Pain and its effects in the human neonate and fetus

Magnetic Non-invasive Auricular Acupuncture During Eye-Exam for Retinopathy of Prematurity in Preterm Infants: A Multicentre Randomized Controlled Trial

Background: Eye exam for Retinopathy of prematurity (ROP) is a painful procedure and pharmacological analgesia might be ineffective. We hypothesized that magnetic auricular acupuncture (MAA) compared to placebo will decrease pain during ROP exam in preterm infants. Methods: Multicentre randomized controlled trial conducted in three hospitals (Australia, Canada, and Malaysia). Eligibility: >32 weeks, ROP exam, not sedated, and parental consent. A total of 100 infants were randomized (1:1) to MAA (n = 50) or placebo (n = 50). MAA stickers or placebo were placed on both ears by an unblinded investigator. Pain was assessed using the Premature Infant Pain Profile. Primary analyses were by intention-to-treat. ClinicalTrials.gov:NCT03650621. Findings: The mean (standard deviation, SD) gestation, birthweight, and postnatal age were (MAA 28(3) vs. placebo 28(2) weeks; MAA 1,057(455) vs. placebo 952(273) g; MAA 7(3) vs. placebo 7(3) weeks. Placebo infants had significantly higher PIPP scores during [mean difference 1.6 points (95%CI 0.1-3.1)] and 1 h mean difference 1.5 points (95%CI 0.7-2.2) after the procedure (p < 0.03). Heart rate was lower (173(22) vs. 184(18)/min) and oxygen saturations were higher (93.8(6.2) vs. 91.7(6.1)%, p = 0.05) in MAA infants. No adverse effects. Interpretation: MAA may reduce physiological pain responses during and after ROP exam in preterm infants. Assessment of long-term effects are warranted. Clinical trial registration: www.ClinicalTrials.gov, identifier: NCT03650621.

Defining and distinguishing infant behavioral states using acoustic cry analysis: is colic painful?

BACKGROUND

To characterize acoustic features of an infant's cry and use machine learning to provide an objective measurement of behavioral state in a cry-translator. To apply the cry-translation algorithm to colic hypothesizing that these cries sound painful.

METHODS

Assessment of 1000 cries in a mobile app (ChatterBaby^TM). Training a cry-translation algorithm by evaluating >6000 acoustic features to predict whether infant cry was due to a pain (vaccinations, ear-piercings), fussy, or hunger states. Using the algorithm to predict the behavioral state of infants with reported colic.

RESULTS

The cry-translation algorithm was 90.7% accurate for identifying pain cries, and achieved 71.5% accuracy in discriminating cries from fussiness, hunger, or pain. The ChatterBaby cry-translation algorithm overwhelmingly predicted that colic cries were most likely from pain, compared to fussy and hungry states. Colic cries had average pain ratings of 73%, significantly greater than the pain measurements found in fussiness and hunger (p < 0.001, 2-sample t test). Colic cries outranked pain cries by measures of acoustic intensity, including energy, length of voiced periods, and fundamental frequency/pitch, while fussy and hungry cries showed reduced intensity measures compared to pain and colic.

CONCLUSIONS

Acoustic features of cries are consistent across a diverse infant population and can be utilized as objective markers of pain, hunger, and fussiness. The ChatterBaby algorithm detected significant acoustic similarities between colic and painful cries, suggesting that they may share a neuronal pathway.

The influence of pain, agitation, and their management on the immature brain

Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct.

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

Effective and safe pain relief in neonates matters. This is not only because of ethical constraints or human empathy, but even more because pain treatment is an important and crucial part of contemporary medical, paramedical, and nursing care to improve the outcome in neonatal intensive care graduates. Paracetamol (acetaminophen) is likely one of the pharmacological tools to attain this, with data on prescription practices suggesting that paracetamol is somehow the "rising star" in neonatal pain management. Besides very rare topical clinical scenarios like peripartal asphyxia and subsequent whole body hypothermia or the use of cardiorespiratory support devices, data on paracetamol pharmacokinetics and metabolism were reported throughout neonatal age or weight ranges, and we have summarized these data. In this review, we subsequently aimed to provide the reader with the currently available observations on the use of paracetamol as analgesic for different pain syndromes (major surgery, minor surgery or trauma, and procedural pain), with focus on the limitations of paracetamol when prescribed for neonatal procedural pain management. We hereby intentionally will not discuss other indications (patent ductus arteriosus and fever) for paracetamol administration in neonates. Based on the available evidence, paracetamol has opioid-sparing effects for major pain syndromes, is effective to treat minor to moderate pain syndromes, but fails for effective procedural pain management in neonates. This efficacy failure for procedural pain management should stimulate us to continue to search for more effective interventions, including non-pharmacological interventions and preventive strategies. Furthermore, there are also upcoming association type of epidemiological studies on the relation between exposure to analgesics-including paracetamol-and the negative short- or long-term outcome characteristics (neuro-behavioral, atopy, and fertility). Consequently and in addition to the search for effective alternatives to prevent or treat pain, studies on long-term outcome following paracetamol exposure are needed to inform all stakeholders on the full effect-side effect balance of the different strategies to treat pain.

Reconsidering fetal pain

Fetal pain has long been a contentious issue, in large part because fetal pain is often cited as a reason to restrict access to termination of pregnancy or abortion. We have divergent views regarding the morality of abortion, but have come together to address the evidence for fetal pain. Most reports on the possibility of fetal pain have focused on developmental neuroscience. Reports often suggest that the cortex and intact thalamocortical tracts are necessary for pain experience. Given that the cortex only becomes functional and the tracts only develop after 24 weeks, many reports rule out fetal pain until the final trimester. Here, more recent evidence calling into question the necessity of the cortex for pain and demonstrating functional thalamic connectivity into the subplate is used to argue that the neuroscience cannot definitively rule out fetal pain before 24 weeks. We consider the possibility that the mere experience of pain, without the capacity for self reflection, is morally significant. We believe that fetal pain does not have to be equivalent to a mature adult human experience to matter morally, and so fetal pain might be considered as part of a humane approach to abortion.

Current state of science in machine learning methods for automatic infant pain evaluation using facial expression information: study protocol of a systematic review and meta-analysis

INTRODUCTION

Infants can experience pain similar to adults, and improperly controlled pain stimuli could have a long-term adverse impact on their cognitive and neurological function development. The biggest challenge of achieving good infant pain control is obtaining objective pain assessment when direct communication is lacking. For years, computer scientists have developed many different facial expression-centred machine learning (ML) methods for automatic infant pain assessment. Many of these ML algorithms showed rather satisfactory performance and have demonstrated good potential to be further enhanced for implementation in real-world clinical settings. To date, there is no prior research that has systematically summarised and compared the performance of these ML algorithms. Our proposed meta-analysis will provide the first comprehensive evidence on this topic to guide further ML algorithm development and clinical implementation.

METHODS AND ANALYSIS

We will search four major public electronic medical and computer science databases including Web of Science, PubMed, Embase and IEEE Xplore Digital Library from January 2008 to present. All the articles will be imported into the Covidence platform for study eligibility screening and inclusion. Study-level extracted data will be stored in the Systematic Review Data Repository online platform. The primary outcome will be the prediction accuracy of the ML model. The secondary outcomes will be model utility measures including generalisability, interpretability and computational efficiency. All extracted outcome data will be imported into RevMan V.5.2.1 software and R V3.3.2 for analysis. Risk of bias will be summarised using the latest Prediction Model Study Risk of Bias Assessment Tool.

ETHICS AND DISSEMINATION

This systematic review and meta-analysis will only use study-level data from public databases, thus formal ethical approval is not required. The results will be disseminated in the form of an official publication in a peer-reviewed journal and/or presentation at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42019118784.

Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit

In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.

Pain in Neonates: A Concept Analysis

Context

The term pain in neonates is emerged in recent decades. However, studies on pain in neonates are still limited and have various indicators. In addition, the term pain still often overlaps with stress in various studies and clinical circumstances. The concepts of pain and stress in the neonates need to be clarified to be better understood and then applied to improve neonates’ quality of life. Therefore, the current study aimed at clarifying the concept of pain in neonates.

Evidence Acquisition

The current study employed the concept analysis approach developed by Walker and Avant. The authors reviewed articles from JSTOR, ScienceDirect, Proquest, Sage, Cochrane, and Springer databases from 1980 to 2016 using keywords pain, stress, neonatal, neonates, and quality of life.

Results

Pain had attributes such as tissue damage, physiological changes, metabolic changes, and behavioral changes. Stress had attributes such as physiological changes, metabolic changes, and behavioral changes.

Conclusions

Attributes of pain and stress have similarities and differences. The main difference is the stimulus that induces a response. Pain has an attribute of tissue damage, whereas stress is not always due to tissue damage. The attributes of physical, metabolic, and behavioral changes between pain and stress are similar.

Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery

BACKGROUND

Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability.

METHODS

This study followed 265 children aged 8-17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy.

RESULTS AND DISCUSSION

The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability.

CONCLUSION

Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.

Doctors and Nurses' Knowledge and Attitudes Towards Pediatric Pain Management: An Exploratory Survey in a Children's Hospital

Despite the existence of protocols for effective pain control, pediatric pain is still high, due to scarce knowledge of its treatment, especially regarding opioids. This study aimed to evaluate doctors and nurses' knowledge of pain treatment and the use of opioids in children, before and after the implementation of Law 38/2010, that represented an important step in guaranteeing patients' rights to gain access to appropriate services for pain control and palliative care in Italy and in establishing the obligation of specific training programs in this matter for health professionals. An ad hoc questionnaire was developed and administered before (investigation A) and after (investigation B) the issuance of the Law. In B both doctors and nurses showed a slight but significant increase in correct answers and a reduction in incorrect ones, mainly concerning the category Myths and Prejudices. In both investigations doctors and nurses showed adequate general knowledge, yet there were some gaps regarding the specific knowledge of opioid drugs. Most of the participants were not familiar with the Law and its provisions.Investigation B showed an improvement in health professionals' knowledge, perhaps due to a hospital environment that followed the provisions of Law 38/2010. Nevertheless, the establishment of training courses according to the Law is needed to improve the knowledge of opioids, as well as to dispel deeply rooted myths and prejudices on pediatric pain.

Preparing for Life After Birth: Introducing the Concepts of Intrauterine and Extrauterine Sensory Entrainment in Mammalian Young

Presented is an updated understanding of the development of sensory systems in the offspring of a wide range of terrestrial mammals, the prenatal exposure of those systems to salient stimuli, and the mechanisms by which that exposure can embed particular sensory capabilities that prepare newborns to respond appropriately to similar stimuli they may encounter after birth. Taken together, these are the constituents of the phenomenon of "trans-natal sensory continuity" where the embedded sensory capabilities are considered to have been "learnt" and, when accessed subsequently, they are said to have been "remembered". An alternative explanation of trans-natal sensory continuity is provided here in order to focus on the mechanisms of "embedding" and "accessing" instead of the potentially more subjectively conceived outcomes of "learning" and "memory". Thus, the mechanistic concept of "intrauterine sensory entrainment" has been introduced, its foundation being the well-established neuroplastic capability of nervous systems to respond to sensory inputs by reorganising their neural structures, functions, and connections. Five conditions need to be met before "trans-natal sensory continuity" can occur. They are (1) sufficient neurological maturity to support minimal functional activity in specific sensory receptor systems in utero; (2) the presence of sensory stimuli that activate their aligned receptors before birth; (3) the neurological capability for entrained functions within specific sensory modalities to be retained beyond birth; (4) specific sensory stimuli that are effective both before and after birth; and (5) a capability to detect those stimuli when or if they are presented after birth in ways that differ (e.g., in air) from their presentation via fluid media before birth. Numerous beneficial outcomes of this process have been reported for mammalian newborns, but the range of benefits depends on how many of the full set of sensory modalities are functional at the time of birth. Thus, the breadth of sensory capabilities may be extensive, somewhat restricted, or minimal in offspring that are, respectively, neurologically mature, moderately immature, or exceptionally immature at birth. It is noted that birth marks a transition from intrauterine sensory entrainment to extrauterine sensory entrainment in all mammalian young. Depending on their neurological maturity, extrauterine entrainment contributes to the continuing maturation of the different sensory systems that are operational at birth, the later development and maturation of the systems that are absent at birth, and the combined impact of those factors on the behaviour of newborn and young mammals. Intrauterine sensory entrainment helps to prepare mammalian young for life immediately after birth, and extrauterine sensory entrainment continues this process until all sensory modalities develop full functionality. It is apparent that, overall, extrauterine sensory entrainment and its aligned neuroplastic responses underlie numerous postnatal learning and memory events which contribute to the maturation of all sensory capabilities that eventually enable mammalian young to live autonomously.

Population pharmacokinetic modeling to facilitate dose selection of tapentadol in the pediatric population

OBJECTIVE

The main aim of this analysis was to characterize the pharmacokinetics (PK) of the strong analgesic tapentadol in 2-year-old to <18-year-old patients with acute pain and to inform the optimal dosing strategy for a confirmatory efficacy trial in this patient population.

METHODS

The analysis dataset included tapentadol concentrations obtained from 92 pediatric patients receiving a single tapentadol oral solution (OS) dose of 1.0 mg/kg bodyweight in two single-dose PK clinical trials. Population PK analysis was performed using nonlinear mixed effects modeling. Simulations were performed to identify tapentadol OS doses in pediatric subjects (2 to <18 years) that would produce exposures similar to those in adults receiving safe and efficacious doses of tapentadol IR (50-100 mg every 4 hrs).

RESULTS

Tapentadol PK in children aged from 2 to <18 years was best described by a one-compartment model. Mean population apparent clearance and apparent volume of distribution for a typical subject weighing 45 kg were 170 L/h and 685 L, respectively. Clearance, expressed in bodyweight units as L/h/kg, decreased with increasing age whereas total clearance (L/h) increased with increasing age. Model-based simulations suggested that a tapentadol OS dose of 1.25 mg/kg to children and adolescents aged 2 to <18 years would result in efficacious tapentadol exposures similar to those in adults receiving tapentadol immediate release 50-100 mg every 4 hrs. The proposed tapentadol OS dose was subsequently applied in a confirmatory efficacy trial in 2 to <18-year-old patients suffering from acute postsurgical pain.

CONCLUSION

This analysis provides an example of a model-based approach for a dose recommendation to be used in an efficacy trial in the pediatric population. Uniform dosing based on bodyweight was proposed for the treatment of acute pain in children aged from 2 to <18 years.

A Pilot Randomized Controlled Trial of Outcomes Associated with Parent-Nurse Controlled Analgesia vs. Continuous Opioid Infusion in the Neonatal Intensive Care Unit

PURPOSE

Prospectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population.

DESIGN/METHODS

A randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction.

RESULTS

The sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction.

CONCLUSIONS

PNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation.

CLINICAL IMPLICATIONS

Patients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement.

STUDY TYPE

Treatment study.

LEVEL OF EVIDENCE

I.

Animal Ethics and Behavioral Science: An Overdue Discussion

Animal ethics—the field of philosophy concerned with the moral status of animals—is experiencing a momentum unprecedented in its history. Surprisingly, animal behavior science remains on the sidelines, despite producing critical evidence on which many arguments in animal ethics rest. In the present article, we explore the origins of the divide between animal behavior science and animal ethics before considering whether behavioral scientists should concern themselves with it. We finally envision tangible steps that could be taken to bridge the gap, encouraging scientists to be aware of, and to more actively engage with, an ethical revolution that is partly fueled by the evidence they generate.

Comparison of two different doses of sucrose in pain relief

BACKGROUND

Procedural pain is one of the most significant problems in neonates, especially in premature babies. Harmless and effective pain relief modalities in newborns should thus be applied. Although sucrose is the most commonly used agent, the most effective dose and concentration of sucrose is not clear. In this study, we compared the efficacy of two different doses of sucrose during venepuncture in neonates.

METHODS

This was a prospective, randomized, double-blind study. The study was conducted during venous sampling. Oral 24% sucrose (Tool sweet^™ Natus Medical, San Carlos, CA, USA) was given by sterile syringe onto the anterior part of the tongue. Group 1 (n = 65) received 0.2 mL/kg 24% sucrose and group 2 (n = 64) received 0.5 mL/kg 24% sucrose. The Bernese Pain Scale for Neonates (BPSN) was used to assess the pain scores before, during and after the procedure.

RESULTS

One hundred and twenty-nine premature infants were enrolled in the study, consisting of 67 girls (51.9%) and 62 boys (48.1%) aged 1-24 days (mean age, 8.34 ± 6.25 days). There was no significant difference in BPSN score between the groups (P > 0.05). There was also no statistically significant difference in BPSN subscale scores between the groups (P > 0.05).

CONCLUSIONS

Twenty-four percent sucrose 0.2 mL/kg may be the minimum effective dose to relieve pain during venepuncture procedures in premature babies.

[Evolution of practices in neonatology]

The care of newborns has benefited from significant progress over the last twenty years. The discovery of new treatments and technologies, the development of care centred on the infants and their family, ethical reflection, the organisation of support and training for professionals are just some examples. The place of the parents in decision-making processes however needs to be reinforced.

Discovering Pain in Newborn Infants

Randomised Trial of Fentanyl Anesthesia in Preterm Babies Undergoing Surgery: Effects on the Stress Response. By Anand KJ, Sippell WG, and Aynsley-Green A. Lancet 1987; 1:243-8. Reprinted with permission.In a randomised controlled trial, preterm babies undergoing ligation of a patent ductus arteriosus were given nitrous oxide and D-tubocurarine, with (n = 8) or without (n = 8) the addition of fentanyl (10 μg/kg intravenously) to the anesthetic regimen. Major hormonal responses to surgery, as indicated by changes in plasma adrenaline, noradrenaline, glucagon, aldosterone, corticosterone, 11-deoxycorticosterone, and 11-deoxycortisol levels, in the insulin/glucagon molar ratio, and in blood glucose, lactate, and pyruvate concentrations were significantly greater in the nonfentanyl than in the fentanyl group. The urinary 3-methylhistidine/creatinine ratios were significantly greater in the nonfentanyl group on the second and third postoperative days. Compared with the fentanyl group, the nonfentanyl group had circulatory and metabolic complications postoperatively. The findings indicate that preterm babies mount a substantial stress response to surgery under anesthesia with nitrous oxide and curare and that prevention of this response by fentanyl anesthesia may be associated with an improved postoperative outcome.

Relationship between sexual hormones, quality of life and postmenopausal sexual function

OBJECTIVE

To assess the relationship between sexual hormones, sexual function and quality of life in postmenopausal women.

METHOD

A cross-sectional study was conducted with a convenience sample of 36 postmenopausal women between the ages of 45 and 65 in follow-up at a climacteric outpatient clinic. Mood, quality of life, sexual function and hormonal profile were assessed.

RESULTS

With regard to sexual hormones and sexual function, a relationship was found between orgasm and luteinizing hormone (r=0.37), orgasm and sex hormone-binding globulin (SHBG) (r=0.39), SHBG and less pain (r=0.44), dehydroepiandrosterone (DHEA) and desire (r=-0.45), as well as between prolactin and lubrication (r=0.33). Sexual hormones and quality of life were related as follows: progesterone and limitations due to physical aspects (r=0.35), SHBG and social aspects (r=0.35), cortisol and pain (r=0.46), DHEA and social aspects (r=-0.40). Finally, the following relationships were found between sexual function and quality of life: sexual desire and vitality, social aspects, state of general health and mental health (r=0.46, r=0.51, r=0.35, and r=0.38, respectively). Arousal, orgasm and satisfaction with sexual life showed a relationship with less physical pain (r=0.40, r=0.42, and r=0.43, respectively). Satisfaction with sexual life was correlated with vitality (r=0.33).

CONCLUSION

Different correlations than expected were found in this study regarding the effect of some hormones on sexual function and some aspects of the quality of life of postmenopausal women.

The challenge of developing pain medications for children: therapeutic needs and future perspectives

It is broadly accepted that children of all age groups including (preterm) neonates and young infants can perceive pain and that there is an absolute need to treat their pain safely and effectively. The approved treatment options for children, particularly (preterm) neonates and young infants, are very limited with only a few medications specifically labelled for this population. This article presents the challenges of developing pain medications for children. A short overview gives information on pain in children, including pain perception, prevalence of pain and the long-term consequences of leaving pain untreated in this vulnerable population. Current pain management practices are briefly discussed. The challenges of conducting pediatric clinical trials in general and trials involving analgesic medications in particular within the regulatory framework available to develop these medications for children are presented. Emphasis is given to the operational hurdles faced in conducting a pediatric clinical trial program. Some suggestions to overcome these hurdles are provided based on our experience during the pediatric trial program for the strong analgesic tapentadol used for the treatment of moderate to severe acute pain.

The Role of the Subplate in Schizophrenia and Autism: A Systematic Review

The subplate (SP) represents a transitory cytoarchitectural fetal compartment containing most subcortical and cortico-cortical afferents, and has a fundamental role in the structural development of the healthy adult brain. There is evidence that schizophrenia and autism may be determined by developmental defects in the cortex or cortical circuitry during the earliest stages of pregnancy. This article provides an overview on fetal SP development, considering its role in schizophrenia and autism, as supported by a systematic review of the main databases. The SP has been described as a cortical amplifier with a role in the coordination of cortical activity, and sensitive growth and migration windows have crucial consequences with respect to cognitive functioning. Although there are not enough studies to draw final conclusions, improved knowledge of the SP's role in schizophrenia and autism spectrum disorders may help to elucidate and possibly prevent the onset of these two severe disorders.

Neonatal Pain: Perceptions and Current Practice

Neonates may experience more than 300 painful procedures throughout their hospitalizations. Prior to 1980, there was a longstanding misconception that neonates do not experience pain. Current studies demonstrate that not only do neonates experience pain but also, due to their immature nervous systems, they are hypersensitive to painful stimuli. Poorly treated pain may lead to negative long-term consequences. Proper assessment of neonate pain is vital. The use of nonpharmacologic treatments may be beneficial in alleviating neonate pain. Pharmacologic treatments in the neonate have been well established. Pharmacologic and nonpharmacologic interventions can be used in conjunction to increase the efficacy of analgesia.

Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship

OBJECTIVES

Pediatric procedural sedation has been increasingly performed by pediatric intensivists over the past decade. Pediatric Critical Care Medicine fellowship guidelines do not specify how fellows obtain proficiency in pediatric procedural sedation. We sought to survey the state of pediatric procedural sedation training during fellowship and whether fellows thought it was sufficient.

DESIGN

A 21-question survey gathered data on pediatric procedural sedation training provided to Pediatric Critical Care Medicine fellows. Surveys were sent to fellowship directors with instructions to distribute to second- and third-year fellows or recent graduates. Over 2 months, up to three e-mail reminders were sent to fellowship directors whose program had not completed at least one survey.

SUBJECTS

Senior fellows and graduates of 65 active Accreditation Council for Graduate Medical Education Pediatric Critical Care Medicine fellowship programs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-five percent of fellowship programs (42/65) returned at least one response. Ninety senior fellows and 27 recent graduates responded. Of respondents, 38% received pediatric procedural sedation training during the fellowship, and 32% reported mandatory training. Nine percent of programs used simulation. Although 61% who received training felt adequately prepared to perform pediatric procedural sedation, 25% needed additional preceptorship to sedate independently. Nearly one third (31%) reported that completion of a predetermined number of cases was required to sedate independently. Forty-eight percent reported a minimum number of cases was required for hospital credentialing. Nearly 45% were allowed to perform pediatric procedural sedation off the unit after receiving credentials. When asked if inadequate pediatric procedural sedation training would be a deterrent to applying for a position that included pediatric procedural sedation, 8.6% replied yes, 52.6% replied no, and 38.8% replied they were unsure.

CONCLUSIONS

Pediatric procedural sedation lacks a clearly defined training pathway. Most fellows find pediatric procedural sedation a valuable skill set. We propose that all Pediatric Critical Care Medicine fellows receive training that includes pediatric procedural sedation critical incident simulation and cases performed outside the PICU to establish proficiency.

The human newborn's umwelt: Unexplored pathways and perspectives

Historically, newborns, and especially premature newborns, were thought to "feel nothing." However, over the past decades, a growing body of evidence has shown that newborns are aware of their environment, but the extent and the onset of some sensory capacities remain largely unknown. The goal of this review is to update our current knowledge concerning newborns' perceptual world and how ready they are to cope with an entirely different sensory environment following birth. We aim to establish not only how and when each sensory ability arises during the pre-/postbirth period but also discuss how senses are studied. We conclude that although many studies converge to show that newborns are clearly sentient beings, much is still unknown. Further, we identify a series of internal and external factors that could explain discrepancies between studies, and we propose perspectives for future studies. Finally, through examples from animal studies, we illustrate the importance of this detailed knowledge to pursue the enhancement of newborns' daily living conditions. Indeed, this is a prerequisite for assessing the effects of the physical environment and routine procedures on newborns' welfare.

A Systematic Review of Behavioral and Environmental Interventions for Procedural Pain Management in Preterm Infants

PROBLEM

Current research suggests behavioral and environmental interventions to prevent neonatal pain prior to an invasive procedure are rarely administered and seldom documented. The aim of this study was to systematically review findings from published randomized controlled trials that tested the effects of behavioral and environmental procedural pain management interventions on behavioral pain response in preterm infants.

ELIGIBILITY CRITERIA

Randomized controlled trials examining the effects of behavioral and environmental pain management interventions on behavioral pain response in preterm infants were identified. Articles accepted for inclusion met the following criteria: English language, original, peer refereed, randomized controlled clinical trials published within the past 5 years, study sample: preterm infants, setting: neonatal intensive care units, study intervention behavioral and environmental, outcome pain measurement score from valid and reliable pain scale.

SAMPLE

Fourteen randomized controlled trials from a literature search of PubMed and Medline databases were included in this review.

RESULTS

Across all age groups, facilitated tucking, oral sucrose, and kangaroo care decreased behavioral and physiologic pain response alone and in combination with other behavioral and environmental interventions.

CONCLUSION

Among preterm infants, facilitated tucking, oral sucrose, and kangaroo care significantly mitigates biobehavioral pain response associated with acutely painful procedures.

IMPLICATIONS

Evidence suggests that behavioral and environmental interventions can decrease biobehavioral pain response associated with acutely painful procedures in preterm infants. This review highlights the need for rigorous studies to help healthcare providers to build a tailored pain treatment plan for preterm infants.

Turkish Neonatal Society guideline on the neonatal pain and its management

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.

Neurotoxicity of Anesthesia in Children: Prevention and Treatment

PURPOSE OF REVIEW

The purpose of this review is to summarize the current evidence regarding the impact of the exposure to anesthetic and sedative agents on neurodevelopment during the period of rapid brain growth in the first 3 years of life. Though much of the definitive data demonstrating anesthesia-induced neurotoxicity has come from studies in young animals, the focus of this review is on emerging human data.

RECENT FINDINGS

In 2016, the first prospective trials investigating the neurodevelopmental impact of early anesthetic exposure (GAS and PANDA studies) were published, both showing no significant impact on IQ from a single brief anesthetic. More recent population cohort analyses have shown varying, but minimal, impacts from early anesthetic exposure on academic performance and IQ, much smaller than that of maternal education and other environmental factors. Animal and human data document that post-anesthetic neurotoxicity is a genuine phenomenon, but its long-term clinical significance is uncertain. Most experts would agree that a single, brief anesthetic likely has no significant impact on neurodevelopment, but it is yet to be determined whether longer exposures or multiple anesthetics are associated with subsequent learning issues. Future research is aimed at determining the mechanisms of neuronal injury from exposure to anesthetic and sedative agents, adjunctive medications that may prevent or ameliorate this injury, and therapeutic approaches such as early intervention that can enhance recovery. While these studies are underway, it is recommended that exposure to anesthetic and sedative agents be minimized in young children and consideration be given to alternative methods of immobilization for nonpainful procedures such as radiologic imaging.

Insights into the etiology and embryology of gastroschisis

The development of gastroschisis has long remained an area of interest and controversy. Successive theories about its pathogenesis are herein reviewed and discussed. Two historical assumptions, that omphalocele results from a persistent umbilical hernia, and that gastroschisis does not involve the umbilical cord, are dismissed. Therefore, one can envision gastroschisis for what it is, i.e. a ruptured physiological hernia. The causal agents for this intrauterine accident to occur are yet to be determined. Further bowel damage and complications can be explained by the mesenteric insult.

Asymmetric detrended fluctuation analysis in neonatal stress

OBJECTIVE

To detect stress in newborns by observing heart rate (HR) variability utilizing an asymmetric detrended fluctuation analysis (ADFA), we sought to determine the fractal structure of the series of inter-beat intervals, so as to distinguish the periods of acceleration of the HR from decelerations. Thus, two scaling exponents, α ⁺ and α ^-, representing decelerations and accelerations respectively, are obtained.

APPROACH

Forty healthy term newborns were included in this study, undergoing two different types of stress stimuli: routine heel lance blood sampling for metabolic screening purposes, and its simulation by applying dull pressure on the heel.

MAIN RESULTS

It appears that when newborns face stress, the scaling exponent related to accelerations significantly increases and becomes higher than the deceleration scaling exponent. To test the diagnostic properties of the scaling exponents, an ROC curve analysis was applied; α ^- showed good diagnostic performance with an AUC between 0.626 and 0.826, depending on the length of the time series. The joint use of α ⁺ and α ^- further increased the diagnostic performance, in particular for shorter series of RR intervals, with an AUC between 0.691 and 0.833.

SIGNIFICANCE

ADFA, particularly of the acceleration scaling exponent, may be a useful clinical diagnostic tool for monitoring neonatal stress.

On the feasibility of accessing acute pain-related facial expressions in the human fetus and its potential implications: a case report

Supplemental Digital Content is Available in the Text.

Introduction:

Although pain facial assessment is routinely performed in term and preterm newborns by the use of facial expression–based tools such as the Neonatal Facial Coding System, the assessment of pain during the intrauterine life has not been extensively explored.

Objective:

Describe for the first time, an experimental model to assess and quantify responses due to acute pain in fetuses undergoing anaesthesia for intrauterine surgery recorded by high-resolution 4D ultrasound machines.

Methods/results-case report:

A 33-year-old pregnant woman had congenital left diaphragmatic hernia of poor prognosis diagnosed, and her fetus was treated by fetoscopic endotracheal occlusion. Later, during the removal of the fetal endotracheal balloon by ultrasound-guided puncture, we have recorded facial expressions of the foetus before and after the anaesthetic puncture by the use of 4D ultrasound recordings, which were presented to 3 blinded coders instructed to use the Neonatal Facial Coding System for acute pain facial coding. The procedure was safe and feasible.

Conclusion:

This is the first description of a recordable acute pain model in the human fetus by the use of a facial expression–based tool. The possibility to assess pain-related intrauterine behaviours would allow not only for the monitoring of the efficacy of anaesthetic procedures in the fetus but would also open the way to explore the evolution of pain-related facial responses during the fetal neurodevelopment. This method may pave the way for objective assessments of pain in fetuses, should it endure the steps of formal validation studies.

Effects of breast milk on pain severity during muscular injection of hepatitis B vaccine in neonates in a teaching hospital in Iran

INTRODUCTION AND AIMS

Human breast milk is a natural pain reliever that contains endorphins. The aim of this study was to compare the effects of breast milk and powdered milk on pain severity after a muscular injection in 1-day-old neonates.

MATERIALS AND METHODS

One hundred neonates admitted to a teaching hospital in Ilam city, Iran, participated in a randomized clinical trial in 2016. One-day-old neonates were divided into four equal groups including: the control group (no feeding); the breastfed group; the bottle-fed mother's milk group and the powdered formula group. All infants received the hepatitis B vaccine by muscle injection in the same position of the thigh. The severity and duration of pain were compared among all groups during and after injection using the DAN scoring method (evaluation behavioral scale of acute pain in newborn infant).

RESULTS

One hundred neonates (57% boys) participated in this study. The mean±SD age and weight for participants were 39.15±0.05 weeks and 3016±28g, respectively. Crying duration either during or after the injection in breastfed infants was significantly shorter compared to the control and powdered formula groups (9.2±3.9 and 16±4.6s vs. 38.2±8.9 and 30.0±4.4s, respectively, during injection, P<0.003); (11.8±3.4 and 20.6±5.1s vs. 56.2±6.5 and 49.8±9.6s, respectively, after injection, P<0.006). There was also a significant relationship between behavioral variations and pain during injection (P<0.0001).

CONCLUSIONS

The results of this study showed that breastfeeding decreases pain severity during painful experiences in neonates, which is in accordance with other reports. Based on this finding, neonates are advised to be breastfed if a painful intervention such as vaccination is needed. The pain-relieving effect of breast milk could also be added to its other suitable effects.

Cost savings with transcutaneous screening versus total serum bilirubin measurement for newborn jaundice in hospital and community settings: a cost-minimization analysis

BACKGROUND

Leading authorities in North America recommend universal screening via total serum bilirubin (TSB) measurement or transcutaneous bilirubinometry (TcB) for kernicterus prevention. We assessed costs associated with these 2 screening methods in hospital and in urban and rural community settings.

METHODS

Our tertiary care centre in Saskatoon, with about 5600 births per year, serves the local population of 300 000; in addition, 30% of patients are referred from outside the local community and surrounding area. We obtained health administrative data for two 6-month periods: before (June 1 to Nov. 30, 2015 [TSB program]) and after (June 1 to Nov. 30, 2016 [TcB-TSB program]) implementation of universal screening with TcB. Data on nurses' time and mileage were collected to assess the mean time for screening and sample transportation. We performed a cost-minimization analysis.

RESULTS

The observed requirement for TSB blood draws decreased by 71.4% after implementation of TcB (1383.2/1000 live births to 397.8/1000 live births), whereas the overall number of screens increased from 1383.2 to 2758.6/1000 live births. The mean time per screen decreased from 12.52 (95% confidence interval [CI] 10.44-14.59) minutes with TSB to 2.94 (95% CI 2.55-3.33) minutes with TcB (p < 0.001). The estimated cost per TcB screen in hospital and community (urban and rural) settings was $3.54 and $3.76, respectively, and the estimated cost per TSB screen in hospital and in urban and rural community settings was $15.82, $50.21 and $65.03, respectively. The estimated overall 6-month savings with the TcB-TSB hospital and community programs were $19 760 and $6417, respectively.

INTERPRETATION

The TcB-TSB program reduced nurses' time to screen and provided immediate results at the point of care. Transcutaneous bilirubinometry reduced the requirement for painful heel pokes while improving access to screening and decreasing the overall program cost.

Tail Docking of Canine Puppies: Reassessment of the Tail's Role in Communication, the Acute Pain Caused by Docking and Interpretation of Behavioural Responses

Simple Summary

Bans or restrictions on non-therapeutic tail docking of canine puppies are becoming more widespread. Justifications for constraining this practice have usually referred to hindrances to the tail contributing to unambiguous communication between different dogs, the marked acute pain presumed to be experienced during the docking procedure itself, the subsequent occurrence of chronic pain and heightened pain sensitivity, and other harmful complications. The present re-examination of these matters led to the following conclusions: first, the contribution the tail makes to canine communication has been seriously underestimated; second, the capacity of puppies to consciously experience any pain at the early ages docking is usually conducted has been markedly overestimated; third, the probability that docking causes significant chronic pain and an ongoing heightened pain sensitivity is reaffirmed as high; and fourth, other harmful effects are apparent, but their prevalence is not well documented. Nevertheless, it is concluded that, overall, the life-long negative welfare impacts of tail docking in puppies, especially impacts associated with impaired communication, as also the occurrence of chronic pain and heightened pain sensitivity, still strongly justify banning or restricting docking unless it is undertaken for therapeutic purposes.

Abstract

Laws, regulations and professional standards increasingly aim to ban or restrict non-therapeutic tail docking in canine puppies. These constraints have usually been justified by reference to loss of tail participation in communication between dogs, the acute pain presumed to be caused during docking itself, subsequent experiences of chronic pain and heightened pain sensitivity, and the occurrence of other complications. These areas are reconsidered here. First, a scientifically robust examination of the dynamic functional foundations, sensory components and key features of body language that are integral to canine communication shows that the role of the tail has been greatly underestimated. More specifically, it shows that tail behaviour is so embedded in canine communication that docking can markedly impede unambiguous interactions between different dogs and between dogs and people. These interactions include the expression of wide ranges of both negative and positive emotions, moods and intentions that are of daily significance for dog welfare. Moreover, all docked dogs may experience these impediments throughout their lives, which challenges assertions by opponents to such bans or restrictions that the tail is a dispensable appendage. Second, and in contrast, a re-examination of the sensory capacities of canine puppies reveals that they cannot consciously experience acute or chronic pain during at least the first week after birth, which is when they are usually docked. The contrary view is based on questionable between-species extrapolation of information about pain from neurologically mature newborns such as calves, lambs, piglets and human infants, which certainly can consciously experience pain in response to injury, to neurologically immature puppies which remain unconscious and therefore unable to experience pain until about two weeks after birth. Third, underpinned by the incorrect conclusion that puppies are conscious at the usual docking age, it is argued here that the well-validated human emotional drive or desire to care for and protect vulnerable young, leads observers to misread striking docking-induced behaviour as indicating that the puppies consciously experience significant acute pain and distress. Fourth, updated information reaffirms the conclusion that a significant proportion of dogs docked as puppies will subsequently experience persistent and significant chronic pain and heightened pain sensitivity. And fifth, other reported negative consequences of docking should also be considered because, although their prevalence is unclear, when they do occur they would have significant negative welfare impacts. It is argued that the present analysis strengthens the rationale for such bans or restrictions on docking of puppies by clarifying which of several justifications previously used are and are not scientifically supportable. In particular, it highlights the major roles the tail plays in canine communication, as well as the lifetime handicaps to communication caused by docking. Thus, it is concluded that non-therapeutic tail docking of puppies represents an unnecessary removal of a necessary appendage and should therefore be banned or restricted.

Small-fiber neuropathy and pain sensitization in survivors of pediatric acute lymphoblastic leukemia

BACKGROUND

Chemotherapy-induced Peripheral Neuropathy (CIPN) of large-fibers affects up to 20% of survivors of pediatric acute lymphoblastic leukemia (ALL). We aimed to describe small-fiber toxicity and pain sensitization in this group.

METHODS

In a cross-sectional, bicentric study we assessed 46 survivors of pediatric ALL (Mean age: 5.7 ± 3.5 years at diagnosis, median 2.5 years after therapy; males: 28).

INCLUSION CRITERIA

≥6 years of age, ≥3 months after last administration of Vincristine, and cumulative dose of Vincristine 12 mg/m². We used a reduced version of the Pediatric-modified Total Neuropathy Score (Ped-mTNS) as bedside test and Quantitative Sensory Testing (QST) for assessment of small- and large-fiber neuropathy as well as pain sensitization. We employed Nerve Conduction Studies (NCS) as the most accurate tool for detecting large-fiber neuropathy.

RESULTS

Fifteen survivors (33%) had abnormal rPed-mTNS values (≥4 points) and 5 survivors (11%) reported pain. In QST, the survivor group showed significant (p < 0.001) inferior large-fiber function and pain sensitization when compared to healthy matched peers. We identified deficits of vibration in 33 (72%) and tactile hypoesthesia in 29 (63%), hyperalgesia to blunt pressure in 19 (41%), increased mechanical pain sensitivity in 12 (26%) and allodynia in 16 (35%) of 46 survivors. Only 7 survivors (15%) had pathologic NCS.

CONCLUSION

QST is a sensitive tool that revealed signs of large-fiber neuropathy in two thirds, small-fiber neuropathy and pain sensitization in one third of survivors. Prospective studies using QST in pediatric oncology may help to elucidate the pathophysiology of small-fiber neuropathy and pain sensitization as well as their relevance for quality of survival.

Pediatric Cardiac Surgery and Pain Management: After 40 Years in the Desert, Have We Reached the Promised Land?

Pain prevention in the pediatric population is mandatory and an integrative aspect of medical practice. Optimal pain management is the right of all patients and the responsibility of all health professionals. The key to adequate pain management is assessing its presence and severity, identifying those who require intervention, and appreciating treatment efficacy. The population of pediatric patients undergoing cardiac surgery is unique in both clinical severity and hemodynamic response to painful stimuli, thus making pain management even more challenging. In this review, we will describe the different pain assessment tools as well as intra- and postoperative regimens of pain management.

A review of factors affecting analgesic selection in large animals undergoing translational research

The widespread physiological effects of pain in experimental animals are likely to reduce the validity of data except when pain itself is studied. Appropriately prescribed analgesics will limit pain and improve the welfare of animals undergoing noxious experimental procedures. However, their injudicious use may also introduce variability in data and limit study reproducibility. Optimizing both animal welfare and the value of scientific data from experimental studies requires the ability to identify, quantify and treat animal pain by applying a knowledge of analgesic pharmacology that is sympathetic to study objectives. This review first examines the reasons for promoting analgesic use in translational animal research and, in focussing on pigs and small ruminants, then identifies factors that should be considered when devising analgesic plans.

Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients

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.

Non-sedation of the neonate for radiologic procedures

On Dec. 16, 2016, the U.S. Food and Drug Administration (FDA) released a warning regarding the potential neurotoxicity of anesthesia and sedation agents on the developing brain in children younger than 3 years and in women during their 3rd trimester of pregnancy. These concerns have relevance to the pediatric radiologist who must take into consideration how the child's state might impact image quality. In this review the author provides background on the special concerns in the potentially highest-risk group, pre-term and term neonates, and provides guidance and rationale for the avoidance of sedation in procedural imaging of the newborn.

Clinical trial designs and models for analgesic medications for acute pain in neonates, infants, toddlers, children, and adolescents: ACTTION recommendations

Clinical trials to test the safety and efficacy of analgesics across all pediatric age cohorts are needed to avoid inappropriate extrapolation of adult data to children. However, the selection of acute pain models and trial design attributes to maximize assay sensitivity, by pediatric age cohort, remains problematic. Acute pain models used for drug treatment trials in adults are not directly applicable to the pediatric age cohorts-neonates, infants, toddlers, children, and adolescents. Developmental maturation of metabolic enzymes in infants and children must be taken into consideration when designing trials to test analgesic treatments for acute pain. Assessment tools based on the levels of cognitive maturation and behavioral repertoire must be selected as outcome measures. Models and designs of clinical trials of analgesic medications used in the treatment of acute pain in neonates, infants, toddlers, children, and adolescents were reviewed and discussed at an Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) Pediatric Pain Research Consortium consensus meeting. Based on extensive reviews and continuing discussions, the authors recommend a number of acute pain clinical trial models and design attributes that have the potential to improve the study of analgesic medications in pediatric populations. Recommendations are also provided regarding additional research needed to support the use of other acute pain models across pediatric age cohorts.