Validation of the Premature Infant Pain Profile-Revised (PIPP-R)

Paracetamol and morphine for infant and neonatal pain; still a long way to go?

INTRODUCTION

Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.

Dexmedetomidine for analgesia and sedation in newborn infants receiving mechanical ventilation

This is the protocol for a review and there is no abstract. The objectives are as follows:

To determine the overall effectiveness and safety of dexmedetomidine for sedation and analgesia in newborn infants receiving mechanical ventilation compared with other non‐opioids, opioids or placebo.

We will perform subgroup analyses according to method of dexmedetomidine administration; dose of dexmedetomidine; age of initiation of dexmedetomidine; indication for mechanical ventilation; gestational age; and duration of treatment.

Development of Cardiovascular Indices of Acute Pain Responding in Infants: A Systematic Review

Background. Cardiovascular indices of pain are pervasive in the hospital setting. However, no prospective research has examined the development of cardiac responses to acutely painful procedures in the first year of life. Objectives. Our main goal was to synthesize existing evidence regarding the development of cardiovascular responses to acutely painful medical procedures over the first year of life in preterm and term born infants. Methods. A systematic search retrieved 6994 articles to review against inclusion criteria. A total of 41 studies were included in the review. Results. In response to acutely painful procedures, most infants had an increase in mean heart rate (HR) that varied in magnitude both across and within gestational and postnatal ages. Research in the area of HR variability has been inconsistent, limiting conclusions. Conclusions. Longitudinal research is needed to further understand the inherent variability of cardiovascular pain responses across and within gestational and postnatal ages and the causes for the variability.

Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals

Background

This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain-related distress (adequacy of sedation, iatrogenic withdrawal syndrome and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient.

Methods

A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain-related distress in critically ill and nonverbal children, and searched the PubMed/Medline, CINAHL and Embase databases for studies describing the psychometric properties of assessment instruments. Furthermore, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added on the basis of the level of evidence.

Results

An ESPNIC position statement was drafted which provides clinical recommendations on assessment of pain (n = 5), distress and/or level of sedation (n = 4), iatrogenic withdrawal syndrome (n = 3) and delirium (n = 3). These recommendations were based on the available evidence and consensus amongst the experts and other members of ESPNIC.

Conclusions

This multidisciplinary ESPNIC position statement guides professionals in the assessment and reassessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4344-1) contains supplementary material, which is available to authorized users.

Skin-to-skin contact reduces near-infrared spectroscopy pain responses in premature infants during blood sampling

AIM

This study investigated if skin-to-skin contact could provide pain relief, measured with near-infrared spectroscopy (NIRS), during venepuncture in premature infants.

METHODS

Ten infants born at 26-35 weeks of gestation were examined during a blood-sampling procedure with venepuncture under two different conditions: in skin-to-skin contact with their mother or lying in their incubator or crib. A double-channel NIRS device was used, and oxygen saturation and heart rate were measured using pulse oximetry. The infant's face and the pulse oximetry values were videotaped throughout the procedures, so that we could carry out a pain assessment using the Premature Infant Pain Profile-Revised (PIPP-R).

RESULTS

We found a significantly smaller increase in oxygenated haemoglobin on the contralateral side during venepuncture when the infants were in skin-to-skin contact with their mothers, compared to when they were laying in their incubator or crib. When venepuncture was compared with a sham procedure, oxygenated haemoglobin increased significantly more with the infant in the incubator or crib than held skin-to-skin, but no significant differences could be seen in the PIPP-R results between the two groups.

CONCLUSION

This study showed that skin-to-skin contact between premature infants and their mothers during venepuncture had a pain-relieving effect.

Prevention and Management of Procedural Pain in the Neonate: An Update

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.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn

BACKGROUND

Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It may be treated with either needle aspiration or insertion of a chest tube. The former consists of aspiration of air with a syringe through a needle or an angiocatheter, usually through the second or third intercostal space in the midclavicular line. The chest tube is usually placed in the anterior pleural space passing through the sixth intercostal space into the pleural opening, turned anteriorly and directed to the location of the pneumothorax, and then connected to a Heimlich valve or an underwater seal with continuous suction.

OBJECTIVES

To compare the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE via PubMed (1966 to 30 November 2015), EMBASE (1980 to 30 November 2015), and CINAHL (1982 to 30 November 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax.

DATA COLLECTION AND ANALYSIS

For each of the included trial, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.

MAIN RESULTS

One randomised controlled trial (72 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.27 to 8.45) or complications related to the procedure. After needle aspiration, the angiocatheter was left in situ (mean 27.1 hours) and not removed immediately after the aspiration. The angiocatheter was in place for a shorter duration than the intercostal tube (mean difference (MD) -11.20 hours, 95% CI -15.51 to -6.89). None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is low.

AUTHORS' CONCLUSIONS

At present there is insufficient evidence to determine the efficacy and safety of needle aspiration versus intercostal tube drainage in the management of neonatal pneumothorax. Randomised controlled trials comparing the two techniques are warranted.

Sedatives and Analgesics Given to Infants in Neonatal Intensive Care Units at the End of Life

OBJECTIVE

To describe the administration of sedatives and analgesics at the end of life in a large cohort of infants in North American neonatal intensive care units.

STUDY DESIGN

Data on mortality and sedative and analgesic administration were from infants who died from 1997-2012 in 348 neonatal intensive care units managed by the Pediatrix Medical Group. Sedatives and analgesics of interest included opioids (fentanyl, methadone, morphine), benzodiazepines (clonazepam, diazepam, lorazepam, midazolam), central alpha-2 agonists (clonidine, dexmedetomidine), ketamine, and pentobarbital. We used multivariable logistic regression to evaluate the association between administration of these drugs on the day of death and infant demographics and illness severity.

RESULTS

We identified 19 726 infants who died. Of these, 6188 (31%) received a sedative or analgesic on the day of death; opioids were most frequently administered, 5366/19 726 (27%). Administration of opioids and benzodiazepines increased during the study period, from 16/283 (6%) for both in 1997 to 523/1465 (36%) and 295/1465 (20%) in 2012, respectively. Increasing gestational age, increasing postnatal age, invasive procedure within 2 days of death, more recent year of death, mechanical ventilation, inotropic support, and antibiotics on the day of death were associated with exposure to sedatives or analgesics.

CONCLUSIONS

Administration of sedatives and analgesics increased over time. Infants of older gestational age and those more critically ill were more likely to receive these drugs on the day of death. These findings suggest that drug administration may be driven by severity of illness.

Should we assess pain in newborn infants using a scoring system or just a detection method?

Newborn infants' pain should be scored indirectly using dedicated pain scales. Unfortunately, while some scales for prolonged pain have given good results, a gold standard to assess acute pain does not exist. Acute pain scales still have weak points, most are complex and are scarcely used in neonatal departments. Moreover, carefully scoring pain in clinical practice seems redundant, because any avoidable pain is a concern. This suggests that researchers must find new ways to assess acute pain. A possible approach is to settle for pain detection instead of pain scoring in selected cases. Here, we describe a two-point method that illustrates this approach.

CONCLUSION

For everyday practice, detecting pain is more useful than scoring it; acute pain scales should be reserved for research, for those clinical settings where the personnel has received a careful training and where overcrowding and hurry are absent.

Pain care for patients with epidermolysis bullosa: best care practice guidelines

BACKGROUND

Inherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB.

METHODS

The process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB.

RESULTS

The first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted.

CONCLUSIONS

Evidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is often times horrific in its effects on quality of life, and whose care is resource-intensive and difficult. The guideline development process also highlighted areas for research in order to improve further the evidence base for future care.