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Liow N, Montaldo P, Lally PJ, Teiserskas J, Bassett P, Oliveira V, Mendoza J, Slater R, Shankaran S, Thayyil S. Preemptive Morphine During Therapeutic Hypothermia After Neonatal Encephalopathy: A Secondary Analysis. Ther Hypothermia Temp Manag 2019; 10:45-52. [PMID: 30807267 DOI: 10.1089/ther.2018.0052] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although therapeutic hypothermia (TH) improves outcomes after neonatal encephalopathy (NE), the safety and efficacy of preemptive opioid sedation during cooling therapy is unclear. We performed a secondary analysis of the data from a large multicountry prospective observational study (Magnetic Resonance Biomarkers in Neonatal Encephalopathy [MARBLE]) to examine the association of preemptive morphine infusion during TH on brain injury and neurodevelopmental outcomes after NE. All recruited infants had 3.0 Tesla magnetic resonance imaging and spectroscopy at 1 week, and neurodevelopmental outcome assessments at 22 months. Of 223 babies recruited to the MARBLE study, the data on sedation were available from 169 babies with moderate (n = 150) or severe NE (n = 19). Although the baseline characteristics and admission status were similar, the babies who received morphine infusion (n = 141) were more hypotensive (49% vs. 25%, p = 0.02) and had a significantly longer hospital stay (12 days vs. 9 days, p = 0.009) than those who did not (n = 28). Basal ganglia/thalamic injury (score ≥1) and cortical injury (score ≥1) was seen in 34/141 (24%) and 37/141 (26%), respectively, of the morphine group and 4/28 (14%) and 3/28 (11%) of the nonmorphine group (p > 0.05). On regression modeling adjusted for potential confounders, preemptive morphine was not associated with mean (standard deviation [SD]) thalamic N-acetylaspartate (NAA) concentration (6.9 ± 0.9 vs. 6.5 ± 1.5; p = 0.97), and median (interquartile range) lactate/NAA peak area ratios (0.16 [0.12-0.21] vs. 0.13 [0.11-0.18]; p = 0.20) at 1 week, and mean (SD) Bayley-III composite motor (92 ± 23 vs. 94 ± 10; p = 0.98), language (89 ± 22 vs. 93 ± 8; p = 0.53), and cognitive scores (95 ± 21 vs. 99 ± 13; p = 0.56) at 22 months. Adverse neurodevelopmental outcome (adjusted for severity of encephalopathy) was seen in 26 (18%) of the morphine group, and none of the nonmorphine group (p = 0.11). Preemptive morphine sedation during TH does not offer any neuroprotective benefits and may be associated with increased hospital stay. Optimal sedation during induced hypothermia requires further evaluation in clinical trials.
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Affiliation(s)
- Natasha Liow
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom.,Neonatal Unit, Università degli Studi della Campania, "Luigi Vanvitelli," Italy
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Justinas Teiserskas
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | | | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Rebeccah Slater
- Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
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102
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Passariello A, Montaldo P, Palma M, Cirillo M, Di Guida C, Esposito S, Caruso M, Pugliese M, Giliberti P. Neonatal painful stimuli: skin conductance algesimeter index to measure efficacy 24% of sucrose oral solution. J Matern Fetal Neonatal Med 2019; 33:3596-3601. [PMID: 30786793 DOI: 10.1080/14767058.2019.1580690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pain management is one of the main challenges in addressing the improved care of hospitalized newborns. The administration of oral sucrose with and without non-nutritive suction has been proposed as a nonpharmacological intervention to relieve procedural pain in newborns. The effects have not yet been well characterized. The aim of this study is to investigate, using skin conductance algesimeter (SCA) pain monitor index, the effects of 24% sucrose solution on pain perception during capillary and arterial blood sampling. It is a prospective, randomized controlled study: sucrose versus placebo. Sucrose was given orally to infants who were submitted to arterial or capillary sampling. The SCA was measured during, and for 3 min before and after the intervention. Fifty-six infants were enrolled: 31 in the sucrose group and 25 in the placebo group. SCA showed that the measurement of peaks per second of pain during and 3 min after the procedures was lower in the sucrose group than the placebo group and that this difference was statistically significant (p < .05). In conclusion, 24% sucrose administered orally is effective in reducing pain during and after capillary and arterial sampling in newborns and can be used for the prevention and treatment of pain in the Neonatal Intensive Care Unit.Brief rationaleTo treat neonatal pain, a tiered approach with nonpharmacological and pharmacological method can be used.Among nonpharmacological therapies, sucrose administration is safe and effective in reducing single episodes of minor procedural pain. This study aimed to investigate, the effects of 24% sucrose solution on pain perception during capillary and arterial blood withdrawn by using an objective method: skin conductance algesimeter (SCA) pain monitor index.This randomized controlled trial in which term and/or preterm neonates (postnatal age maximum of 28 days corrected for postmenstrual age) received sucrose for procedural pain. Oral sucrose was administered directly by a disposable plastic vial. SCA was measured by means of a specific device.We demonstrated, using SCA pain monitor index, the efficacy of 24% sucrose solution on pain perception during capillary and arterial blood withdrawn. The results of this study provide an objective evidence of sucrose efficacy for the prevention and treatment of neonatal painful procedures.
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Affiliation(s)
- Annalisa Passariello
- Department of Translational Medical Science, Pediatric Section of University "Federico II", Naples, Italy.,Santobono-Pausilipon Hospital of Naples, Naples, Italy
| | - Paolo Montaldo
- Neonatal Intensive Care Unit, University of Campania "Luigi Vanvitelli", Naples, Italy.,Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Marta Palma
- Department of Translational Medical Science, Pediatric Section of University "Federico II", Naples, Italy
| | - Marilù Cirillo
- Neonatal Intensive Care Unit, Dei Colli Hospital, Naples, Italy
| | - Carmela Di Guida
- Department of Translational Medical Science, Pediatric Section of University "Federico II", Naples, Italy
| | - Simona Esposito
- Department of Translational Medical Science, Pediatric Section of University "Federico II", Naples, Italy
| | - Marco Caruso
- Department of Translational Medical Science, Pediatric Section of University "Federico II", Naples, Italy
| | - Manuela Pugliese
- Department of Translational Medical Science, Pediatric Section of University "Federico II", Naples, Italy
| | - Paolo Giliberti
- Neonatal Intensive Care Unit, Dei Colli Hospital, Naples, Italy
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103
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Toye JM, Yang J, Sankaran K. Narcotics and sedatives use in the mechanical ventilation in preterm infants: Predictors and outcome. J Neonatal Perinatal Med 2019; 12:135-141. [PMID: 30614810 DOI: 10.3233/npm-17157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mechanical ventilation (MV) causes discomfort but whether it causes pain remains controversial. Around the world neonatal intensive care units (NICU) often utilize narcotics and/or sedatives during MV of vulnerable infants yet the association with adverse neonatal outcomes has not been adequately addressed. OBJECTIVE Test for associations between the use of narcotics/sedatives during MV and mortality/morbidity in preterm infants in a large infant cohort in Canada. DESIGN/METHODS Preterm infants born <35 weeks gestational age (GA) requiring MV for >24 hrs were identified retrospectively from the Canadian Neonatal Network database, 2010-12. Infants were categorized according to whether they received narcotics/sedatives for greater than 24 hours concurrently with MV. Infants were excluded if moribund on admission, had major congenital anomalies, diagnoses where narcotic administration is routine and suspected seizures. Multivariable logistic and linear regression analysis tested for association of narcotics/sedatives use during MV with mortality/morbidity (nosocomial infections, BPD, ROP, IVH) and length of MV. RESULTS After exclusions the cohort included 2672 infants; 467(17%) exposed only to narcotics 101(4%) only to sedatives and 299(11%) to both. All models were adjusted for GA, gender, small for GA, SNAP-II score >20, multiple births, delivery mode, outborn, PDA status, MV type, use of high flow, muscle relaxant use, indwelling lines, caffeine and surfactant therapy. The composite mortality/morbidity, and MV days were significantly higher for MV infants exposed to narcotics, sedatives or both compared to infants not exposed. CONCLUSION Mounting evidence of the adverse short and long-term impacts of narcotics/sedatives during MV supports the need for further work in alternative therapies.
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Affiliation(s)
- J M Toye
- University of Alberta, Division of Neonatology, Department of Pediatrics, Alberta, Canada
| | - J Yang
- Mount Sinai Hospital, Maternal-Infant Care Research Centre, Ontario, Canada
| | - K Sankaran
- Department of Pediatrics, University of Saskatchewan, Division of Neonatology, SK, Canada
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104
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Yiğit Ş, Ecevit A, Köroğlu ÖA. Turkish Neonatal Society guideline on the neonatal pain and its management. TURK PEDIATRI ARSIVI 2018; 53:S161-S171. [PMID: 31236029 PMCID: PMC6568292 DOI: 10.5152/turkpediatriars.2018.01802] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Pain control is an important ethical issue to be considered and constitutes the basis of treatment in premature and term newborns. The inadequacy of pain control in these infants in neonatal intensive care units leads to neurodevelopmental and behavioral problems in the long term. For this reason, it is extremely important to raise awareness of the presence of pain in newborn infants, to reduce invasive procedures applied to infants as much as possible, and to minimize pain with non-pharmacologic or pharmacologic treatments when it is inevitable.
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Affiliation(s)
- Şule Yiğit
- Division of Neonatology, Department of Pediatrics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Ayşe Ecevit
- Division of Neonatology, Department of Pediatrics, Başkent University, Faculty of Medicine, Ankara, Turkey
| | - Özge Altun Köroğlu
- Division of Neonatology, Department of Pediatrics, Ege University, Faculty of Medicine, İzmir, Turkey
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105
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Pandita A, Panghal A, Gupta G, Verma A, Pillai A, Singh A, Naranje K. Is kangaroo mother care effective in alleviating vaccination associated pain in early infantile period? A RCT. Early Hum Dev 2018; 127:69-73. [PMID: 30321774 DOI: 10.1016/j.earlhumdev.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/15/2018] [Accepted: 10/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Childhood vaccination is a common procedure and a part of routine medical care during infancy. Although vaccination is the cornerstone for prevention of many infectious diseases, it is associated with significant pain, which is often ignored. Non pharmacological interventions such as breast feeding and kangaroo mother care (KMC) have been used to decrease this procedural pain. However there is paucity of published data on effective use of KMC in term neonates and infants beyond the neonatal age. METHOD This randomized controlled trial included 61 infants ≤14 weeks of postnatal age, and compared KMC to swaddling during vaccination. Neonatal infant pain scale (NIPS) was used to assess the pain associated with vaccination. RESULTS NIPS scores at 1 min and 5 min after vaccination and duration of cry were significantly less in the KMC group. CONCLUSION KMC is effective in reducing vaccination associated pain in young infants.
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Affiliation(s)
| | | | - Girish Gupta
- Department of Neonatology, SGPGI, Lucknow, India
| | - Anup Verma
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgratuate Institute of Medical Sciences, Lucknow, India
| | - Anish Pillai
- Division of Neonatology, BC Women's and Children's Hospital, Vancouver, Canada
| | - Anita Singh
- Department of Neonatology, SGPGI, Lucknow, India
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106
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Dur S, Balci S. Assessing Neonatal Pain, Duration of Crying and Procedure Time following Use of Automatic or Manual Heel Lances: A Randomized Controlled Study. J Trop Pediatr 2018; 64:488-494. [PMID: 29253244 DOI: 10.1093/tropej/fmx100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The objective of this study was to compare neonatal pain, duration of crying and procedure time following use of automatic or manual heel lancets. METHODS This randomized trial was conducted with neonates undergoing heel prick procedures in a neonatal intensive care unit for routine blood bilirubin monitoring. An information form, an observation form and the Neonatal Infant Pain Scale (NIPS) were used. Pain before, during and after (1 and 3 min) was assessed using NIPS scoring. RESULTS Seventy neonates were included (automatic lancet, n = 35; manual lancet, n = 35); there was no difference between the groups (p > 0.01). Pain scores were significantly lower, with automatic lancets compared with manual lancets (p = 0.001). The duration of crying after the procedure (p = 0.001) and procedure time (p = 0.001) was significantly shorter with automatic lancets compared with manual lancets. CONCLUSION Automatic heel lancets in neonates are more effective than manual lancets at reducing pain, and shorten the procedure time and duration of post-procedural crying.
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Affiliation(s)
- Sadiye Dur
- Pediatric Nursing Department, Istanbul University Florence Nightingale Faculty of Nursing, Istanbul 34381, Turkey
| | - Serap Balci
- Pediatric Nursing Department, Istanbul University Florence Nightingale Faculty of Nursing, Istanbul 34381, Turkey
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107
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Singh AP, Lakshminrusimha S, Thompson ME. Regional analgesia in neonates undergoing thoracoabdominal surgeries: A pilot study. J Neonatal Perinatal Med 2018; 12:73-79. [PMID: 30320598 DOI: 10.3233/npm-1827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The primary aim of this pilot study was to assess feasibility and to evaluate if peri-operative pain management with regional analgesia resulted in decreased use of narcotic medication and earlier return to preoperative respiratory/nutritional status. STUDY DESIGN Cases were defined as infants who received regional analgesia as part of their perioperative anesthetic management. Controls were matched for surgical procedures without regional analgesia. RESULTS Fifteen cases were identified and matched with 17 controls. Infants undergoing inguinal hernia repair returned to baseline earlier and were not intubated. There was no difference in time to extubation in other thoracoabdominal surgeries. There was no difference in cumulative narcotic analgesia administered between the two groups. CONCLUSION Postoperative regional analgesia is feasible in neonates. Inguinal hernia repair with regional anesthesia was performed without intubation and returned to preoperative status earlier. No differences were observed with other surgeries. Further prospective, randomized, multicenter studies are needed.
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Affiliation(s)
- Ajay Pratap Singh
- Department of Pediatrics, Texas Tech University at El Paso, El Paso, TX, USA
| | | | - Mark E Thompson
- University at Buffalo, Oishei Children's Hospital, Buffalo, NY, USA
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108
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Richter M, Seipolt B. Schmerztherapie bei Früh- und Neugeborenen. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0558-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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109
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Abstract
BACKGROUND Proper assessment of pain is essential to allow for safe and compassionate care of infants in the neonatal intensive care unit (NICU). The Neonatal Infant Pain Scale (NIPS) used in an urban level IV NICU addresses acute pain but may not adequately measure chronic neonatal pain. PURPOSE The purpose of this quality improvement study was to improve acute and chronic pain measurements for neonates in an NICU through implementation of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS). METHODS/SEARCH STRATEGY An evidence search for a comprehensive tool to assess neonatal pain in the setting of a 45-bed level IV NICU was completed. The N-PASS was found to be inclusive of measuring acute and chronic neonatal pain. Participants for a quality improvement study, including NICU nurses and providers, were educated on the N-PASS. Nurses documented in the N-PASS and the NIPS during routine pain assessments for NICU infants for comparison. Participants completed a survey assessing knowledge of the N-PASS. FINDINGS/RESULTS When compared, the N-PASS generated 98% of pain scores greater than the NIPS. Surveys demonstrated an increase in staff knowledge for the N-PASS. IMPLICATIONS FOR PRACTICE Implementation of a multidimensional pain tool that measures acute and chronic pain is essential for proper pain assessment. Providers can manage neonatal pain when accurate documentation is available. IMPLICATIONS FOR RESEARCH Further research evaluating guided management of acute and chronic pain scores on the N-PASS would aid hospital policies on therapies for neonatal pain.
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110
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Salerno S, Granata C, Trapenese M, Cannata V, Curione D, Rossi Espagnet MC, Magistrelli A, Tomà P. Is MRI imaging in pediatric age totally safe? A critical reprisal. Radiol Med 2018; 123:695-702. [PMID: 29725913 DOI: 10.1007/s11547-018-0896-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/20/2018] [Indexed: 12/11/2022]
Abstract
Current radiological literature is strongly focussed on radiation imaging risks. Indeed, given there is a small but actual augment in cancer risk from exposure to ionizing radiation in children, it is important to understand what the risk of alternative techniques could be. We retrospectively review literature data concerning possible MR imaging risks, focussing on the biological effects of MR, sedation and gadolinium compound risks when dealing with infant patients. The main concerns can be summarized in: (1) Biological effects of non-ionizing electromagnetic fields (EMF) employed-whose mechanisms of interaction with human tissues are polarization, induced current, and thermal heating, respectively. (2) Risks associated with noises produced during MRI examinations. (3) Hazards from ferromagnetic external and/or implanted devices-whose risk of being unintentionally brought inside MR room is higher in children than in adults. (4) Risks associated with sedation or general anaesthesia, essential problem in performing MR in very young patients, due to the exam long-lasting. (5) Risks related to gadolinium-based contrast agents, especially considering the newly reported brain deposition.
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Affiliation(s)
- Sergio Salerno
- Dipartimento di Diagnostica per Immagini, Policlinico Università degli Studi di Palermo, Via del Vespro 127, CAP 90127, Palermo, Italy.
| | - Claudio Granata
- UOC Radiologia - Ospedale Pediatrico Giannina Gaslini, Genoa, Italy
| | - Marco Trapenese
- Dipartimento di Energia, Ingegneria dell'Informazione e Modelli Matematici, Università degli Studi di Palermo, Palermo, Italy
| | - Vittorio Cannata
- Servizio Prevenzione e Protezione/Fisica Sanitaria, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Davide Curione
- Dipartimento Diagnostica per Immagini, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Andrea Magistrelli
- Dipartimento Diagnostica per Immagini, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Paolo Tomà
- Dipartimento Diagnostica per Immagini, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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111
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Schwerdtle T, Vollmer G, Wallace H, Benford D, Calò G, Dahan A, Dusemund B, Mulder P, Németh-Zámboriné É, Arcella D, Baert K, Cascio C, Levorato S, Schutte M, Vleminckx C. Update of the Scientific Opinion on opium alkaloids in poppy seeds. EFSA J 2018; 16:e05243. [PMID: 32625895 PMCID: PMC7009406 DOI: 10.2903/j.efsa.2018.5243] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.
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112
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Zeilmaker GA, Pokorna P, Mian P, Wildschut ED, Knibbe CAJ, Krekels EHJ, Allegaert K, Tibboel D. Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients. Expert Opin Drug Metab Toxicol 2018; 14:417-428. [PMID: 29623729 DOI: 10.1080/17425255.2018.1461836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.
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Affiliation(s)
- Gerdien A Zeilmaker
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Paula Pokorna
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Pediatrics, General Faculty Hospital Prague, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,c Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Paola Mian
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Enno D Wildschut
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Catherijne A J Knibbe
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands.,e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Elke H J Krekels
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Karel Allegaert
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,f Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Dick Tibboel
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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113
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Abstract
Pain is a central topic on neonatal intensive care units (NICU). Acute as well as prolonged (continuous and chronic) pain frequently occurs. Due to a lack of validated physiological measurement instruments for pain (e. g. saliva cortisol, skin conductance and heart rate variability) pain in neonatology can only be assessed by external observation through the bedside team with pain scores using a regular, standardized procedure. During this very vulnerable period pain and medications (analgesics/sedatives) can negatively influence the brain development of premature babies and neonates. Therefore, limitation of the number of pain stimuli and the medicinal guideline "as much as necessary but as little as possible" are eminently important. When dealing with prolonged (continuous and chronic) pain, further challenges are a reduction of analgesics and sedatives as well as avoidance of withdrawal symptoms.
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Affiliation(s)
- M Richter
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland.
| | - B Seipolt
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
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114
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Mele C. The Use of Near Infrared Spectroscopy to Assess Infant Pain. J Pediatr Nurs 2018; 39:85-88. [PMID: 29321105 DOI: 10.1016/j.pedn.2017.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Cheryl Mele
- Children Hospital of Philadelphia, Philadelphia, PA, USA.
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115
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Efendi D, Rustina Y, Gayatri D. Pacifier and swaddling effective in impeding premature infant's pain score and heart rate. ENFERMERIA CLINICA 2018. [DOI: 10.1016/s1130-8621(18)30035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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116
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M Toye J, Mirea L, Yang J, Sankaran K. Trends in narcotics and sedative use during mechanical ventilation of preterm infants in Canadian neonatal intensive care units. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:5-11. [PMID: 29335074 PMCID: PMC7390316 DOI: 10.7499/j.issn.1008-8830.2018.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Mechanical ventilation (MV) in preterm infants (PTI) causes discomfort. Whether it causes pain is controversial. Meta analysis reviews of published work on PTI during MV have shown no clinically significant impact of opioids on pain scales, and hence not recommended for routine use in neonatal intensive care units (NICUs). Similarly regular use of sedative midazolam is also not recommended. Therefore we hypothesized a downward trend in narcotics and sedatives used in MV of PTI in NICUs. This study aimed to assess trends of sedatives and narcotics use during MV of PTI in Canadian NICUs during 2004-2009. METHODS PTI born at gestational age (GA) of <35 weeks requiring invasive MV for >24 hours were identified retrospectively from the Canadian Neonatal Network database for 2004-2009. PTI were excluded if moribund on admission, had major congenital anomalies, surgery (except laser eye surgery), necrotizing enterocolitis, chest tube or history of maternal narcotic abuse. PTI were classified according to whether they received any narcotics (morphine, fentanyl, methadone, sufentanyl, meperidine, alfentynl and codiene) or sedatives (chloral hydrate, midazolam, lorazepam, phenobarbital, pentobarbital, ketamine and propofol) for >24 consecutive hours during MV. Trends of narcotics and sedatives were assessed using the Cochrane-Armitage Trend test separately for PTI born at <29 and 29-34 weeks of GA. RESULTS Among 5 638 study subjects, 2 169 (38.5%) received narcotics and 897 (15.9%) received sedatives. The most common narcotics were morphine (62.2%) and fentanyl (63.8%) and sedatives were phenobarbital (44.9%) and chloral hydrate (44.2%). A significant decreasing trend (P<0.01) in the use of any sedatives during MV was observed in PTI <29 and 29-34 weeks of GA. However, the use of any narcotics during MV increased significantly (P=0.03) among PTI <29 weeks of GA, and no change in trend was detected for PTI born at 29-34 weeks of GA. CONCLUSIONS The use of sedatives during MV in PTI born at <35 weeks of GA was positively affected, however the narcotics use during MV remained constant for PTI born at 29-34 weeks, and increased in extremely low GA group (less than 29 weeks) suggesting evidence based practice change was not observed during the study period.
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Affiliation(s)
- Jennifer M Toye
- Division of Neonatology, Department of Pediatrics, University of Alberta, EdmontonDivision of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Lucia Mirea
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto
| | - Junmin Yang
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto
| | - Koravangattu Sankaran
- Division of Neonatology, Department of Pediatrics, University of Saskatchewan, Saskatoon)
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Andersen RD, Munsters JMA, Vederhus BJ, Gradin M. Pain assessment practices in Swedish and Norwegian neonatal care units. Scand J Caring Sci 2017; 32:1074-1082. [PMID: 29282767 DOI: 10.1111/scs.12553] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/29/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of measurement scales to assess pain in neonates is considered a prerequisite for effective management of pain, but these scales are still underutilised in clinical practice. AIM The aim of this study was to describe and compare pain assessment practices including the use of pain measurement scales in Norwegian and Swedish neonatal care units. METHODS A unit survey investigating practices regarding pain assessment and the use of pain measurement scales was sent to all neonatal units in Sweden and Norway (n = 55). All Norwegian and 92% of Swedish units responded. RESULTS A majority of the participating units (86.5%) assessed pain. Swedish units assessed and documented pain and used pain measurement scales more frequently than Norwegian units. The most frequently used scales were different versions of Astrid Lindgren's Pain Scale (ALPS) in Sweden and Echelle Douleur Inconfort Noveau-Ne (EDIN), ALPS and Premature Infant Pain Profile (PIPP) in Norway. Norwegian head nurses had more confidence in their pain assessment method and found the use of pain measurement scales more important than their Swedish colleagues. CONCLUSION The persisting difference between Swedish and Norwegian units in pain assessment and the use of pain measurement scales are not easily explained. However, the reported increased availability and reported use of pain measurement scales in neonatal care units in both countries may be seen as a contribution towards better awareness and recognition of pain, better pain management and potentially less suffering for vulnerable neonates.
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Affiliation(s)
- Randi Dovland Andersen
- Department of Child and Adolescent Health Services, Telemark Hospital, Skien, Norway.,Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Josanne M A Munsters
- Department of Women's and Children's Health, University Children's Hospital Uppsala, Uppsala, Sweden
| | | | - Maria Gradin
- Department of Paediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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118
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Field T. Preterm newborn pain research review. Infant Behav Dev 2017; 49:141-150. [DOI: 10.1016/j.infbeh.2017.09.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/01/2017] [Accepted: 09/02/2017] [Indexed: 11/16/2022]
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Bonutti DP, Daré MF, Castral TC, Leite AM, Vici-Maia JA, Scochi CGS. Dimensioning of painful procedures and interventions for acute pain relief in premature infants. Rev Lat Am Enfermagem 2017. [PMCID: PMC5614232 DOI: 10.1590/1518-8345.1387.2917] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: to dimension the exposure of premature infants to painful procedures, relating the
distribution of the exposure to contextual factors, as well as to describe the
pharmacological and non-pharmacological interventions health professionals use
during the first two weeks of the infant’s hospitalization at two neonatal
services. Method: descriptive-exploratory study in which the professionals registered the painful
procedures and pain relief interventions on a specific form in the patient file.
Results: the daily average of the 89 premature infants was 5.37 painful procedures,
corresponding to 6.56 during the first week of hospitalization and 4.18 during the
second week (p<0.0001). The most frequent procedures were nasal/oral
(35.85%) and tracheal aspirations (17.17%). The children under invasive
ventilation were the most exposed to painful procedures (71.2%). Only 44.9% of the
painful procedures received some intervention for the purpose of pain relief, the
most frequent being sucrose (78.21%) and continuing sedation (19.82%). Conclusion: acute pain was undertreated at these neonatal services, recommending greater
sensitization of the team for the effective use of the existing protocol and
implementation of other knowledge transfer strategies to improve neonatal pain
management.
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120
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Sposito NPB, Rossato LM, Bueno M, Kimura AF, Costa T, Guedes DMB. Assessment and management of pain in newborns hospitalized in a Neonatal Intensive Care Unit: a cross-sectional study. Rev Lat Am Enfermagem 2017; 25:e2931. [PMID: 28902934 PMCID: PMC5599073 DOI: 10.1590/1518-8345.1665.2931] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/07/2017] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE: to determine the frequency of pain, to verify the measures adopted for pain relief during the first seven days of hospitalization in the Neonatal Intensive Care Unit and to identify the type and frequency of invasive procedures to which newborns are submitted. METHOD: cross-sectional retrospective study. Out of the 188 hospitalizations occurred during the 12-month period, 171 were included in the study. The data were collected from the charts and the presence of pain was analyzed based on the Neonatal Infant Pain Scale and on nursing notes suggestions of pain. For statistical analysis, the Statistical Package for the Social Sciences was used, and the significance level was set at 5%. RESULTS: there was at least one record of pain in 50.3% of the hospitalizations, according to the pain scale adopted or nursing note. The newborns underwent a mean of 6.6 invasive procedures per day. Only 32.5% of the pain records resulted in the adoption of pharmacological or non-pharmacological intervention for pain relief. CONCLUSION: newborns are frequently exposed to pain and the low frequency of pharmacological or non-pharmacological interventions reinforces the undertreatment of this condition. OBJETIVO: determinar a frequência de dor e verificar as medidas realizadas para seu alívio durante os sete primeiros dias de internação na Unidade de Terapia Intensiva Neonatal, bem como identificar o tipo e frequência de procedimentos invasivos aos quais os recém-nascidos foram submetidos. MÉTODO: estudo retrospectivo transversal. Das 188 internações ocorridas no período estipulado de 12 meses, 171 foram incluídas na pesquisa. Os dados foram coletados a partir dos prontuários e a presença de dor foi analisada tanto com base na escala de dor Neonatal Infant Pain Scale quanto mediante anotação de enfermagem sugestiva de dor. Para análise estatística, utilizou-se o programa Statistical Package for the Social Sciences, adotando-se nível de significância de 5%. RESULTADOS: em 50,3% das internações houve ao menos um registro de dor, conforme escala de dor adotada ou anotação de enfermagem. Os recém-nascidos foram submetidos à média de 6,6 procedimentos invasivos por dia. Apenas 32,5% dos registros de dor resultaram na adoção de condutas farmacológicas ou não farmacológicas para seu alívio. CONCLUSÃO: observa-se que os recém-nascidos são frequentemente expostos à dor e a baixa frequência de intervenções farmacológicas ou não farmacológicas reforça o subtratamento dessa condição. OBJETIVO: determinar la frecuencia del dolor, comprobar las medidas tomadas para su alivio durante los siete primeros días de internación en una Unidad de Terapia Intensiva Neonatal e identificar el tipo de procedimientos invasivos y la frecuencia a que se sometieron los recién nacidos. MÉTODO: estudio retrospectivo transversal. De las 188 internaciones realizadas en el período estipulado de 12 meses, se incluyeron 171 en la investigación. Los datos se recolectaron a partir de los prontuarios; la presencia de dolor se analizó según la Escala de Valorización del Dolor en el Neonato (Neonatal Infant Pain Scale) y las notas de enfermería sobre el dolor. Para el análisis estadístico, se utilizó el programa 'Paquete estadístico para las ciencias sociales' (Statistical Package for the Social Sciences), adoptándose el nivel de significación del 5%. RESULTADOS: en el 50,3% de las internaciones hubo al menos un registro de dolor, según la escala de dolor adoptada o las notas de la enfermería. Se sometió a los recién nacidos a un promedio de 6,6 procedimientos invasivos por día. Sólo el 32,5% de los registros de dolor resultaron en la adopción de conductas farmacológicas o no farmacológicas para su alivio. CONCLUSIÓN: se observa que los recién nacidos a menudo están expuestos al dolor, y la frecuencia baja de intervenciones farmacológicas o de las no farmacológicas refuerza el subtratamiento de dicha condición.
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Affiliation(s)
- Natália Pinheiro Braga Sposito
- MSc, RN, Hospital Universitário, Universidade de São Paulo, São Paulo,
SP, Brazil. Professor, Universidade Cidade de São Paulo, São Paulo, SP, Brazil
| | | | - Mariana Bueno
- PhD, Professor, Escola de Enfermagem, Universidade de São Paulo, São
Paulo, SP, Brazil
| | - Amélia Fumiko Kimura
- PhD, Professor, Escola de Enfermagem, Universidade de São Paulo, São
Paulo, SP, Brazil
| | - Taine Costa
- MSc, RN, Hospital Infantil Waldemar Monastier, Campo Largo, PR, Brazil
| | - Danila Maria Batista Guedes
- Doctoral student, Escola de Enfermagem, Universidade de São Paulo, São
Paulo, SP, Brazil. Scholarship holder at Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior (CAPES), Brazil
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LINHARES MBM, GASPARDO CM. Non-pharmacological management of neonatal pain: Research and clinical practice in the Neonatal Intensive Care Unit. ESTUDOS DE PSICOLOGIA (CAMPINAS) 2017. [DOI: 10.1590/1982-02752017000300003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract According to the World Health Organization and the International Association for the Study of Pain, pain is a relevant worldwide problem in the healthcare field. The present study aimed to describe the definition of pediatric pain and the main characteristics, and to examine the findings regarding the impact of pain on the development of the child. The best clinical practices in Neonatal Intensive Care Units should include developmental care and specifically implement pain management, aiming to protect the health and development of the infants. The efficacious non-pharmacological management of neonatal pain includes breastfeeding, skin-to-skin, non-nutritive sucking, facilitated-tucking and swaddling. Sweet solutions also have pain relief effects. Psychologists could actively participate in the implementation of non-pharmacological interventions and in the whole process to sensitize and train the professional teams, to alert parents to protection against pain and to support policymakers in the implementation of pain guidelines in the hospital.
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122
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Pölkki T, Korhonen A, Laukkala H. Nurses' perceptions of pain assessment and management practices in neonates: a cross-sectional survey. Scand J Caring Sci 2017; 32:725-733. [PMID: 28833371 DOI: 10.1111/scs.12503] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 06/14/2017] [Indexed: 01/06/2023]
Abstract
AIMS This study aimed to describe pain assessment and management practices for neonates based on nurses' perceptions in neonatal intensive care units (NICUs). DESIGN A descriptive cross-sectional survey was conducted in Finland. METHODS Of all nurses (N = 422) working in the NICUs in the country's five university hospitals, 294 responded to a questionnaire. The data were analysed by statistical methods. RESULTS Nurses agreed that pain assessment is important, but over half of them reported being able to assess pain in a reliable way without using pain assessment scales. Physiological parameters and changes in neonate's behaviour were reported as routinely observed, but many specific facial expressions indicative of pain were less often observed. Only a few pain assessment scales were known, and they were not routinely used in clinical practice. Most nurses reported using physical methods and giving oral sucrose along with non-nutritive sucking. Counselling parents to continue breastfeeding or guiding them to use skin-to-skin care or music was rarely reported as used to alleviate infants' pain. CONCLUSIONS Educational interventions for nurses are needed to improve pain assessment and management practices in the NICUs. In addition, there is a need for national guidelines in order to ensure the equal treatment to all neonates.
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Affiliation(s)
- Tarja Pölkki
- Specialist in Clinical Nursing Science, Unit of Children and Women, Oulu University Hospital, Oulu, Finland
| | | | - Helena Laukkala
- Department of Research Methodology, University of Lapland, Rovaniemi, Finland
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123
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van Ganzewinkel CJ, Andriessen P. We need to change how we deal with continuous pain in neonates. Acta Paediatr 2017; 106:1212-1214. [PMID: 28692199 DOI: 10.1111/apa.13922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Peter Andriessen
- Máxima Medical Center; Neonatal Intensive Care Unit; Veldhoven The Netherlands
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124
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Sorrentino G, Fumagalli M, Milani S, Cortinovis I, Zorz A, Cavallaro G, Mosca F, Plevani L. The impact of automatic devices for capillary blood collection on efficiency and pain response in newborns: A randomized controlled trial. Int J Nurs Stud 2017; 72:24-29. [DOI: 10.1016/j.ijnurstu.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 03/29/2017] [Accepted: 04/04/2017] [Indexed: 01/12/2023]
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125
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Acupuncture in the neonatal intensive care unit-using ancient medicine to help today's babies: a review. J Perinatol 2017; 37:749-756. [PMID: 27977013 DOI: 10.1038/jp.2016.227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/21/2016] [Accepted: 11/01/2016] [Indexed: 11/08/2022]
Abstract
Acupuncture has been used for thousands of years in Eastern medicine for a variety of conditions and illnesses, including pain. Neonatal intensive care, on the other hand, is a relatively new branch of medicine that has emerged as the pivotal influence in increasing survival of critically ill newborn infants only within the last 50 years. Unfortunately, pain is an inevitable part of treatment in a neonatal intensive care unit (NICU). The control and prevention of pain remains a major issue for clinicians despite recognition and understanding of the myriad of short- and long-term problems that are associated with both pain and its treatment within the NICU environment. In this review, we examine the potential role of acupuncture to decrease and treat pain in babies requiring neonatal intensive care and discuss future therapeutic and research implications for the use of this ancient therapy within the modern environment of the NICU.
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126
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Bellieni CV, Tei M, Cornacchione S, Di Lucia S, Nardi V, Verrotti A, Buonocore G. Pain perception in NICU: a pilot questionnaire. J Matern Fetal Neonatal Med 2017; 31:1921-1923. [PMID: 28514889 DOI: 10.1080/14767058.2017.1332038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Neonatal pain management has made a great step forward over the last several years. Despite the drafting of International guidelines, an under-treatment of neonatal pain is still reported. MATERIALS AND METHODS Medical and paramedical personnel working in five Italian NICUs were asked to complete a questionnaire about pain management. The questionnaire was comprised of three sections: (i) brief explanation of the purpose; (ii) demographic information, including age, profession, religious beliefs, and hospital level; (iii) questionnaire about pain management and prevention. RESULTS One-hundred and forty caregivers participated in this study. Non-pharmacological analgesia during heel prick or venipuncture was used by 64% and 60% of them, respectively; topical analgesia was performed in 13% of venipunctures; no analgesia was used in 30% of cases for both heel prick and venipuncture. In the case of lumbar puncture, 35% of participants used topical analgesia, 15% non-pharmacological approach, 10% opioids, and 6% intravenous paracetamol. While 65% of participants gave a score of 4 out of 5 about the importance of pain treatment, 39% of them reported that in their department no pain scales were used. CONCLUSIONS Pain treatment in these NICUs is still far to be optimal. This nonetheless reflects a worldwide trend, which requires more attention on pain prevention, assessment, and treatment.
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Affiliation(s)
- C V Bellieni
- a Department of Paediatrics, Obstetrics and Reproductive Medicine , University of Siena , Siena , Italy
| | - M Tei
- a Department of Paediatrics, Obstetrics and Reproductive Medicine , University of Siena , Siena , Italy
| | - S Cornacchione
- a Department of Paediatrics, Obstetrics and Reproductive Medicine , University of Siena , Siena , Italy
| | - S Di Lucia
- a Department of Paediatrics, Obstetrics and Reproductive Medicine , University of Siena , Siena , Italy
| | - V Nardi
- b Department of Paediatrics , University of L'Aquila , L'Aquila , Italy
| | - A Verrotti
- b Department of Paediatrics , University of L'Aquila , L'Aquila , Italy
| | - G Buonocore
- a Department of Paediatrics, Obstetrics and Reproductive Medicine , University of Siena , Siena , Italy
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127
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Veneziano G, Tobias JD. Chloroprocaine for epidural anesthesia in infants and children. Paediatr Anaesth 2017; 27:581-590. [PMID: 28321983 DOI: 10.1111/pan.13134] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 11/30/2022]
Abstract
Continuous epidural infusions are an effective and safe method of providing anesthesia and postoperative analgesia in infants and children with multiple advantages over systemic medications, including earlier tracheal extubation, decreased perioperative stress response, earlier return of bowel function, and decreased exposure to volatile anesthetic agents with uncertain long-term neurocognitive effects. Despite these benefits, local anesthetic toxicity remains a concern in neonates and infants because of their decreased metabolic capacity for amide local anesthetics. Chloroprocaine, an ester local anesthetic agent, which is rapidly metabolized in plasma at all ages, is an attractive alternative for this special population, particularly in the presence of superimposed liver impairment or when higher infusion rates are needed for surgical incisions stretching many dermatomes. The current manuscript reviews the literature pertaining to the use of 2-chloroprocaine for regional anesthesia in infants and children. Dosing regimens are presented and the applications of 2-chloroprocaine in this population are discussed.
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Affiliation(s)
- Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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128
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Randomized Clinical Trial of 24% Oral Sucrose to Decrease Pain Associated With Peripheral Intravenous Catheter Insertion in Preterm and Term Newborns. Adv Neonatal Care 2017; 17:E3-E11. [PMID: 27533333 DOI: 10.1097/anc.0000000000000326] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To determine whether 24% sucrose solution given orally before insertion of a peripheral intravenous (PIV) catheter decreases neonatal pain. BACKGROUND Prior studies of pain caused by heel and arterial needlesticks found oral administration of 24% sucrose to significantly blunt pain during these painful procedures. No studies have evaluated this treatment with needlestick pain associated with PIV catheter insertion. METHODS Oral 24% sucrose or placebo solution was administered 2 minutes prior to PIV catheter insertion. Outcome measures were obtained prior to, during, and for 5 minutes after PIV catheter insertion. Investigators and caregivers were blinded to group assignment. Data were analyzed with longitudinal analysis of repeated measures, with P < .05 for significance. RESULTS A total of 40 neonates (24% sucrose: N = 20; placebo: N = 20) were studied. Pain scores significantly increased from 3.2 ± 1.6 to a maximum of 7.6 ± 3.8 at the time of catheter insertion, returning to baseline levels 8 minutes after PIV catheter insertion (P < .001). No significant differences were found in pain, heart rate, or noninvasive oxygen saturation (SpO2) between the sucrose and placebo groups (P > 0.05). IMPLICATIONS FOR PRACTICE Results from this study did not find that 24% sucrose administered prior to PIV catheter insertion altered the infant's pain response. IMPLICATIONS FOR RESEARCH Since this is the first study to evaluate the pain-blunting effects of 24% sucrose administration before PIV catheter insertion, replication of this study is needed before widespread application of findings.
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129
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Abstract
Procedural distress is a common occurrence in the NICU and is tied to attempts to support the life and development of vulnerable premature infants. We discuss the epidemiology of procedural distress and the potential negative consequences on infant neurodevelopment. We define procedural distress in the NICU and outline three approaches to limit or to reduce its detrimental effects including minimizing the number of procedures, instituting measures for developmentally supportive care, and using preemptively pharmacologic and nonpharmacologic analgesia. Despite the pervasiveness of procedural distress in the NICU, clinical and administrative measures are available to ameliorate possible harmful outcomes.
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130
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Lima AGCF, Santos VS, Nunes MS, Barreto JAA, Ribeiro CJN, Carvalho J, Ribeiro MCO. Glucose solution is more effective in relieving pain in neonates than non-nutritive sucking: A randomized clinical trial. Eur J Pain 2016; 21:159-165. [PMID: 27460979 DOI: 10.1002/ejp.912] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Few studies have compared the analgesic effect of 25% glucose and non-nutritive sucking. We compared the analgesic effect of 25% glucose and non-nutritive sucking in newborns undergoing hepatitis B vaccination. Our hypothesis is that 25% glucose is more effective in relieving pain than non-nutritive sucking. METHODS A randomized clinical trial with 78 healthy newborns was performed. Neonates were assigned randomly to receive 25% glucose (G25) and non-nutritive sucking (NNS). Pain was assessed using the Neonatal Infant Pain Scale (NIPS) before and during the immunization procedure. In addition, we evaluated various physiological parameters and crying time. RESULTS Neonates who received 25% glucose registered lower NIPS scores than those from the NNS group [mean (SD), 3.3 (2.1) vs. 5.6 (1.6), p < 0.001]. The crying time was shorter among newborns in the G25 group than in the NNS and control groups. CONCLUSION The use of 25% glucose before the vaccination procedure was more effective in relieving acute pain, with newborns in the G25 group registering scores two times lower on the NIPS scale. The clinical practice of administering 25% glucose is therefore a suggested nondrug measure for pain relief during painful procedures. SIGNIFICANCE Neonates who received 25% glucose registered lower NIPS scores than those from the NNS group; the crying time was shorter among newborns in the G25 group than in the NNS and control groups; the use of 25% glucose before the vaccination procedure was more effective in relieving acute pain.
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Affiliation(s)
- A G C F Lima
- Postgraduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
| | - V S Santos
- Postgraduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
| | - M S Nunes
- Department of Nursing, Federal University of Sergipe, Lagarto, Brazil
| | - J A A Barreto
- Department of Nursing, Federal University of Sergipe, Lagarto, Brazil
| | - C J N Ribeiro
- Postgraduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
| | - J Carvalho
- Department of Nursing, Federal University of Sergipe, Aracaju, Brazil
| | - M C O Ribeiro
- Postgraduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil.,Department of Nursing, Federal University of Sergipe, Aracaju, Brazil
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131
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Smits A, van den Anker JN, Allegaert K. Clinical pharmacology of analgosedatives in neonates: ways to improve their safe and effective use. ACTA ACUST UNITED AC 2016; 69:350-360. [PMID: 27364566 DOI: 10.1111/jphp.12599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/11/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To propose approaches tailored to the specific needs of neonates, such as structured product development programmes, with the ultimate goal to improve the safe and effective use of analgosedatives in these fragile patients. KEY FINDINGS The feasibility and relevance of a structured product development programme in neonates (optimal study design based on preliminary data; model development; internal, external and prospective evaluation; an individualized dosing regimen; long-term safety; pharmacogenetics) are illustrated for the use of morphine. Based on changes in clinical practices, similar development plans are in progress for short-acting analgosedatives such as propofol, but are in need of tailored pharmacodynamic tools to assess and quantify effects. Furthermore, for drugs like paracetamol where there is already sufficient clinical pharmacology knowledge, attention needs to be given to long-term safety aspects. Finally, new covariates such as pharmacogenetics might further improve neonatal pain management, but clearly need to be integrated with other well-established covariates like age or weight. SUMMARY Product development programmes for analgosedatives in neonates are needed. These programmes should be tailored to their specific needs (short-acting sedation, pain relief), should include long-term safety and should incorporate the exploration of newer covariates like pharmacogenetics.
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Affiliation(s)
- Anne Smits
- Neonatal Intensive Care Unit, VU Medical Center, Amsterdam, The Netherlands.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - John N van den Anker
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland.,Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Departments of Pediatrics, Integrative Systems Biology, Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karel Allegaert
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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132
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Lemmon ME, Bidegain M, Boss RD. Palliative care in neonatal neurology: robust support for infants, families and clinicians. J Perinatol 2016; 36:331-7. [PMID: 26658120 DOI: 10.1038/jp.2015.188] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/16/2015] [Accepted: 10/21/2015] [Indexed: 11/09/2022]
Abstract
Infants with neurological injury and their families face unique challenges in the neonatal intensive care unit. As specialty palliative care support becomes increasingly available, we must consider how to intentionally incorporate palliative care principles into the care of infants with neurological injury. Here, we review data regarding neonatal symptom management, prognostic uncertainty, decision making, communication and parental support for neonatal neurology patients and their families.
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Affiliation(s)
- M E Lemmon
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Division of Pediatric Neurology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - M Bidegain
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - R D Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Berman Institute of Bioethics, Johns Hopkins School of Medicine
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133
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Abstract
The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor, yet painful procedures. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures.
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134
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Victoria NC, Murphy AZ. Exposure to Early Life Pain: Long Term Consequences and Contributing Mechanisms. Curr Opin Behav Sci 2016; 7:61-68. [PMID: 27525299 DOI: 10.1016/j.cobeha.2015.11.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
From an evolutionary perspective, adaptations of an organism to its early environment are essential for survival. The occurrence of early life perturbation, coincident with increased developmental plasticity, provides a unique opportunity for such adaptations to become programmed and persist throughout life. However, adaptations that are beneficial to maintaining homeostasis in one's early environment may result in extreme response strategies that confer vulnerability or dysfunction later in life. This review summarizes recent findings in human and animal studies demonstrating that early life pain results in a hypo-/hyper-sensitive phenotype in response to acute and persistent pain and stress later in life. Changes in cognition and immune function in response to early life pain have also been observed. Recent data on the neural mechanisms underlying these long-term changes are discussed, as well as potential strategies to minimize the impact of early life pain.
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Affiliation(s)
- Nicole C Victoria
- Neuroscience Institute, Georgia State University, 100 Piedmont Ave, Atlanta, GA USA 30303
| | - Anne Z Murphy
- Neuroscience Institute, Georgia State University, 100 Piedmont Ave, Atlanta, GA USA 30303
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135
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Campbell-Yeo M. 'First, do no harm'--the use of analgesia or placebo as control for babies in painful clinical trials. Acta Paediatr 2016; 105:119-20. [PMID: 26751416 DOI: 10.1111/apa.13255] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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136
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Cook SF, Roberts JK, Samiee-Zafarghandy S, Stockmann C, King AD, Deutsch N, Williams EF, Allegaert K, Wilkins DG, Sherwin CMT, van den Anker JN. Population Pharmacokinetics of Intravenous Paracetamol (Acetaminophen) in Preterm and Term Neonates: Model Development and External Evaluation. Clin Pharmacokinet 2016; 55:107-19. [PMID: 26201306 PMCID: PMC5564323 DOI: 10.1007/s40262-015-0301-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of this study were to develop a population pharmacokinetic model for intravenous paracetamol in preterm and term neonates and to assess the generalizability of the model by testing its predictive performance in an external dataset. METHODS Nonlinear mixed-effects models were constructed from paracetamol concentration-time data in NONMEM 7.2. Potential covariates included body weight, gestational age, postnatal age, postmenstrual age, sex, race, total bilirubin, and estimated glomerular filtration rate. An external dataset was used to test the predictive performance of the model through calculation of bias, precision, and normalized prediction distribution errors. RESULTS The model-building dataset included 260 observations from 35 neonates with a mean gestational age of 33.6 weeks [standard deviation (SD) 6.6]. Data were well-described by a one-compartment model with first-order elimination. Weight predicted paracetamol clearance and volume of distribution, which were estimated as 0.348 L/h (5.5 % relative standard error; 30.8 % coefficient of variation) and 2.46 L (3.5 % relative standard error; 14.3 % coefficient of variation), respectively, at the mean subject weight of 2.30 kg. An external evaluation was performed on an independent dataset that included 436 observations from 60 neonates with a mean gestational age of 35.6 weeks (SD 4.3). The median prediction error was 10.1 % [95 % confidence interval (CI) 6.1-14.3] and the median absolute prediction error was 25.3 % (95 % CI 23.1-28.1). CONCLUSIONS Weight predicted intravenous paracetamol pharmacokinetics in neonates ranging from extreme preterm to full-term gestational status. External evaluation suggested that these findings should be generalizable to other similar patient populations.
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Affiliation(s)
- Sarah F Cook
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Samira Samiee-Zafarghandy
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Chris Stockmann
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Amber D King
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Nina Deutsch
- Division of Anesthesiology, Sedation, and Perioperative Medicine, Children's National Health System, Washington, DC, USA
| | - Elaine F Williams
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Diana G Wilkins
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
- Division of Medical Laboratory Sciences, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, Integrative Systems Biology, Pharmacology and Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
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137
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Härmä A, Aikio O, Hallman M, Saarela T. Intravenous Paracetamol Decreases Requirements of Morphine in Very Preterm Infants. J Pediatr 2016; 168:36-40. [PMID: 26323200 DOI: 10.1016/j.jpeds.2015.08.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/29/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether intravenous paracetamol therapy is effective in pain therapy in premature infants. STUDY DESIGN From June 2009 to December 2011, 108 infants born very low gestational age (<32 weeks) (VLGA) were given intravenous paracetamol before the age of 72 hours. The loading dose was 20 mg/kg followed by 7.5 mg/kg every 6 hours. One hundred ten VLGA infants admitted from October 2007 to May 2009 formed the comparison group who received no paracetamol. Intravenous morphine was exclusively used as the opiate. Morphine dosage was calculated as the cumulative dose administered during the neonatal intensive care unit period. Pain symptoms were screened using pain scale scoring Neonatal Infant Acute Pain Assessment Scale. The number of apneas during the neonatal intensive care unit stay, and ventilation days per patient, were calculated. RESULTS The mean (SD) total number of paracetamol doses per patient was 16.9 (11.7), and the postnatal age for the first dose was 13.3 (13.8) hours. Infants in the paracetamol group needed significantly fewer morphine doses per patient than the comparisons, 1.78 (4.56) doses vs 4.35 (11.53), P = .044. The exposed had lower cumulative morphine dosage 0.17 (0.45) mg/kg vs 0.37 (0.96) mg/kg, P = .047. There were no differences in the Neonatal Infant Acute Pain Assessment Scale scores, or the numbers of apneas, or ventilation days. There was no evidence of adverse events including hepatic toxicity. CONCLUSION The need for morphine decreased significantly after the introduction of paracetamol for the VLGA infants.
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Affiliation(s)
- Antti Härmä
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Outi Aikio
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.
| | - Mikko Hallman
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Timo Saarela
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
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138
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van den Anker JN, Allegaert K. Treating Pain in Preterm Infants: Moving from Opioids to Acetaminophen. J Pediatr 2016; 168:13-15. [PMID: 26490127 DOI: 10.1016/j.jpeds.2015.09.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/23/2015] [Indexed: 10/22/2022]
Affiliation(s)
- John N van den Anker
- Division of Pediatric Clinical Pharmacology, Department of Pediatrics, Children's National Medical Center, Washington, DC; Department of Paediatric Pharmacology, University of Basel Children's Hospital, Basel, Switzerland; Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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139
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Leng HY, Zheng XL, Zhang XH, He HY, Tu GF, Fu Q, Shi SN, Yan L. Combined non-pharmacological interventions for newborn pain relief in two degrees of pain procedures: A randomized clinical trial. Eur J Pain 2015; 20:989-97. [PMID: 26685099 DOI: 10.1002/ejp.824] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Non-pharmacological interventions are effective neonatal pain reduction strategies. We aimed to study the effects of non-nutritive sucking (NNS) and swaddling on infants' behavioural and physiological parameters during shallow or deep heel stick procedures. METHOD In this prospective, multi-centred, randomized controlled clinical trial, we enrolled 671 newborns. The infants undergoing shallow or deep heel stick procedures were randomized into four groups: oral sucrose (routine care, group S), oral sucrose combined with NNS (group NS), oral sucrose combined with swaddling (group SS) and oral sucrose combined with NNS and swaddling (group NSS). The behavioural responses were evaluated by the Revised Neonatal Facial Coding System and the physiological signals were monitored by electrocardiogram monitors. RESULTS A significant synergistic analgesic effect was observed between the NS and SS groups in both the shallow (F = 5.952, p = 0.015) and deep heel stick (F = 7.452, p = 0.007) procedure. NSS group exhibited the lowest pain score. For the deep heel stick procedure, the NS group had a significantly lower increase in heart rate (HR)% and decrease in SPO2 % than the S group (F = 17.540, p = 0.000, F = 10.472, p = 0.001), while this difference was not observed in the shallow heel stick procedure. No difference was found between the S and SS groups, in terms of different physiological parameters. CONCLUSION Non-nutritive sucking and swaddling had synergistic effects on pain relief when used with oral sucrose. For the deep heel stick procedure, oral sucrose combined with NNS and swaddling provided the best pain relief effect. For the shallow heel stick procedure, addition of NNS and swaddling did not improve the effects.
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Affiliation(s)
- H-Y Leng
- Department of PICU, Children's Hospital of Chongqing Medical University, Chongqing City, China
| | - X-L Zheng
- Department of PICU, Children's Hospital of Chongqing Medical University, Chongqing City, China
| | - X-H Zhang
- Department of PICU, Children's Hospital of Chongqing Medical University, Chongqing City, China
| | - H-Y He
- Department of PICU, Children's Hospital of Chongqing Medical University, Chongqing City, China
| | - G-F Tu
- Department of Nursing, Chengdu Women's & Children's Central Hospital, Chengdu City, China
| | - Q Fu
- Department of Nursing, Shenzhen Children's Hosptial, Shenzhen City, China
| | - S-N Shi
- Department of Nursing, Hunan Children's Hosptial, Changsha City, China
| | - L Yan
- Department of PICU, Children's Hospital of Chongqing Medical University, Chongqing City, China
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140
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Victoria NC, Murphy AZ. The long-term impact of early life pain on adult responses to anxiety and stress: Historical perspectives and empirical evidence. Exp Neurol 2015. [PMID: 26210872 DOI: 10.1016/j.expneurol.2015.07.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately 1 in 6 infants are born prematurely each year. Typically, these infants spend 25 days in the Neonatal Intensive Care Unit (NICU) where they experience 10-18 painful and inflammatory procedures each day. Remarkably, pre-emptive analgesics and/or anesthesia are administered less than 25% of the time. Unalleviated pain during the perinatal period is associated with permanent decreases in pain sensitivity, blunted cortisol responses and high rates of neuropsychiatric disorders. To date, the mechanism(s) by which these long-term changes in stress and pain behavior occur, and whether such alterations can be prevented by appropriate analgesia at the time of insult, remains unclear. Work in our lab using a rodent model of early life pain suggests that inflammatory pain experienced on the day of birth blunts adult responses to stress- and pain-provoking stimuli, and dysregulates the hypothalamic pituitary adrenal (HPA) axis in part through a permanent upregulation in central endogenous opioid tone. This review focuses on the long-term impact of neonatal inflammatory pain on adult anxiety- and stress-related responses, and underlying neuroanatomical changes in the context of endogenous pain control and the HPA axis. These two systems are in a state of exaggerated developmental plasticity early in postnatal life, and work in concert to respond to noxious or aversive stimuli. We present empirical evidence from animal and clinical studies, and discuss historical perspectives underlying the lack of analgesia/anesthetic use for early life pain in the modern NICU.
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Affiliation(s)
- Nicole C Victoria
- Neuroscience Institute, Georgia State University, 100 Piedmont Ave, Atlanta, GA 30303, USA.
| | - Anne Z Murphy
- Neuroscience Institute, Georgia State University, 100 Piedmont Ave, Atlanta, GA 30303, USA.
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