N. Mdzinwa, University of Pretoria, South Africa


A Chiari 3 Malformation is characterized by a high cervical or occipital encephalocoele, occipital or cervical bony deformities and a small posterior fossa with caudal displacement of the hindbrain. There is a paucity of data on the anaesthetic management of neonates with Chiari 3 malformations due to high mortality rates. Challenges faced by anaesthetists while managing neonates with a giant occipital encephalocoele include airway management, positioning, fluid and blood management, temperature management, drug dosing and associated conditions. The aim of this case report is to discuss how these challenges were overcome while managing a premature neonate.

The case:

A 10-day-old preterm neonate, born at 36 weeks gestation to an unbooked mother, presented for surgical correction of a Giant Occipital Encephalocoele (106 x 141 x 158 mm) associated with a Chiari 3 malformation. MRI of the brain revealed no neural tissue within the sac. Deficient C1 and C2 posterior arches and kinking of the high cervical cord with resultant CSF obstruction rendered the neck unstable. The airway was managed in a lateral position with strict neutral position of the neck using a video laryngoscope. Prone position, as required for optimal surgical exposure, without applying pressure on the c-spine and the face required innovation. The neonate became hypotensive immediately after the encephelocoele was drained. Fluid management was guided by continuous invasive blood pressure monitoring and arterial blood gas (ABG) sampling. Packed red blood cells were transfused at 10ml/kg/hour from the start of the case with a target haematocrit of 30%. Drugs were dosed at an ideal body weight of 2.8kg based on estimated gestation from the history, which was likely inaccurate as the neonate’s postoperative weight was 3.3kg.


The neonate had relatively few negative prognostic factors and did well in the perioperative period. Intubation techniques described in the literature include pre-induction drainage of the encephalocoele, maximum atlantoaxial extension and caudal displacement of the mass with gentle traction. A newer technique is hybrid pillow designs which would allow the patient to be in a supine position with no pressure on the mass. A lateral position with strict neutral head position seemed the most suitable choice for this neonate with an unstable C-spine. The use of a video laryngoscope and a three-man technique aided in tracheal intubation which proved difficult. A method for fluid replacement is required after the encephalocoele is drained, without fluid overloading the neonate. We advise the use of invasive monitoring and ABG analysis to guide this replacement. Weight estimation to facilitate drug and fluid dosing is also challenging. We utilized nomograms to estimate the neonate’s ideal body weight, which is the best available tool. Future research should explore utilizing advanced imaging to estimate the weight of the mass.




Ivashchuk G, Loukas M, Blount JP, Tubbs RS, Oakes WJ. Chiari III malformation: a comprehensive review of this enigmatic anomaly. Childs Nerv Syst. 2015 Nov;31(11):2035-40. doi: 10.1007/s00381-015-2853-9.

Ganeriwal V, Dey P, Bawage R, Gore B. Giant meningoencephalocele with Arnold-Chiari type III malformation and anaesthetic challenges: A rare case report. Saudi J Anaesth. 2019 Apr-Jun;13(2):136-139. doi: 10.4103/sja.SJA_616_18.

Kavita J, Surendra Kumar S, Neena J, Veena P. Anaesthetic management of a huge occipital meningoencephalocele in a 14 days old neonate. Ain Shams Journal of Anesthesiology [Internet]. 2018; 10(1):13.

Pahuja HD, Deshmukh SR, Lande SA, Palsodkar SR, Bhure AR. Anaesthetic management of neonate with giant occipital meningoencephalocele: Case report. Egyptian Journal of Anaesthesia [Internet]. 2015; 31(4):331-4




S. Dean, T. Molitor, A. Mayell

University Hospitals Coventry and Warwickshire (UHCW) NHS Trust, UK


Paediatric testicular torsion is a urological emergency. NICE guidance states surgical repair should occur within four hours (1). This quality improvement project reviewed the management of paediatric torsion over two years at a large university Trust.


Paediatric anaesthetists, during the pandemic, had concerns that children were increasingly undergoing emergency inhalational inductions. This was due to no, or inadequate topical local anaesthetic (LA) being applied in ED before induction, putting children at additional risk.

Strategy for change

We set the following standards:

  1. 100% patients receive topical LA in ED when presenting with scrotal pain?
  2. How many gas inductions are performed on patients with full stomachs and why? Were there adverse events?
  3. How many emergency scrotal explorations prove to be torsions?
  4. Are there delays between admission, decision to operate, booking and anaesthesia?

Measure of improvement

We performed a retrospective data collection on all emergency scrotal explorations performed at UHCW NHS Trust in 2019-2020, pre-Covid, and 2020-2021, during the pandemic, when cases were consultant led out of hours.

Data on time intervals, anaesthetic management and the use of topical LA were sought.

Lessons learnt

Results are shown in table 1. We follow the NICE guidelines for emergency scrotal surgery in over 80% of children. However, we identified unnecessary delays in the patients journey to theatre, and inadequate topical LA use for emergency paediatric surgery. Time from surgical decision to theatre indicated that even if topical LA was applied at surgical decision, there was time for this to be effective. This led to children having an unnecessarily painful cannula in 30% and 56% of cases respectively. Gas inductions were performed regularly on non-fasted children. No adverse anaesthetic events were recorded.

Message for others

This QI project highlighted several areas for further improvement.

  • Topical LA administration as standard on initial assessment in Paediatric ED for all children with testicular pain.
  • Updating guidelines/pathways in children’s ED urology and training.
  • Re-audit with standards implemented - in progress.


  1. National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Scrotal pain and swelling. 2024. https://cks.nice.org.uk/topics/scrotal-pain-swelling/ [Accessed 1st February 2024]




C. M. Perry, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK


Excessive fasting can lead to psychological and physiological changes in young patients, with behavioural changes that are challenging for parents, nursing staff, and anaesthetists. Prolonged fasting times are known to cause dehydration and increase anxiety (1).


Despite introducing 6-4-1 fluid fasting guidelines in October 2017, an audit of data still demonstrated prolonged fasting times in our institution.

Strategy for change: 

Learning from the publication of successful implementation of 6-4-0 strategies in other institutions (2,3), we implemented a similar 6-4-0 – “Sips to theatre” protocol in October 2021 with carefully described steps, including an initial water or squash on arrival (3-5ml/kg), and ongoing access to carefully controlled “sips”. We selected 3 appropriate wards with elective day case and day of surgery patients for a 24-month period.

Careful education of the concept of “sips until theatre” was carried out in a cascade manner on these wards.

Measure of improvement: 

Fasting times prior to theatre were monitored and a reporting system for perioperative regurgitation events was established. A nursing satisfaction survey was completed to establish if the delivery of the protocol was seen as a positive step.

The median fluid fasting time reduced from around 310 mins (2017, on 6-4-2) to 224 mins (2020, on 6-4-1) to 150 mins (mid-2023 with 6-4-0).

YEAR          PROTOCOL                   MEDIAN FOOD FASTING (MINS)                     MEDIAN FLUID FASTING (MINS)   % < 4hr FLUID FAST

2010     6-4-2            732                                                            390                                                   n/a

2014     6-4-2            775                                                            425                                                   39.7

2017     6-4-2            731                                                            311                                                   35

2018     6-4-1            757                                                            237                                                   50.4

2020     6-4-1            696                                                            224                                                   55

2023     6-4-0            840                                                            150                                                   68.5

Three reported peri-operative regurgitation events were investigated.  Two were deemed unlikely to be related, but one may have been linked to incorrect implementation of the trial guideline. In this case, a 3yr old was intubated after intraoperative regurgitation of chocolately fluid. The child was extubated after completion of surgery, had an uneventful recovery and was discharged the following morning.

The nursing survey demonstrated 100% support for the new guideline, mainly due to general improvement in patient behaviour and perceived experience.

Lessons learnt:

Careful education of the fasting protocol is imperative. We felt it was safer to only allow fluids provided by our nursing staff, rather than allowing patients to drink freely from their own water bottles.

Message for others:

Allowing sips until theatre has been a positive step reportedly improving the experience of the children, parents, ward staff and anaesthetic teams. There has not been any evidence of an increase in aspiration-related morbidity or mortality.


  1. AAGBI Safety guideline, Preoperative Assessment and Patient Preparation: The Role of the Anaesthetist 2010
  2. Andersson H, Hellström PM, Frykholm P. Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children. Paediatr Anaesth. 2018 Jan;28(1):46-52.
  3. Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Paediatr Anaesth. 2015 Aug;25(8):770-777.




B. Burrill1, S. Rastogi2

1Sheffield Children’s NHS FT, UK

2Great North Children’s Hospital, Newcastle Hospitals NHS FT, UK


Pain in children is common, often under-recognised and under-treated(1). If poorly managed it can have significant long-term consequences in later life including impact on mood, sleep and chronic pain in adulthood(2). Chronic pain is a significant burden on health care systems globally and is the leading cause of morbidity in children, with studies suggesting that between one-quarter and one-third of children experience chronic pain(3). In the UK there is a national unmet need for anaesthetists with an interest in paediatric pain and therefore we set out to explore anaesthetic trainees' awareness and interest in this sub-speciality.  We hoped to understand any potential barriers they may see to pursuing this career choice and how we may begin to address them.


An on-line survey was sent to anaesthetic trainees across the UK through the Royal College of Anaesthetists (RCOA) college tutors at their base hospital. The survey included questions on the trainee’s current stage of training, their awareness of paediatric pain as a sub-speciality and if they have an interest in pursuing it in their future career. They were invited to indicate why or why they were not interested and what may be done to encourage more interest.


One hundred and seventy-one anaesthetic trainees completed the survey from across England and Scotland, no responses were received from Wales or Northern Ireland. These represented trainees at each stage of training of the 2021 RCOA Anaesthetic Curriculum: 29% stage 1, 40% stage 2 and 31% stage 3. Fifty-six percent indicated they were not aware of paediatric pain as a sub-speciality, with 23% reporting an interest in pursuing paediatric pain, acute and/or chronic, in their future career. The top 3 reasons for wanting to do paediatric pain were: variety in job plan e.g. clinics, ward rounds, theatre (34%), regional/interventional opportunities (38%) and the increasing demand (28%). The top 3 reasons trainees were not interested were: other career aspiration (67%), not knowing enough about the sub-speciality (43%) and the complex patient/family groups (34%). The best way trainees felt to increasing interest in the sub-speciality was through local teaching sessions (68%) and greater clarity and information on career progression (68%).


The results revealed the majority of trainees surveyed were unaware of paediatric pain as a sub-speciality. It is positive nearly 1 in 4 anaesthetic trainees are considering a career involving paediatric pain. However, given that there are generally few paediatric pain consultants across the UK there appears to be gap between trainee interest and practicing consultant. Increasing awareness of the speciality needs to be targeted. We plan to do this through an online educational seminar providing information on what paediatric pain has to offer, training requirements needed and career progression opportunities for trainees.


  1. International Association for the Study of Pain. Fact Sheet; Pain in Children: Management. 2019.
  2. K McCarthy and S Rastogi. Complex pain in children and young people: part I- assessment. BJA Education, 17 (10): 317–322 (2017)
  3. World Health Organisation. Guideline on the management of chronic pain in children. 2020.




G. Dhotar, Oxford University Hospitals NHS Foundation Trust, UK


A 9 year old girl attended our hospital for elective right upper lid thickness grafting surgery for ptosis. She had no previous medical history and had a previous anaesthetic in Poland for a similar surgery with no issues. She had no allergies and no family history of anaesthetic problems.

She underwent a volatile induction with sevoflurane.  She was cannulated and intubated with a non-depolarising muscle relaxant.  Anaesthesia was maintained with sevoflurane.  She had  AAGBI standard monitoring throughout this period.

Sixty minutes after the commencement of anaesthesia; a raised ETCO2 (13.0kPa), tachycardia (125 bpm) with unusual ECG morphology, and high FiO2 requirements were noted.  Later, the core temperature rose to 39.9 Celsius.  There was a high index of suspicion of Malignant Hyperthermia.

There was rapid mobilisation of the multi-disciplinary team in theatres and treatment was initiated as per the AAGBI 2011 guidance which was readily available in theatres.  Initial management took a three pronged approach, which included 1) stopping the trigger (stopping sevoflurane, switching to TIVA and use of charcoal filters); 2) the prompt administration of dantrolene; and 3) controlling temperature (with ice packs and cold bladder washouts).  PICU involvement was acquired early to aid with subsequent sequale management of acidosis and hyperkalaemia.

The patient successfully responded and stabilised within normal parameters.  They were transferred to PICU and later extubated.  The patient had no lasting adverse effects and discharged from hospital three days later. Referral to the Malignant Hyperthermia Centre in Leeds was made. Results are still pending.


Malignant Hyperthermia (MH) is a progressive, life-threatening hypothermic reaction during general anaesthesia to suxamethonium and inhalational anaesthetic gases.  Incidences are high in the paediatric populations. MH is one of the most logistically challenging anaesthetic emergencies to manage and in a paediatric patient, there is an added level of complexity.

In this case, MH was recognised quickly and management was initiated in a timely manner.  Teamwork and communication were good. Early PICU involvement was invaluable in sequalae management.

Areas which were noted to be suboptimal were: 1) MH guidelines that were readily available in theatres were outdated, new guidance in 2020 had been released; 2) Dantrolene stock was only available on one floor of our theatre complex and expired stock was provided by pharmacy.

Suggested areas of improvement include: updating existing guideline availability in theatres to include AAGBI MH 2020 guidance; discuss with pharmacy regarding in-date dantrolene supply and availability; and continuing simulation in managing MH within theatres.

This case illustrates that a history of previous uneventful GA does not rule out future MH events and how teamwork is vital in managing a complex anaesthetic emergency.


Consent provided by parents.  Oxford Anaesthetic, PICU and supporting teams involved in care of patient.


  1. Malignant Hyeprthermia 2020 Guideline for the Association of Anaesthetists. Hopkins PM, Girard T, Daley S et al. Accessed online from: https://anaesthetists.org/Home/Resources-publications/Guidelines/Malignant-hyperthermia-2020




S. Yeung1, G. Rennie1, J. Turnbull2

1Sheffield Children's Hospital, UK

2Barnsley District General Hospital, UK


Prior to the 2021 Curriculum change, the South Yorkshire Deanery did not provide specific, tertiary led, paediatric focused training and education to CT1 - CT3 level anaesthetic trainees. CT1 - CT3 anaesthetic trainees received local education on paediatric anaesthesia but this was inconsistent. On discussion with trainees, it was decided that CT1 - CT3 trainees would benefit from a paediatric education event similar to the already held CART (Core Anaesthetic Regional training) events. From this, a paediatric CART session was developed.


A paediatric CART session was developed using expertise from Sheffield Children’s Hospital, as well as DGH consultants. It is held at Barnsley Hospital, using their state of the art simulation suite. This event started in December 2021 and runs yearly. Verbal and written feedback were used to inform content for future sessions. Verbal feedback was collected at time of event and written feedback was obtained in the form of a graded questionnaire.


Feedback from trainees has been overwhelmingly positive. Written feedback, collected from the 2022 and 2023 sessions, shows that 100% of participants felt that learning objectives were met and that the knowledge and skills gained were appropriate for the stage of training. Over 90% in the 2022 cohort, and 100% in the 2023, found the simulation sessions enjoyable and well organised. Individual comments acknowledged the blend of lecture based teaching, the relaxed atmosphere that allowed discussion and simulation with knowledgeable tutors. Trainees appreciated the range of experience from both DGH and tertiary paediatric anaesthetists.


The feedback from trainees confirm they are receptive to have specific tertiary led, paediatric focused anaesthetic training embedded within their CT1-CT3 years. The faculty has directed the teaching and simulation sessions to cover common, emergency presentations, including bronchiolitis, sepsis, and intubation of the child under five. Following feedback and discussion with trainees, the organisers want to involve ODP (Operating Department Practitioners) and student ODPs. This would allow a multidisciplinary approach by ensuring realistic scenarios for simulation where people can perform their own role. Another team that has been invited into the day is Embrace, the local paediatric retrieval team. This would consolidate the knowledge and skills necessary for paediatric retrieval in DGHs. Ultimately, this will result in a smooth and safe transfer to a tertiary hospital.


The paediatric CART session has been highly popular and beneficial to trainees. Now in its fourth year, it has been restructured to continue to be an informative and enjoyable learning event. We would like to see this course develop further, becoming embedded as a permanent part of anaesthetic teaching within South Yorkshire. From our results we would encourage other deaneries to start similar paediatric education days.




T. Fowles, P. Arnold

Alder Hey Children's NHS Trust, Liverpool, UK


Performance of a regional anaesthetic block at an incorrect site is undesirable and can be associated with patient harm. Wrong sided blocks are considered a ‘Never Event’ in current NHS England Serious Incident Framework(1). Historically a ‘stop before you block’ (SBYB) policy has been in place in our hospital for several years following an initial incident. In accordance with national guidance this consisted of a pause prior to performing the block and additional checks conducted by anaesthetists and anaesthetic practitioners (2).


Following a further incorrect side block an attempt was made to improve this process. An audit was instigated to monitor compliance with completion of the SBYB and with the recommended procedure. Initial attempts at this audit had poor compliance and proved time consuming.

Strategy For Change

Following engagement and discussion with anaesthetists and anaesthetic practitioners, posters and teaching were distributed to reinforce the correct process. In addition, a modified approach to the audit utilising electronic forms (assessed using a QR code displayed in all anaesthetic rooms) and cross validation with electronic patient records. Emphasis was placed on:

  • nerve block was highlighted in the morning/afternoon huddle.
  • that SBYB must be performed for all cases.
  • that SBYB should occur immediately before needle insertion.
  • that the surgical site mark is marked and checked against consent.

Measure of Improvement

In December and January, there were a total of 274 nerve blocks performed. In 230 of these an audit form was completed (response of 84%). 225 (98%) of the blocks were highlighted in the huddle, all but one (99%) of SBYB’s occurred immediately before needle insertion and in all cases the consent form was checked. Site markings were checked in 76% whilst 24% it was confirmed the site marking was not appropriate (i.e. bilateral truncal blocks). In only one case was the site marking not checked. Of the 44 cases in which an audit form was not completed the majority were blocks placed by surgeons within the field. However, in 7 cases these were Quadratus Lumborum blocks placed by anaesthetists.

Conclusions and lessons learnt

Compliance with the SBYB process was high. This was achieved by a process of engagement, publicity, and education. Wrong sided blocks are rare and we cannot comment from this audit on the success at avoiding wrong sided blocks.  There is a need to consider how compliance with this process when blocks are performed by the surgical team is recorded.

The use of combined methods and interdisciplinary cooperation, reporting by anaesthetic support staff using a QR code and recording by anaesthetists on the anaesthetic record, allowed us to describe this level of compliance successfully. This is potentially a model for future collaborative service evaluations and quality improvement.


  1. Never Events list 2018 (updated February 2021): NHS England; 2021 [Available from: https://www.england.nhs.uk/publication/never-events/] Accessed 6/2/2024
  2. Haslam N, Bedforth N, Pandit JJ. 'Prep, stop, block': refreshing 'stop before you block' with new national guidance. Anaesthesia. 2022;77(4):372-5.




H. Patel, R. Mooney, C. Holmes

Children's Health Ireland at Temple Street, Dublin, Ireland


A tracheal (or “pig”) bronchus is a rare congenital anatomical variant where an accessory bronchus originates from the trachea and directs to the upper lobe.

An eight-month-old child presented for elective right upper lung lobectomy to remove a massive congenital lobar emphysema (CLE), which had caused extensive contralateral mediastinal shift as seen on the image below. Following anaesthesia induction, microlaryngobronchoscopy identified a right sided tracheal bronchus supplying the right upper lobe.  It was agreed between anaesthesiologist, ENT surgeon and general surgeon to attempt to isolate this bronchus and emphysematous lobe before positive pressure ventilation.

Using rigid bronchoscopy, with patient breathing spontaneously, an oral uncuffed size 2.5 endotracheal tube was placed directly into the tracheal bronchus and left open to air.  This served as a both a bronchial blocker and ventilation tube - obstructing the emphysematous lobe from positive pressure ventilation (and thus worsening mediastinal shift and instability) and decompressing the right upper lobe. This was followed by an oral size 3.5 cuffed endotracheal tube placed above the carina, which was then used for positive pressure ventilation.  An open thoracotomy was performed in the left lateral position and right upper lobectomy was performed, with the patient remaining stable throughout with optimum surgical conditions.  Following isolation and ligation of the emphysematous lobe, the smaller uncuffed endotracheal tube was removed. The remainder of the peri-operative course was uneventful, with a planned overnight admission to pediatric ICU and extubation the following day.


This case highlights the need for multidisciplinary collaboration within paediatric care when creating and adapting a treatment plan for complex surgical patients. In addition, it highlights the need for flexibility and occasional improvisation when encountering unanticipated and rare clinical conditions.


This case is reported with the permission of the child’s parents.


  1. Ghaye B, Shapiro D, Fanchamps JM, Dondelinger RF. Congenital bronchial abnormalities revisited.Radiographics.2001;21(1):105-119.doi:10.1148/radiographics.21.1.g01ja06105.

2.Lee DK,Kim YM, Kim HZ,Lim SH.Right upper lobe tracheal bronchus:anesthetic challenge in one lung -ventilated patients- a report of three cases.Korean J Anesthesiologists.2013;63(5):448-450.doi: 10.4097/kjae.2013.64.5.448

3.Rasooly AJ, Noor S,Ullah S, Baryali AT,Haidary AM.Forty days old infant with Pig Bronchus,presenting with recurrent pneumonia,A cse report.Dove press:30 October 2023 Volume 2023:14 pages 379-383/https://doi.org/10.2147/PHMT.S429852.




O. R. Beesley, A. Hunt, C. Y. Kowa, M. Patel, J. Williamson, Y. Haroon-Mowahed

University College Hospital London, UK


Many children presenting for surgery are managed in general hospitals, rather than specialist paediatric centres. Paediatric surgical patients in such settings can challenge medical and nursing teams less experienced with the unique requirements of paediatric perioperative medicine. While recent improvement initiatives have focused on the care of adults, recent data suggest that rates of adverse outcomes for children undergoing some surgeries are higher(1), highlighting a need to augment training in paediatric perioperative medicine.


Guidance for developing paediatric perioperative services is limited, and training programmes often fail to address the specific needs of children. This contributes to a lack of confidence. The 2022 Training Review In Paediatric Anaesthesia survey, examining national paediatric caseload exposure highlighted significant regional variability(2). Trainees at all stages in London and Scotland reported greater experience, including at lower ages and higher complexity levels. This may suggest geographic discrepancies in competence and confidence.

Strategy for change

We have developed a Massive Online Open Course (MOOC), in partnership with UCL and FutureLearn, following the paediatric perioperative journey. It has been built by a team with prior experience of MOOC development. Content has been developed by a multidisciplinary team of experts from specialist paediatric centres including University College Hospital, Great Ormond Street Hospital, Evelina London Children’s Hospital, Royal Brompton Hospital and the Royal London Hospital.

The course addresses preoperative optimisation, intraoperative management, and postoperative care, including recent advances. It is aimed at all those providing perioperative care for children: anaesthetists, paediatricians, surgeons and perioperative nursing teams. It presents a multidisciplinary model and can guide hospital teams in improving delivery of paediatric perioperative care.

Measure of improvement

Formative assessments are included throughout, as well as objective quizzes at the end of each weekly chapter to reinforce learning points. We encourage active participation in the form of message boards, supported by expert reviewers. Structured feedback is invited on course completion to gauge improvements in participant confidence.

Lessons learnt

The process began with a project proposal to provide an ongoing implementation guide. Subsequently, the team met with digital educators to understand the MOOC process, including the importance of material accessibility and readability, as well as ensuring variety in course activities. A content tracker was used to monitor project progress, and experts sought for content development. Regular team meetings ensured the smooth transfer of this material to the MOOC platform. Our experience highlighted the significant resources required to develop multimedia content, including patient, parent and MDT videos.

Message for others

The course is planned for launch later this year and will be freely accessible worldwide, in keeping with all FutureLearn MOOCs. The incredibly rewarding process of course creation has been worth the significant time investment, and greatly enriched the team’s educational skills.


  1. McMullin JL, Hu QL, Merkow RP, Bilimoria KY, Hu YY, Ko CY, et al. Are Kids More Than Just Little Adults? A Comparison of Surgical Outcomes. The Journal of Surgical Research [Internet]. 2022 Nov 1 [cited 2024 Jan 28];279:586–91. Available from: https://pubmed.ncbi.nlm.nih.gov/35926308/
  2. Chan SM. Training Review In Paediatric Anaesthesia(Trip): An Exposure & Workload Distribution Survey. Pediatric Anesthesia. 2023 Oct 10;33(12):1110–4




E. Earnshaw, G. Yesudian, J. Short, D. Yeomanson

Sheffield Children's Hospital NHS Trust, UK


Oral mucositis is a significant consequence of chemotherapy, radiotherapy and haematopoietic stem cell transplantation, affecting 52 to 80% of children and young people receiving treatment for cancer (1). It is a complex condition that causes severe mouth and throat pain, oral ulceration, xerostomia and can lead to difficulties in eating and drinking, hospitalisation for hydration, pain relief and parenteral nutrition. It has become a major dose-limiting toxicity which can affect the delivery of effective anticancer therapy and impact quality of life.


Many strategies are used in the treatment of oral mucositis including oral rinses, cryotherapy, growth factors and opiates. A meta-analysis by Oberoi et al., highlighted the effectiveness another modality, Photobiomodulation (PBM) treatment (2). Oberoi stated that when used prophylactically, PBM treatment reduces the severity of oral mucositis and the need for opioid analgesia. However, PBM is rarely utilised in the paediatric population.

Strategy for change

Photobiomodulation (PBM) treatment was introduced to the Haematology/Oncology ward at Sheffield Children’s Hospital in January 2022. A Service Evaluation was undertaken to assess the thoughts and experiences of children and their carers on the effectiveness of this new intervention.

Measure of improvement

Grading of oral mucositis were undertaken in accordance with current WHO recommendations. PBM dose was determined by grade of mucositis, with pain scores recorded pre- and post-operatively. A free text option was offered to the child and their carers to capture their thoughts and experiences of this new intervention.

Lessons Learnt

Sixty patient episodes of PBM treatment were reported over a one-year period, with 21 children and young people engaging with the service. The age range was 3 to 16 years.

70% of patient episodes (18 patients) reported a positive impact on their oral mucositis, with significant reduction in their pain scores pre- and post-treatment. 15% (3 patients) requested prophylactic PBM treatment prior to commencement of their chemotherapy with one child stating they

‘liked to have it before chemo as it makes chemo not as bad’.


One child reported that it felt ‘tickly’ while another stated that the effect was ‘magical’. Two patients were unable to report their outcome due being upset at the time of treatment.

A parent reported the treatment was beneficial to their child as they were able to eat after treatment.

Message for others

This study highlights the beneficial effect of PBM in children and young people who experience oral mucositis as a result of their chemotherapy. NICE guidance (2018) exists for PBM but is largely based on adult evidence (3). A systematic review by Redman et al., (2022), highlighted a paucity of good quality studies to confirm its efficacy as a prevention or treatment tool for oral mucositis in children with cancer (4).


  1. Ethier MC, Regier DA, Tomlinson D, et al., Perspectives toward oral mucositis prevention from parents and health care professionals in paediatric cancer. Support Care Cancer 2012;20: 1771-7.
  2. Oberoi S, Zamperlini–Netto G, Beyene J, Treister NS, Sung L (2014) Effect of Prophylactic Low Level Laser Therapy on Oral Mucositis: A Systematic Review and Meta-Analysis. PLoS ONE 9(9):

e107418. https://doi.org/10.1371/journal.pone.0107418

  1. National Institute for Health and Care Excellence. Low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy, 2018. Available:


  1. Redman MG, Harris K, Phillips BS. Low-level laser therapy for oral mucositis in children with cancer. Archives of Disease Childhood 2022;107: 128-133.
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