Describe two cases of pediatric small fiber neuropathy complicated by cold immersion and subsequent rewarming injury. 

It is well known that cold temperatures can provide pain relief to patients with small fiber neuropathy. However, achieving this pain control with cold water immersion can produce secondary injury, exacerbating pain and morbidity. We review the four stages of cold water immersion and subsequent rewarming injury in the context of two cases of pediatric small fiber neuropathy. Further we discuss the importance of counseling regarding appropriate management of small fiber neuropathy, a pathology which is not commonly seen in child neurology practice.

Retrospective clinical description of two cases.

Patient 1: A child with small fiber neuropathy secondary to rapid HbA1C correction who self treated with ice water baths for hyperalgesia. Case complicated by secondary rewarming injury on hospitalization that significantly increased morbidity and extended hospital stay.

Patient 2: A child with new diagnosis of small fiber neuropathy who self treated with ice water baths for thermal hyperalgesia. Secondary rewarming injury resulted in significant allodynia that ultimately required systemic ketamine and lidocaine infusions as well as an epidural analgesic infusion.

Though cold water immersion can provide immediate analgesic relief for small fiber neuropathy, secondary tissue injury increases morbidity and extends hospitalization. Knowledge of the four stages of cold water immersion and rewarming injury can aid in the treatment of these patients to minimize further injury. Importantly, early counseling on appropriate management of small fiber neuropathy in children can prevent these complications.