in protein and nucleic acid synthesis: one group showed a decrease in the severity and duration of oropharyngeal mucositis in autologous HSCT patients but not in allogeneic HSCT patients. It is possibly because of interaction with methotrexate (Anderson et al., 1998a,b). While similar results were shown in a trial of intravenous glutamine in HSCT (MacBurney et al., 1994), and from an uptake-enhanced glutamine suspension used orally (Peterson, 2006), others have found no benefit (Schloerb & Skikne, 1999). Mucositis invariably requires systemic analgesics, adjunctive medications, physical therapy and psychologic therapy in addition to oral care. A recent Cochrane review (Worthington, 2004) concluded that there was *no evidence that patient controlled analgesia (PCA) is better than continuous infusion method for controlling pain, but less opiate was used per hour, and duration of pain was shorter, for PCA.* Only weak and unreliable evidence that allopurinol mouthwash, vitamin E, immunoglobulin or human placental extract improve or

Pain from established mucositis can be reduced by systemic analgesics with non-steroidal agents and othernon-opiods used first, combined with opioids such as morphine and hydromorphone when pain is severe. In the in-patient setting, PCA provides the most effective pain control with lower total doses of opioid. Topical analgesics may combat pain and dysphagia when used prior to meals. Capsaicin may also provide analgesia (Berger et

**5.2.3 Prevention and treatment options** 

*preventionofmucositis.*

eradicate mucositis.

Tooth caries (decay) remains a substantial problem in young children and is made worse by existing barriers that prevent them from obtaining dental care. Because most children are exposed to medical care but not dental care at an early age, pediatricians have the opportunity to play an important role in helping children and their families gain access to dental care. Instructional efforts to increase pediatricians' dental knowledge or opinions of the importance of oral diseases are unlikely to be effective in increasing dental referral unless they include methods to increase confidence in providers' ability to identify and appropriately refer children with disease. Pediatricians can provide oral health promotion and disease prevention activities, thereby eliminating or delaying dental disease and the need for treatment at a very young age.

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**9** 

**Interdisciplinary Model of** 

**Attention for Children Undergoing** 

**Hospitalized Surgical Procedures** 

 *School of Medicine of Riberao Preto, University of Sao Paulo, 2Pediatric Surgery, Department of Surgery and Anatomy,* 

Ricardo Gorayeb1 and Yvone A.M.V. Vicente2

 *School of Medicine of Riberao Preto,* 

 *University of Sao Paulo* 

*Brazil* 

Renata Panico Gorayeb1, Maria de Fátima Galli Sorita Tazima2, Flávio de Oliveira Pileggi2, Maria Angela Marchini Gorayeb1,

*1Psychology, Department of Neurology, Psychiatry and Medical Psychology,* 

In this chapter we aim to present a model of comprehensive care for hospitalized children in a public Brazilian university hospital. This service is provided by a team of pediatric surgeons, psychologists, nurses and social workers, all of who specialize either in pediatrics

As part of their continuing education, these professionals regularly participate in conferences and courses specific to developments in maternal/pediatric care, therapeutic coping techniques in the realm of maternal/pediatric care, and the major diseases that affect

The team is responsible for the care of children and adolescents aged 0-18 years, of both sexes, who require either outpatient or inpatient medical and surgical care. In this chapter we will discuss the provided surgical care and the specific details of its treatment, care, and

The interdisciplinary approach has been emphasized in recent years by promoting a broader understanding of the patient, his or her medical condition, and its context, demonstrating that this joint service improves the diagnosis, prognosis and quality of life of the patient.

• To wholly assist the patient and his or her family, caring for their bio-psycho-social

• To assist the patient and his or her family in acquiring a better understanding of the

guidance, for both the child and the child's family, in bio-psycho-social aspects.

or in the surgical procedures of the pediatric surgical clinic.

The main objectives of this interdisciplinary model of care are:

diagnosis and prognosis of each condition

**1. Introduction** 

children in this age group.

needs

