ABSTRACT. This paper describes the tracheomalacia seen in two groups of children: in association with tracheo‐oesophageal fistula, and in so‐called “innominate artery compression”. The underlying cause in both groups is believed to be related to malformation and deficiency in the cartilage of the tracheal wall, with an increase in the width of the membranous trachea. Symptoms in tracheomalacia range from mild to severe. Indications for surgery are “reflex apnoea”, severe respiratory obstruction, or severe and repeated respiratory infections with retention of sputum and cyanotic attacks. Endoscopy is essential to confirm the cause, and the need for surgery. The operative technique of aorto‐tracheal suspension is described, and the results in 20 patients submitted to tracheopexy since January 1969 are reported.

The ideal goal of pain management for pediatric procedures is to make the procedure comfortable for the child and his or her parents. Success will be manifested by the child who is not afraid of subsequent procedures and not merely by a child who can be held still for procedures. This goal is often difficult to achieve entirely, but at least an attempt to achieve it should be considered as evidence for an adequate standard of care. The orientation of this section will be a developmental one, with specific recommendations for five age categories: 0 to 6 months of age, 6 months to 2 years of age, 2 to 5 years of age, 5 to 12 years of age, ≥12 years of age. Initially, we discuss general principles of pain management (Table 5). The painful procedures include bone marrow aspiration and biopsy (Table 6); lumbar puncture (Table 7); and needle sticks including intravenous and intramuscular injection, phlebotomy, finger sticks, heel lances, and suturing (Table 8). Nonpainful radiographic diagnostic and therapeutic procedures that require patient cooperation in remaining still (eg, computed tomographic scan, magnetic resonance imaging, radiation therapy) are also discussed (Table 9). GENERAL PRINCIPLES OF MANAGEMENT There are several principles of management that are applicable for all age groups and procedures. These points need to be highlighted because pediatric procedures currently are not being managed in an organized fashion at many hospitals and oncology units. In a survey of the major pediatric oncology centers, more than 75% of the centers had no defined protocol for procedures of pain management (Hickman et al. 1988.

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