Procedural pain and brain development in premature newborns

Effect of Routine Nurse Caregiving on the Stress Responses and Behavior State in Preterm Infants: A Systematic Review

BACKGROUND

Although routine nurse caregiving is vital for the overall health of preterm infants, variations in approaches may exert distinct effects on preterm infants' stress responses and behavior state.

PURPOSE

The purpose of this systematic review was to examine routine nurse caregiving in the neonatal intensive care unit and its effect on stress responses and behavior state in preterm infants.

DATA SOURCES

A systematic search was conducted using PubMed, Embase, and CINAHL for studies published between 2013 and 2023.

STUDY SELECTION

Included studies enrolled preterm infants born <37 weeks gestational age and investigated nurse caregiving practices and effects on stress responses and/or behavior state.

DATA EXTRACTION

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, data about study design, methods, findings, and limitations were extracted and summarized. Included studies were evaluated for bias using the National Health, Lung, and Blood Institute quality assessment tools.

RESULTS

All 13 studies included in the review received a fair quality rating. Nurse caregiving activities, including suctioning, diaper changes, bathing, and weighing, were associated with increases in heart and respiratory rates, blood pressure, energy expenditure, and motor responses, lower oxygen saturations, and fewer sleep states.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Adapting nurse caregiving frequency and duration, aligning caregiving with infant state, and integrating developmental care strategies may reduce infant stress responses and support behavioral rest. Further research is needed to understand how caregiving activities affect stress responses and behavior state in preterm infants, aiding in identifying modifiable caregiving stressors to promote optimal development.

Glucose attenuates the long-term adverse neurodevelopment effect of neonate pain stimulus via CRF/GR in rats

BACKGROUND

Neonates undergo numerous painful procedures throughout their hospitalization. Repeated procedural pain may cause adverse long-term effects. Glucose as a non-pharmacological analgesia, is used for neonate pain management. In this study, potential mechanism of attenuate pain induced by glucose in neurodevelopment effect of neonate pain stimulus was investigated.

METHODS

Neonatal rats to perform a repetitive injury model and glucose intervention model in the postnatal day 0-7(P0-7). Pain thresholds were measured by von Frey test weekly. The puberty behavioral outcome, tissue loss and protein expression in hippocampus were analyzed.

RESULTS

Oral administration of glucose after repeated pain stimulation can maintain the hippocampal structure in, and reduce the expressions of corticotropin releasing factor (CFR) and glucocorticoid receptor (GR), therefore, resulted in long-term threshold of pain and cognitive improvement.

CONCLUSION

Exposure to neonatal repeated procedural pain causes persistent mechanical hypersensitivity and the dysfunction of spatial memory retention at puberty. In addition, glucose can relieve these adverse effects, possibly via decreasing CRF/GR levels to change the hypothalamus-pituitary-adrenal (HPA) axis.

Preterm Sex Differences in Neurodevelopment and Brain Development From Early Life to 8 years

OBJECTIVE

To examine sex differences in neurodevelopmental outcomes and brain development from early life to 8 years in males and females born preterm.

STUDY DESIGN

This was a prospective cohort study of infants born very preterm (24-32 weeks' gestation) and followed to 8 years with standardized measures of neurodevelopment. Brain magnetic resonance imaging (MRI) scans were performed soon after birth, term-equivalent age, and 8 years. The relationship between sex, severe brain injury, early pain exposure, fractional anisotropy (FA), and neurodevelopmental outcomes were assessed using multivariable generalized estimating equations.

RESULTS

Males (N=78) and females (N=66) were similar in clinical risk factors. Male sex was associated with lower cognitive scores (β=-3.8, P=0.02) and greater motor impairment (OR=1.8, P=0.04) across time. Male sex was associated with lower superior white matter FA across time (β=-0.01, P=0.04). Sex moderated the association between severe brain injury, early pain, and neurodevelopmental outcomes. With severe brain injury, males had lower cognitive scores at 3 years (P<0.001). With increasing pain, females had lower cognitive scores at 8 years (P=0.008), and males had greater motor impairment at 4.5 years (P=0.001) and 8 years (P=0.05).

CONCLUSIONS

Males born preterm had lower cognitive scores and greater motor impairment compared with females, which were associated with differences in white matter maturation. The association between severe brain injury, early pain exposure, and neurodevelopmental outcomes was moderated by sex, indicating a differential response to early-life adversity in males and females born preterm.

Neonatal amygdala volumes, procedural pain and the association with social-emotional development in children born very preterm

Very preterm birth (< 32 weeks' gestational age) is associated with later social and emotional impairments, which may result from enhanced vulnerability of the limbic system during this period of heightened vulnerability. Evidence suggests that early procedural pain may be a key moderator of early brain networks. In a prospective cohort study, neonates born very preterm (< 30 weeks' gestation) underwent MRI scanning at term-equivalent age (TEA) and clinical data were collected (mechanical ventilation, analgesics, sedatives). Procedural pain was operationalized as the number of skin breaking procedures. Amygdala volumes were automatically extracted. The Strengths and Difficulties questionnaire was used to assess social-emotional outcomes at 5 years of age (mean age 67.5 months). General linear models were employed to examine the association between neonatal amygdala volumes and social-emotional outcomes and the timing and amount of procedural pain exposure (early within the first weeks of life to TEA) as a moderator, adjusting for biological sex, gestational age, 5-year assessment age, days of mechanical ventilation and total cerebral volumes. A total of 42 preterm infants participated. Right amygdala volumes at TEA were associated with prosocial behaviour at age 5 (B = -0.010, p = 0.005). Procedural pain was found to moderate the relationship between right amygdala volumes in the neonatal period and conduct problems at 5 years, such that early skin breaking procedures experienced within the first few weeks of life strengthened the association between right amygdala volumes and conduct problems (B = 0.005, p = 0.047). Late skin breaking procedures, experienced near TEA, also strengthened the association between right amygdala volumes and conduct problems (B = 0.004, p = 0.048).

Effects of pain, sedation and analgesia on neonatal brain injury and brain development

Critically ill newborns experience numerous painful procedures as part of lifesaving care in the Neonatal Intensive Care Unit. However, painful exposures in the neonatal period have been associated with alterations in brain maturation and poorer neurodevelopmental outcomes in childhood. The most frequently used medications for pain and sedation in the NICU are opioids, benzodiazepines and sucrose; these have also been associated with abnormalities in brain maturation and neurodevelopment making it challenging to know what the best approach is to treat neonatal pain. This article provides clinicians with an overview of how neonatal exposure to pain as well as analgesic and sedative medications impact brain maturation and neurodevelopmental outcomes in critically ill infants. We also highlight areas in need of future research to develop standardized neonatal pain monitoring and management strategies.

The skin microbiota of preterm infants and impact of diaper change frequency

OBJECTIVE

To evaluate the impact of diaper change frequency, clinical characteristics, and skin health metrics on development of the skin microbiota in preterm infants.

DESIGN

A randomized controlled parallel design was used.

METHODS

Medically stable preterm infants born <33 weeks' gestation were randomized to receive diaper changes at a frequency of every 3-hours or every 6-hours. Skin swabs were collected longitudinally from the diapered skin (buttocks) and chest. Skin pH and transepidermal water loss were measured with each sample collection. Stool samples were collected from the diaper. The microbiome at each site was characterized by 16S rRNA gene sequencing. Associations between microbiome features, diaper change frequency, and other covariates were examined using mixed effect models and redundancy analysis.

RESULTS

A total of 1179 samples were collected from 46 preterm infants, beginning at a median postnatal age of 44 days and continuing through hospital discharge. Alpha-diversity of the skin microbiota increased over time, but did not differ significantly between 3-hour (n = 20) and 6-hour (n = 26) diaper change groups. Alpha-diversity of the skin microbiota was inversely correlated with skin pH, but not transepidermal water loss. Microbiota community structure differed significantly between body sites (buttocks, chest, and stool) and between individuals. Among samples collected from the diapered skin, diaper change frequency, infant diet, antibiotic exposure, and delivery mode accounted for minor proportions of the variation in microbiota community structure between samples. Relative abundances of multiple genera differed between 3- and 6-hour diaper change groups over time.

DISCUSSION/CONCLUSION

The diversity and composition of the diapered skin microbiota is dynamic over time and differs from other body sites. Multiple factors including interindividual effects, diaper change frequency, diet, and antibiotics contribute to variation in the diapered skin microbiota.

Effects of automatic heel lancet on invasiveness in neonates: A systematic review and meta-analysis

AIM

We conducted a meta-analysis comparing the invasiveness of automatic lancet devices, which can collect adequate amount of blood at shallow puncture depths, with conventional manual lance devices (lancet or needle) to statistically identify less invasive instruments for neonatal heel lance.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Ichushi databases for studies comparing the invasiveness between automatic lancet and manual lancet or needle in term and preterm neonates in neonatal intensive care unit.

RESULTS

This review included 9 out of 449 searched articles, with 673 neonates. Automatic lancet had significantly lower pain scores (standardised mean difference: -2.0, 95% confidence interval: -3.3 to -0.7), heart rate (mean difference: -8.0, 95% confidence interval: -13.8 to -2.1), cry duration (mean difference: -21.5, 95% confidence interval: -32.5 to -10.4), number of punctures (mean difference: -0.6, 95% confidence interval: -1.1 to -0.2), and duration of procedures (mean difference: -37.7, 95% confidence interval: -75.2 to -0.2) than manual lancet or needle. Furthermore, peripheral oxygen saturation was significantly higher in automatic lancet than in manual lancet or needle (mean difference: 4.5, 95% confidence interval: 0.5-8.5).

CONCLUSION

Automatic heel lancet devices were less invasive than manual heel lance devices (lancet or needle).

Peripheral arterial catheters in extremely preterm infants born at less than 28 weeks of gestation-a single-center experience

The aim of this study was to perform a retrospective data analysis of established peripheral artery catheters (pAC) in extremely preterm infants. The primary outcome was the pAC life span and its correlation to gestational age, birth weight, localizations, and pAC removal. Retrospective data analysis of electronic patient records of all extremely preterm infants (born less than 28 weeks gestation) admitted to the neonatal intensive care unit in Graz (Austria) between January 2014 and December 2020. A total of 196 preterm infants with a median (IQR) gestational age of 25.7 (24.6-26.6) weeks and a birth weight of 730 (614-898) g were included. In 155 (79%) of these preterm infants, 286 pAC and six umbilical artery catheters were inserted successfully. The first pAC was inserted 2.5 (1.4-7.4) h after birth, and the median pAC life span was 57.5 (22.-107.2) h. Gestational age, birth weight, and catheter localization did not correlate with the pAC life span. The pAC localizations were the radial artery (63%), tibial posterior artery (21%), ulnar artery (6%), dorsal artery of the foot (6%), others (1%), and not documented (3%). Adverse reactions including temporarily impaired peripheral perfusion, local inflammation, extravasation, or bleeding were reported in 13% of all pAC, but none of these resulted in long-term sequelae. A median (IQR) of 9 (5-18) arterial blood samples were drawn via pAC, resulting in a notable reduction of pain stimuli.Conclusion: The use of pAC in extremely preterm infants is feasible and safe. Neither gestational age, birth weight nor localization did affect the life span of pAC. No long-term sequelae were observed, and pain events were reduced by using pAC for blood drawing. What is Known: • Peripheral artery catheters can be used for continuous blood pressure measurement and blood draw even in extremely preterm infants. • (Severe) adverse reactions such as bleeding, necrosis, or amputation occur between 1 and 4%. • What is New: • The median peripheral arty catheter life span is 58 h and is not affected by gestational age, birth weight, nor localization. • A median of nine blood samples can be taken per each single pAC and, therefore, prevent pain events in extremely preterm infants.

The Why and How of Family-Centered Care

Although the Accreditation Council for Graduate Medical Education states that neonatal-perinatal medicine fellows must demonstrate an understanding of the emotional impact of admission to the NICU on a family, few curricula are in place to teach this important competency. Family-centered care (FCC) in the NICU is an approach to health care that focuses on decreasing mental and emotional trauma for families while empowering them to reclaim their role as caregivers. FCC is deeply rooted in trauma-informed care and is crucial during transition periods throughout the NICU admission. In this article, we provide a review of FCC and trauma-informed care and how to use these approaches at different stages during an infant's hospitalization. We also discuss parent support networks and how to integrate FCC into an existing NICU practice.

Deep learning to quantify care manipulation activities in neonatal intensive care units

Early-life exposure to stress results in significantly increased risk of neurodevelopmental impairments with potential long-term effects into childhood and even adulthood. As a crucial step towards monitoring neonatal stress in neonatal intensive care units (NICUs), our study aims to quantify the duration, frequency, and physiological responses of care manipulation activities, based on bedside videos and physiological signals. Leveraging 289 h of video recordings and physiological data within 330 sessions collected from 27 neonates in 2 NICUs, we develop and evaluate a deep learning method to detect manipulation activities from the video, to estimate their duration and frequency, and to further integrate physiological signals for assessing their responses. With a 13.8% relative error tolerance for activity duration and frequency, our results were statistically equivalent to human annotations. Further, our method proved effective for estimating short-term physiological responses, for detecting activities with marked physiological deviations, and for quantifying the neonatal infant stressor scale scores.

Evaluation of the Relationship between Pain Exposure and Somatosensory Evoked Potentials in Preterm Infants: A Prospective Cohort Study

BACKGROUND AND AIM

First, to compare somatosensory evoked potentials (SEPs) in preterm newborns without major brain injury studied at term equivalent age (TEA) with a term historical control group. Second, to investigate the impact of pain exposure during the first 28 days after birth on SEPs. Third, to evaluate the association between SEPs and Bayley-III at 2 years corrected age (CA).

METHODS

Infants born at <32 weeks' gestational age (GA) were studied with continuous-SEPs. First, SEP differences between preterm and term infants were analyzed. Second, regression analyses were conducted to explore the association between SEPs and painful procedures, and then between SEPs and neurodevelopment.

RESULTS

86 preterm infants were prospectively enrolled. Preterm infants exhibited prolonged N1 latencies, central conduction times (CCTs), lower N1-P1 amplitudes, and more recurrently abnormal SEPs compared to term infants. Higher pain exposure predicted longer N1 latency and slower CCT (all p < 0.005), adjusting for clinical risk factors. Younger GA and postmenstrual age (PMA) at SEP recording were associated with longer N1 latency and lower N1-P1 amplitude (all p < 0.005). A normal SEP at TEA positively predicted cognitive outcome at 2 years CA (p < 0.005).

CONCLUSION

Pain exposure and prematurity were risk factors for altered SEP parameters at TEA. SEPs predicted cognitive outcome.

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

Grade 7 school performance of children born preterm: a retrospective Canadian Cohort study

IMPORTANCE

Data on the middle school outcomes of preterm children are limited and have methodologic issues.

OBJECTIVE

To study the association between preterm birth and grade 7 school performance.

METHODS

A retrospective population-based cohort study of children born in Manitoba, Canada between 1994 and 2006 using their grade 7 school performance data. A secondary sibling cohort was created comprising children born preterm and their full-term siblings. Primary exposure was preterm birth categorized as <28, 28-33 and 34-36 weeks gestation. The two co-primary grade 7 outcome measures were: not meeting the mathematics competencies, and not meeting the student engagement competencies. Multivariable logistic regression models tested the association between preterm birth and both co-primary outcomes; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

7653 preterm (gestational age median [IQR]: 35 weeks [34,36]) and 110,313 term (40 [39,40]) were included. 43% of < 28 weeks, 18% of 28-33 weeks and 17% of 34-36 weeks had the mathematics co-primary outcome compared to 13% of term children. The corresponding % for the student engagement outcome were 42%, 24%, 24% and 24% respectively. Preterm birth was associated with the mathematics (<28 weeks: 5.48, 3.89-7.70; 28-33 weeks: 1.47, 1.27-1.70; 34-36 weeks: 1.26, 1.16-1.35) and student engagement outcomes (<28 weeks: 2.49, 1.76-3.51; 28-33 weeks: 1.21, 1.06-1.39; 34-36 weeks: 1.09, 1.01-1.16). However, there was no difference in outcomes among the sibling cohort.

CONCLUSIONS AND RELEVANCE

Children born preterm had lower grade 7 performance compared to children born term in this population-based cohort. Screening and supports for them in their middle school years are warranted.

Brain health in preterm infants: importance of early-life pain and analgesia exposure

"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.

A comparison of the effect of procedural pain on cerebral oxygen saturation between late preterm and term infants

OBJECTIVES

We prospectively compared cerebral oxygen saturation (CrSO2) and pain score changes during procedures in late preterm (LPT) versus term infants.

METHODS

Near-infrared spectroscopy, pulse oximetry, Neonatal Infant Pain Scale (NIPS) and Premature Infant Pain Profile-Revised (PIPP-R) scores were assessed and CrSO2 data analyzed.

RESULTS

Thirty infants in each group were evaluated. LPT infants displayed a milder significant drop in Minimum post-procedural CrSO2 and smaller Maximum-Minimum post-procedural CrSO2 disparity. CrSO2 minute changes between the groups were non-significant. Moderate correlations were observed in both groups between NIPS and Minimum post-procedural CrSO2, and a moderate correlation was found in the Maximum-Minimum post-procedural CrSO2 difference in LPT infants. No correlation between PIPP-R and CrSO2 values was noted.

CONCLUSION

LPT and term infants demonstrated decreased CrSO2 in response to painful procedures. Correlations between CrSO2 and PIPP-R or NIPS scores were poor to moderate, reflecting the complex nature of these associations relative to gestational age.

Effect of music-based interventions on physiologic stability of hospitalized preterm infants. A pilot study

BACKGROUND AND OBJECTIVE

Hospitalized preterm infants experience reduced meaningful auditory exposures during a critical period of brain development. Music-based interventions (MBI) may be beneficial, though it remains unclear which stimuli optimally enhance infant stabilization. We investigated the relationship between three conceptually-different MBIs and short-term responses in hospitalized preterm infants.

STUDY DESIGN

This is a case-crossover pilot study including 21 preterm infants between 30 and 35 weeks postmenstrual age. Participants listened to three MBIs and 'no music'; each condition was provided three times in random order. We monitored physiologic and behavioral parameters around each exposure and analyzed results using linear mixed models.

RESULTS

Respiratory rates decreased after each MBI compared with 'no music' (p = 0.02). The most notable decrease occurred following exposure to a low, repetitive musical pattern resembling a lullaby (p = 0.01). We noted no significant changes for the remaining parameters.

CONCLUSION

Specific MBI characteristics may preferentially enhance physiologic stabilization in hospitalized preterm infants.

Sensitivity and Specificity of the Newborn Infant Parasympathetic Evaluation Index in Pain Assessment of Very Low Birth Weight Infants

OBJECTIVE

This article describes the results of a study investigating the sensitivity and specificity of the Newborn Infant Parasympathetic Evaluation (NIPE) index for detecting the physiological changes resulting from nociception in painful procedures in very low birth weight (VLBW) infants.

STUDY DESIGN

A prospective observational study was carried on of 44 newborns at 23 to 32 weeks' gestational age. The sensitivity and specificity of the NIPE index are analyzed using a receiver operating characteristic curve. Most of the painful procedures performed were skin-lancing and venipunctures. Nonpainful procedures consist of no intervention, with an interval of at least 1 hour with painful procedures in each newborn.

RESULTS

The accuracy of the NIPE index to diagnose mild nociceptive stimulation in VLBW newborns is 73.2%.

CONCLUSION

The NIPE index is a useful technique for assessing nociceptive stimulation in newborns, presenting less observer-dependent variability than other pain assessment scales.

KEY POINTS

· The NIPE index offers an objective assessment of pain.. · Moderate-high sensitivity of the NIPE index in the evaluation of pain in premature newborns.. · Painful procedures in VLBW newborns are reflected as a decrease in the NIPE score..

Efficacy of sucrose application in minimizing pain perception related to dental injection in children aged 3 to 9 years: a randomized control trial

Background

Dental fear and anxiety are significant challenges in managing behavior in children. Oral administration of sucrose or sweet-tasting solutions has shown effectiveness in reducing procedural pain in infants and neonates. This study aimed to investigate whether pre-application of sucrose solution had an effect on minimizing pain perception during injection and to assess the potential impact of the child's age and sweet preference.

Methods

A randomized control clinical trial was conducted on 60 children aged 3-9 years requiring buccal infiltration injections. Following parental consent, demographic data of the children were recorded. Sweet preferences was assessed using a modified forced-choice test. Children were equally and randomly allocated into study (sucrose) and control groups using a lottery method. Sucrose solution or distilled water, respectively, was applied to the lateral surface of the tongue for 2 min. Topical anesthetic was applied at the site of injection, followed by local anesthesia administration. The children rinsed their mouths thrice with water immediately after anesthetic injection. A video was recorded during injection which was then scored by three blinded examiners on the Sound Eye Motor (SEM) scale. The children also self-evaluated using Wong-Baker Faces Pain Rating Scale (WBFPS).

Results

The mean SEM scores and WBFPS scores were analyzed using the Kruskall-Wallis test. The mean SEM score in the study group was 1.37 ± 0.61, compared to 3.17 ± 0.87 in the control group, showing a statistically significant difference (P < 0.001). Mean pain scores assessed by WBFPS in the study group were 0.60 ± 1.4, while in the control group, they were 6.27 ± 2.33, also showing a statistically significant difference (P < 0.001). Children with a sweet preference demonstrated a subjective reduction in pain perception.

Conclusion

Application of sucrose before dental injections in children helps to minimize pain upon injection across all age groups.

Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series)

The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.

Pain Exposure and Brain Connectivity in Preterm Infants

Importance

Early-life exposure to painful procedures has been associated with altered brain maturation and neurodevelopmental outcomes in preterm infants, although sex-specific differences are largely unknown.

Objective

To examine sex-specific associations among early-life pain exposure, alterations in neonatal structural connectivity, and 18-month neurodevelopment in preterm infants.

Design, Setting, and Participants

This prospective cohort study recruited 193 very preterm infants from April 1, 2015, to April 1, 2019, across 2 tertiary neonatal intensive care units in Toronto, Canada. Structural connectivity data were available for 150 infants; neurodevelopmental outcomes were available for 123 infants. Data were analyzed from January 1, 2022, to December 31, 2023.

Exposure

Pain was quantified in the initial weeks after birth as the total number of invasive procedures.

Main Outcome and Measure

Infants underwent early-life and/or term-equivalent-age magnetic resonance imaging with diffusion tensor imaging to quantify structural connectivity using graph theory measures and regional connection strength. Eighteen-month neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition. Stratifying by sex, generalized estimating equations were used to assess whether pain exposure modified the maturation of structural connectivity using an interaction term (early-life pain exposure × postmenstrual age [PMA] at scan). Generalized estimating equations were used to assess associations between structural connectivity and neurodevelopmental outcomes, adjusting for extreme prematurity and maternal education.

Results

A total of 150 infants (80 [53%] male; median [IQR] gestational age at birth, 27.1 [25.4-29.0] weeks) with structural connectivity data were analyzed. Sex-specific associations were found between early-life pain and neonatal brain connectivity in female infants only, with greater early-life pain exposure associated with slower maturation in global efficiency (pain × PMA at scan interaction P = .002) and local efficiency (pain × PMA at scan interaction P = .005). In the full cohort, greater pain exposure was associated with lower global efficiency (coefficient, -0.46; 95% CI, -0.78, to -0.15; P = .004) and local efficiency (coefficient, -0.57; 95% CI, -1.04 to -0.10; P = .02) and regional connection strength. Local efficiency (coefficient, 0.003; 95% CI, 0.001-0.004; P = .005) and regional connection strength in the striatum were associated with cognitive outcomes.

Conclusions and Relevance

In this cohort study of very preterm infants, greater exposure to early-life pain was associated with altered maturation of neonatal structural connectivity, particularly in female infants. Alterations in structural connectivity were associated with neurodevelopmental outcomes, with potential regional specificities.

'Baby Liberation' - Developing and implementing an individualised, developmentally-supportive care bundle to critically unwell infants in an Australian Paediatric Intensive Care Unit

BACKGROUND

Infants requiring high acuity care within a Paediatric Intensive Care Unit are at multifactorial risk of neurological injury to the immature brain, resulting in long-term developmental difficulties. In 2020, Queensland Children's Hospital implemented an individualised family-centred developmental care program, 'Baby Liberation', to address an identified service gap for critically unwell infants, aimed at optimising early neuroprotective strategies and minimising risk of suboptimal developmental outcomes.

AIM

To implement Baby Liberation for infants admitted to a quaternary paediatric intensive care referral centre. Secondary aims were to describe environmental changes, enablers and limitations related to implementation.

STUDY DESIGN

A single-centre, prospective implementation pilot study investigated the feasibility of implementing Baby Liberation. Subjects included infants less than six months of age admitted to Queensland Children's Hospital Paediatric Intensive Care Unit.

OUTCOME MEASURES

Primary measures comprised data collected during the implementation period, including number of eligible patients and number of developmental care plans provided. Environmental audit data were collected pre and post implementation to inform secondary outcomes.

RESULTS

Baby Liberation was feasibly implemented into the Queensland Children's Hospital Paediatric Intensive Care Unit. During implementation, 181 individualised care plans were provided to 313 eligible infants (57.8 %). Environmental audits showed improvements in all areas of developmental care, with greatest improvements noted in pain and stress management (+95 %) and staff support and development (+83.3 %).

CONCLUSION

Implementation of Baby Liberation was feasible within a large quaternary paediatric intensive care unit and has potential to be expanded into other clinical areas providing acute infant care.

Optimizing haemoglobin measurements in VLBW newborns: Insights from a comparative retrospective study

INTRODUCTION

Haemoglobin levels assessment is a crucial part of neonatal intensive care practice, the painful experience of repeated heel pricks and venepunctures blood sampling may negatively affect neonatal clinical course. To date the reliability of haemoglobin levels obtained by point-of-care testing (POCT) analysis if compared to standard blood cell count remains controversial.

MATERIALS AND METHODS

Retrospective study conducted on all inborn premature infants (gestational age < 32 weeks) admitted to NICU of the IRCCS Giannina Gaslini Institute during the period May 2021-April 2023. We considered blood samplings occurred within the first 28 days of life recording the laboratory haemoglobin levels (Hblab) (reference method), the point-of-care haemoglobin levels (HbPOCT) (alternative method) and the type of puncture (arterial, venous and capillary). A Bland-Altman analysis was performed to evaluate the Hb agreement, it determines the bias (mean difference between the reference and alternative methods) and limits of agreement (LOA; lower, l-LOA; upper, u-LOA) of measures. An acceptable limit of agreement was 1 g/dl according to the existing literature.

RESULTS

We considered 845 blood samplings from 189 enrolled patients. The comparison between the reference and the alternative method showed a good agreement for the capillary sampling technique with l-LOA of -0.717 (-0.776; -0.659) and u-LOA of 0.549 (0.490; 0.607), these results were not achievable with the other techniques, with LOAs over ±1 g/dl threshold (venous

CONCLUSIONS

The reliability of capillary POCT measured haemoglobin levels may reduce clinical-related costs and the number of painful experiences, with obvious positive effects on the daily neonatal life in the NICU and on the developing brain structures.

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Key Words

• Capillary sampling
• Haemoglobin
• Neurodevelopment
• Newborn
• POCT
• Procedural pain

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MESH Headings

• Infant
• Humans
• Infant, Newborn
• Retrospective Studies
• Reproducibility of Results
• Hemoglobins/analysis
• Point-of-Care Testing
• Infant, Premature

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Affiliation(s)

Andrea Calandrino Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Carolina Montobbio Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy.
Irene Bonato Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Gaia Cipresso Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Francesco Vinci Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Samuele Caruggi Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Marcella Battaglini Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Chiara Andreato Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Federica Mongelli Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Paolo Massirio Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Giorgia Brigati Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Diego Minghetti Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Luca Antonio Ramenghi Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy

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The effect of music on pain management in preterm infants during daily painful procedures: a systematic review and meta-analysis

Background

The present systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to investigate the effects of music on pain management in preterm neonates during painful procedures.

Methods

The PubMed, Embase, Web of Science, EBSCO and Cochrane Library databases were searched to identify relevant articles published from their inception to September 2023. The study search strategy and all other processes were implemented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

Four RCTs that satisfied the inclusion criteria were included in this meta-analysis. The music group had significantly lower Premature Infant Pain Profile (PIPP) scores during (RR = -1.21; 95% CI = -2.02--0.40, p = 0.0032) and after painful procedures (RR = -0.65; 95% CI = -1.06--0.23, p = 0.002). The music group showed fewer changes in PIPP scores after invasive operations than did the control group (RR = -2.06; 95% CI -3.16--0.96; p = 0.0002). Moreover, our results showed that music improved oxygen saturation during (RR = 3.04, 95% CI = 1.64-4.44, p < 0.0001) and after painful procedures (RR = 3.50, 95% CI = 2.11-4.90, p < 0.00001). However, the change in peak heart rate during and after painful procedures was not statistically significant (RR = -12.14; 95% CI = -29.70-5.41 p = 0.18; RR = -10.41; 95% CI = -22.72-1.90 p = 0.10).

Conclusion

In conclusion, this systematic review demonstrated that music interventions are effective for relieving procedural pain in preterm infants. Our results indicate that music can reduce stress levels and improve blood oxygen saturation. Due to the current limitations, large-scale, prospective RCTs should be performed to validate the present results.

Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates

BACKGROUND

Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations. Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain.

OBJECTIVES

To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention.

SEARCH METHODS

We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals.

DATA COLLECTION AND ANALYSIS

Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates. Facilitated tucking versus standard care (four studies) Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD -2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence). Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD -3.06 beats per minute (bpm), 95% CI -9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI -1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD -1.20, 95% CI -3.47 to 1.07; 1 study, 20 infants; low-certainty evidence). Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence). No studies reported intraventricular haemorrhage (IVH). Familiar odour versus standard care (one study) Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD -0.30, 95% CI -2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD -6.30 bpm, 95% CI -16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD -0.80, 95% CI -4.82 to 3.22; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. White noise (one study) White noise during endotracheal suctioning probably has little or no effect on PIPP (MD -0.65, 95% CI -2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD -1.85 bpm, 95% CI -11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI -2.03 to 6.53; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH.

AUTHORS' CONCLUSIONS

Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning. Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.

Pediatricians' focus of sight at pain assessment during a neonatal heel puncture

OBJECTIVE

To evaluate the focus of pediatricians' gaze during the heel prick of neonates.

METHODS

Prospective study in which pediatricians wearing eye tracker glasses evaluated neonatal pain before/after a heel prtick. Pediatricians scored the pain they perceived in the neonate in a verbal analogue numerical scale (0=no pain; 10=maximum pain). The outcomes measured were number and time of visual fixations in upper face, lower face, and hands, in two 10-second periods, before (pre) and after the puncture (post). These outcomes were compared between the periods, and according to pediatricians' pain perception: absent/mild (score: 0-5) and moderate/intense (score: 6-10).

RESULTS

24 pediatricians (31 years old, 92% female) evaluated 24 neonates. The median score attributed to neonatal pain during the heel prick was 7.0 (Interquartile range: 5-8). Compared to pre-, in the post-periods, more pediatricians fixed their gaze on the lower face (63 vs. 92%; p=0.036) and the number of visual fixations was greater on the lower face (2.0 vs. 5.0; p=0.018). There was no difference in the number and time of visual fixations according to the intensity of pain.

CONCLUSIONS

At bedside, pediatricians change their focus of attention on the neonatal face after a painful procedure, focusing mainly on the lower part of the face.

Predictors of Stress Exposure in Hospitalized Preterm Infants

BACKGROUND

Stress exposure in the neonatal intensive care unit (NICU) is associated with poor outcomes in preterm infants. However, factors predicting subsequent NICU stress exposure have not been identified.

PURPOSE

To characterize NICU stressors experienced by preterm infants during the first 2 weeks of life and identify demographic, perinatal, and institutional variables associated with stress exposure.

METHODS

A secondary analysis of data from a nonexperimental, prospective study was conducted using data from 60 very preterm infants born 28 to 31 weeks gestational age. Stress exposures during the first 2 weeks of life, operationalized as number of invasive procedures, were characterized by type and quantity for each infant using data extracted from electronic health records. Associations between number of invasive procedures and demographic, perinatal, or institutional variables were analyzed using linear regressions with robust standard errors.

RESULTS

Preterm infants experienced, on average, 98 (SD = 41.8) invasive procedures. Of these invasive procedures, nasal and/or oral suctioning episodes (58.1%), followed by skin-breaking procedures (32.6%), were most frequent. Differences in the number of invasive procedures were found for maternal race; infants born to Black mothers experienced fewer total invasive procedures than infants born to White mothers. The number of invasive procedures also varied across NICUs.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Preterm infant stress exposure differed by maternal race and NICU, consistent with research findings of differential treatment of diverse infants. Further research is needed to understand the reasons for these differences and to identify best practices to standardize neonatal care.

Experience of early-life pain in premature infants is associated with atypical cerebellar development and later neurodevelopmental deficits

BACKGROUND

Infants born very and extremely premature (V/EPT) are at a significantly elevated risk for neurodevelopmental disorders and delays even in the absence of structural brain injuries. These risks may be due to earlier-than-typical exposure to the extrauterine environment, and its bright lights, loud noises, and exposures to painful procedures. Given the relative underdeveloped pain modulatory responses in these infants, frequent pain exposures may confer risk for later deficits.

METHODS

Resting-state fMRI scans were collected at term equivalent age from 148 (45% male) infants born V/EPT and 99 infants (56% male) born at term age. Functional connectivity analyses were performed between functional regions correlating connectivity to the number of painful skin break procedures in the NICU, including heel lances, venipunctures, and IV placements. Subsequently, preterm infants returned at 18 months, for neurodevelopmental follow-up and completed assessments for autism risk and general neurodevelopment.

RESULTS

We observed that V/EPT infants exhibit pronounced hyperconnectivity within the cerebellum and between the cerebellum and both limbic and paralimbic regions correlating with the number of skin break procedures. Moreover, skin breaks were strongly associated with autism risk, motor, and language scores at 18 months. Subsample analyses revealed that the same cerebellar connections strongly correlating with breaks at term age were associated with language dysfunction at 18 months.

CONCLUSIONS

These results have significant implications for the clinical care of preterm infants undergoing painful exposures during routine NICU care, which typically occurs without anesthesia. Repeated pain exposures appear to have an increasingly detrimental effect on brain development during a critical period, and effects continue to be seen even 18 months later.

Association of Neonatal Midazolam Exposure With Hippocampal Growth and Working Memory Performance in Children Born Preterm

BACKGROUND AND OBJECTIVES

Early exposure to analgesics and sedatives is a key concern for later learning disorders in children. The hippocampus, a key region for learning and memory, may be selectively affected by exposure to benzodiazepines that are commonly used for sedation, particularly in the neonatal period. In this prospective cohort study, the long-term association of neonatal midazolam exposure, a widely used benzodiazepine in neonatal intensive care, with school age hippocampal growth was examined. Higher-order cognitive function in preterm born children was assessed in relation to hippocampal volumes.

METHODS

Very preterm born children underwent MRI to characterize the hippocampus and its subfields and neuropsychological testing. Generalized linear models were used to determine the predictors of 8-year hippocampal volumes. Children were assessed on the Wechsler Abbreviated Scales of Intelligence, Second Edition, and the Wechsler Intelligence Scales for Children, Fifth Edition (WISC-V).

RESULTS

A total of 140 preterm children who were 8 years of age participated, and 25 (18%) were exposed to midazolam as neonates. Reduced hippocampal volumes at age 8 years were associated with neonatal midazolam exposure (B = -400.2, 95% CI -14.37 to -786.03, p = 0.04), adjusting for neonatal clinical care factors. Boys exposed to higher doses of midazolam as neonates had smaller hippocampal volumes (χ2 = 14.4, p = 0.002) compared with nonexposed boys and girls (both, p < 0.03). Analysis of the hippocampal subfields in relation to neonatal midazolam dose revealed that higher doses were associated with smaller volumes of the subiculum (p = 0.008), a hippocampal-cortical relay region implicated in memory processes. Furthermore, smaller school age subiculum volumes predicted significantly lower working memory scores on the WISC-V (B = 0.04, 95% CI 0.01-0.07, p = 0.017).

DISCUSSION

Early midazolam exposure and the association with impaired hippocampal growth seem long-lasting and are most apparent in boys. Alterations in subiculum volumes may underlie hippocampus-dependent memory formation processes in preterm born children exposed to midazolam as neonates.

Serial neuroimaging of brain growth and development in very preterm infants receiving tailored neuropromotive support in the NICU. Protocol for a prospective cohort study

Introduction

Children born very preterm (VP) remain at risk for long-term neurodevelopmental impairment. Patterns of brain growth and injury, and how early neuropromotive therapies might mitigate developmental risk in VP infants remain insufficiently understood.

Methods

This is a prospective cohort study of VP infants born at/before 32 weeks gestation. The study will enroll n = 75 consecutively-born VP infants in a level-III NICU. Exposed infants will be categorized into two groups (group 1: low-risk, n = 25 or group 2: high-risk, n = 25) based on the degree of neurological injury on early brain magnetic resonance imaging (MRI) at enrollment. Infants in the low-risk group (i.e., without significant injury defined as intraventricular hemorrhage with dilation, moderate or severe white matter injury, or cerebellar hemorrhage) will receive neurodevelopmental support utilizing the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, while infants in the high-risk group (with neurological injury) will receive more intensive neurorehabilitative support (SENSE-plus). Age-specific, tailored sensory experiences will be facilitated contingently, preferentially by the infant's family with coaching from NICU staff. VP infants in exposure groups will undergo a brain MRI approximately every 2 weeks from enrollment until term-equivalent to monitor brain growth and evolution of injury. Exposed infants will be compared with a reference group (group 3: n = 25), i.e. VP infants whose families decline initial enrollment in SENSE, and subsequently undergo a term-equivalent brain MRI for other purposes. The primary aim of this study is characterization of term-equivalent brain growth and development among VP infants receiving NICU-based neuropromotive interventions compared to VP infants receiving the standard of care. Secondary aims include defining the timing and factors associated with total and regional brain growth on serial brain MRI among VP infants, (Aim 2), and using early imaging to tailor developmental intervention in the NICU while exploring associations with outcomes in VP infants at discharge and at two years corrected age (Aim 3).

Discussion

This study will address gaps in understanding patterns of brain growth and injury drawing on serial MRI of hospitalized VP infants. These data will also explore the impact of intensive, tailored neuropromotive support delivered prior to term-equivalent on child and family outcomes.

Effects of fentanyl and sucrose on pain in retinopathy examinations with pain scale, near-infrared spectroscopy, and ultrasonography: a randomized trial

BACKGROUND

This study aimed to compare the efficacy of intravenous, intranasal fentanyl and oral sucrose in reducing the pain response during retinopathy of prematurity examinations using premature infant pain profile (PIPP) scores.

METHOD

The study included 42 infants who underwent retinopathy screening examinations. The infants were divided into three groups: oral sucrose, intranasal fentanyl, and intravenous fentanyl. Vital signs (heart rate, arterial oxygen saturation, and mean arterial pressure) were recorded. The PIPP was used to determine pain severity. Cerebral oxygenation and middle cerebral artery blood flow were evaluated using near-infrared spectroscopy and Doppler ultrasonography, respectively. The data obtained were compared between groups.

RESULTS

There was no significant difference between the three groups regarding postconceptional and postnatal ages or birth weights and weight at the time of examination. All babies had moderate pain during the examination. No correlation was observed between analgesia method and pain scores (P = 0.159). In all three groups, heart rate and mean arterial pressure increased, whereas oxygen saturation decreased during the exam compared with pre-examination values. However, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation (sPO2) values did not differ between groups (HR, P = 0.150; MAP, P = 0.245; sPO2, P = 0.140). The cerebral oxygenation (rSO2) values between the three groups were found to be similar [rSO2: P = 0.545, P = 0.247, P = 0.803; fractional tissue oxygen extraction (FTOE): P = 0.553, P = 0.278]. Regarding cerebral blood flow values, we also did not find any difference between the three groups [mean blood flow velocity (Vmean): P = 0.569, P = 0.975; maximum flow velocity (Vmax): P = 0.820, P = 0.997].

CONCLUSIONS

Intravenous and intranasal fentanyl and oral sucrose were not superior to each other in preventing pain during the examination for retinopathy of prematurity (ROP). Sucrose may be a good alternative for pain control during ROP examination. Our findings suggest that ROP exam may not affect cerebral oxygenation or cerebral blood flow. Larger scale studies are needed to determine the best pharmacological option to reduce pain during ROP exams and evaluate the effects of this procedure on cerebral oxygenation and blood flow.

Sucrose analgesia for heel-lance procedures in neonates

BACKGROUND

Sucrose has been examined for calming and pain-relieving effects in neonates for invasive procedures such as heel lance.

OBJECTIVES

To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long-term outcomes SEARCH METHODS: We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries.

SELECTION CRITERIA

We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non-nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin-to-skin care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. We assessed heterogeneity by the I2 test. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD -1.74 (95% CI -2.11 to -1.37); I2 = 62%; moderate-certainty evidence) and 60 seconds after lancing (MD -2.14, 95% CI -3.34 to -0.94; I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD -1.90, 95% CI -8.58 to 4.78; heterogeneity not applicable (N/A); very low-certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD -2.00, 95% CI -2.42 to -1.58; heterogeneity N/A; moderate-certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI -0.30 to 1.50; heterogeneity not applicable; very low-certainty evidence) and on DAN scores at 30 seconds after lancing (MD -1.20, 95% CI -7.87 to 5.47; heterogeneity N/A; very low-certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD -4.90, 95% CI -5.73 to -4.07; heterogeneity not applicable; very low-certainty evidence) and during recovery after lancing (MD -3.80, 95% CI -4.47 to -3.13; heterogeneity N/A; very low-certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD -0.60, 95% CI -1.47 to 0.27; heterogeneity N/A; very low-certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI -0.70 to 1.22; heterogeneity not applicable; low-certainty evidence) and 60 seconds after lancing (MD -0.02, 95% CI -0.79 to 0.75; heterogeneity N/A; low-certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD -0.70, 95% CI -0.49 to 1.88; I2 = 94%; very low-certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD -2.60, 95% CI -3.06 to -2.14; heterogeneity N/A; very low-certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP-R scores compared to expressed breast milk during (MD 0.3, 95% CI -0.24 to 0.84; heterogeneity not applicable; low-certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI -0.11 to 0.71; heterogeneity N/A; low-certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP-R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low-certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD -1.80, 95% CI -8.47 to 4.87; heterogeneity N/A; very low-certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP-R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD -0.86, 95% CI -1.43 to -0.29; heterogeneity N/A; very low-certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD -2.27, 95% CI -4.66 to 0.12; heterogeneity N/A; very low-certainty evidence) and during recovery after lancing (MD -0.31, 95% CI -1.72 to 1.10; heterogeneity N/A; very low-certainty evidence). Sucrose vs skin-to-skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 30 seconds after 1st (MD 0.13, 95% CI -0.70 to 0.96); 2nd (MD -0.56, 95% CI -1.57 to 0.45); or 3rd lancing (MD-0.15, 95% CI -1.26 to 0.96); heterogeneity N/A, low-certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 60 seconds after 1st (MD -0.61, 95% CI -1.55 to 0.33); 2nd (MD -0.12, 95% CI -0.99 to 0.75); or 3rd lancing (MD-0.40, 95% CI -1.48 to 0.68); heterogeneity N/A, low-certainty evidence for all comparisons. Minor adverse events required no intervention.

AUTHORS' CONCLUSIONS

Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate-certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin-to-skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence.

Pharmacological pain and sedation interventions for the prevention of intraventricular hemorrhage in preterm infants on assisted ventilation - an overview of systematic reviews

BACKGROUND

Germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH) may contribute to neonatal morbidity and mortality and result in long-term neurodevelopmental sequelae. Appropriate pain and sedation management in ventilated preterm infants may decrease the risk of GMH-IVH; however, it might be associated with harms.

OBJECTIVES

To summarize the evidence from systematic reviews regarding the effects and safety of pharmacological interventions related to pain and sedation management in order to prevent GMH-IVH in ventilated preterm infants.

METHODS

We searched the Cochrane Library August 2022 for reviews on pharmacological interventions for pain and sedation management to prevent GMH-IVH in ventilated preterm infants (< 37 weeks' gestation). We included Cochrane Reviews assessing the following interventions administered within the first week of life: benzodiazepines, paracetamol, opioids, ibuprofen, anesthetics, barbiturates, and antiadrenergics. Primary outcomes were any GMH-IVH (aGMH-IVH), severe IVH (sIVH), all-cause neonatal death (ACND), and major neurodevelopmental disability (MND). We assessed the methodological quality of included reviews using the AMSTAR-2 tool. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included seven Cochrane Reviews and one Cochrane Review protocol. The reviews on clonidine and paracetamol did not include randomized controlled trials (RCTs) matching our inclusion criteria. We included 40 RCTs (3791 infants) from reviews on paracetamol for patent ductus arteriosus (3), midazolam (3), phenobarbital (9), opioids (20), and ibuprofen (5). The quality of the included reviews was high. The certainty of the evidence was moderate to very low, because of serious imprecision and study limitations. Germinal matrix hemorrhage-intraventricular hemorrhage (any grade) Compared to placebo or no intervention, the evidence is very uncertain about the effects of paracetamol on aGMH-IVH (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.38 to 2.07; 2 RCTs, 82 infants; very low-certainty evidence); midazolam may result in little to no difference in the incidence of aGMH-IVH (RR 1.68, 95% CI 0.87 to 3.24; 3 RCTs, 122 infants; low-certainty evidence); the evidence is very uncertain about the effect of phenobarbital on aGMH-IVH (RR 0.99, 95% CI 0.83 to 1.19; 9 RCTs, 732 infants; very low-certainty evidence); opioids may result in little to no difference in aGMH-IVH (RR 0.85, 95% CI 0.65 to 1.12; 7 RCTs, 469 infants; low-certainty evidence); ibuprofen likely results in little to no difference in aGMH-IVH (RR 0.99, 95% CI 0.81 to 1.21; 4 RCTs, 759 infants; moderate-certainty evidence). Compared to ibuprofen, the evidence is very uncertain about the effects of paracetamol on aGMH-IVH (RR 1.17, 95% CI 0.31 to 4.34; 1 RCT, 30 infants; very low-certainty evidence). Compared to midazolam, morphine may result in a reduction in aGMH-IVH (RR 0.28, 95% CI 0.09 to 0.87; 1 RCT, 46 infants; low-certainty evidence). Compared to diamorphine, the evidence is very uncertain about the effect of morphine on aGMH-IVH (RR 0.65, 95% CI 0.40 to 1.07; 1 RCT, 88 infants; very low-certainty evidence). Severe intraventricular hemorrhage (grade 3 to 4) Compared to placebo or no intervention, the evidence is very uncertain about the effect of paracetamol on sIVH (RR 1.80, 95% CI 0.43 to 7.49; 2 RCTs, 82 infants; very low-certainty evidence) and of phenobarbital (grade 3 to 4) (RR 0.91, 95% CI 0.66 to 1.25; 9 RCTs, 732 infants; very low-certainty evidence); opioids may result in little to no difference in sIVH (grade 3 to 4) (RR 0.98, 95% CI 0.71 to 1.34; 6 RCTs, 1299 infants; low-certainty evidence); ibuprofen may result in little to no difference in sIVH (grade 3 to 4) (RR 0.82, 95% CI 0.54 to 1.26; 4 RCTs, 747 infants; low-certainty evidence). No studies on midazolam reported this outcome. Compared to ibuprofen, the evidence is very uncertain about the effects of paracetamol on sIVH (RR 2.65, 95% CI 0.12 to 60.21; 1 RCT, 30 infants; very low-certainty evidence). Compared to midazolam, the evidence is very uncertain about the effect of morphine on sIVH (grade 3 to 4) (RR 0.08, 95% CI 0.00 to 1.43; 1 RCT, 46 infants; very low-certainty evidence). Compared to fentanyl, the evidence is very uncertain about the effect of morphine on sIVH (grade 3 to 4) (RR 0.59, 95% CI 0.18 to 1.95; 1 RCT, 163 infants; very low-certainty evidence). All-cause neonatal death Compared to placebo or no intervention, the evidence is very uncertain about the effect of phenobarbital on ACND (RR 0.94, 95% CI 0.51 to 1.72; 3 RCTs, 203 infants; very low-certainty evidence); opioids likely result in little to no difference in ACND (RR 1.12, 95% CI 0.80 to 1.55; 5 RCTs, 1189 infants; moderate-certainty evidence); the evidence is very uncertain about the effect of ibuprofen on ACND (RR 1.00, 95% CI 0.38 to 2.64; 2 RCTs, 112 infants; very low-certainty evidence). Compared to midazolam, the evidence is very uncertain about the effect of morphine on ACND (RR 0.31, 95% CI 0.01 to 7.16; 1 RCT, 46 infants; very low-certainty evidence). Compared to diamorphine, the evidence is very uncertain about the effect of morphine on ACND (RR 1.17, 95% CI 0.43 to 3.19; 1 RCT, 88 infants; very low-certainty evidence). Major neurodevelopmental disability Compared to placebo, the evidence is very uncertain about the effect of opioids on MND at 18 to 24 months (RR 2.00, 95% CI 0.39 to 10.29; 1 RCT, 78 infants; very low-certainty evidence) and at five to six years (RR 1.6, 95% CI 0.56 to 4.56; 1 RCT, 95 infants; very low-certainty evidence). No studies on other drugs reported this outcome.

AUTHORS' CONCLUSIONS

None of the reported studies had an impact on aGMH-IVH, sIVH, ACND, or MND. The certainty of the evidence ranged from moderate to very low. Large RCTs of rigorous methodology are needed to achieve an optimal information size to assess the effects of pharmacological interventions for pain and sedation management for the prevention of GMH-IVH and mortality in preterm infants. Studies might compare interventions against either placebo or other drugs. Reporting of the outcome data should include the assessment of GMH-IVH and long-term neurodevelopment.

Morphine exposure and neurodevelopmental outcome in infants born extremely preterm

AIM

To investigate the association between morphine exposure in the neonatal period and neurodevelopment at 2 and 5 years of age while controlling for potential confounders.

METHOD

We performed a retrospective, single-centre cohort study on 106 infants (60 males, 46 females; mean gestational age 26 weeks [SD 1]) born extremely preterm (gestational age < 28 weeks). Morphine administration was expressed as cumulative dose (mg/kg) until term-equivalent age. Neurodevelopmental outcome was assessed at 2 years with the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version and at 5 years with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition, Dutch version. Multiple linear regression analysis was used to assess the association between morphine exposure and outcome.

RESULTS

Sixty-four out of 106 (60.4%) infants included in the study received morphine. Morphine exposure was not associated with poorer motor, cognitive, and language subscores of the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version at 2 years. Morphine exposure was associated with lower Full-Scale IQ scores (p = 0.008, B = -9.3, 95% confidence interval [CI] = -15.6 to -3.1) and Performance IQ scores (p = 0.005, B = -17.5, 95% CI = -27.9 to -7) at 5 years of age.

INTERPRETATION

Morphine exposure in infants born preterm is associated with poorer Full-Scale IQ and Performance IQ at 5 years. Individualized morphine administration is advised in infants born extremely preterm.

Pain and neurodevelopmental outcomes of infants born very preterm

AIM

To investigate the impact of the level of pain experienced by infants born preterm on neurodevelopmental outcomes during their stay in a neonatal intensive care unit.

METHOD

In this retrospective data analysis we included all surviving infants born preterm with a gestational age between 23 and 32 weeks from 2011 to 2015, who were assessed using the Neonatal Pain, Agitation, and Sedation Scale and examined at 1 year of age using the Bayley Scales of Infant Development. We excluded all infants who had suffered severe neurological morbidities and undergone surgical interventions.

RESULTS

A total of 196 infants born preterm were included in the analyses: 105 in the 'no pain group' and 91 in the 'pain group'. Significant differences between the groups were detected for both mental and motor development (p = 0.003, 95% confidence interval [CI] 2.23-10.92; p = 0.025, 95% CI 0.64-9.78). The results remained significant after controlling for other important medical conditions (p = 0.001, 95% CI -19.65 to -5.40; p = 0.010, 95% CI -16.18 to -2.29).

INTERPRETATION

Neonatal pain exposure was associated with altered neurodevelopmental outcomes of infants born very preterm at a corrected age of 12 months. This observation highlights the importance of adequate pain management to reduce the risk of poor neurodevelopmental outcomes in these vulnerable patients.

Evaluation of the effectiveness of sucrose versus xylitol application in minimizing pain related to dental injection in 5-7-year-old children - A randomized controlled pilot study

Background

Oral application of sweet-tasting solutions has found to be effective in minimizing pain on dental injection in children. Xylitol has never been tested in this regard.

Aim

The aim of this study was to compare the effectiveness of prior application of sucrose versus xylitol solution in minimizing pain on dental injection in 5-7-year-old children.

Settings and Design

This study was a randomized controlled clinical trial.

Materials and Methods

Informed consent was taken. A total of 30 children who required maxillary buccal infiltration injection were selected. The children were randomly allocated into the sucrose group, xylitol group, or control group by lottery method. In the sucrose and xylitol groups, 30% sucrose or 30% xylitol solution was applied on the lateral surface of the tongue for 2 min. In the control group, distilled water was applied. In all the groups, the topical anesthetic was applied at the site of injection followed by buccal infiltration. A video was taken during injection, and the sound eye-motor (SEM) scale was recorded by a blinded examiner. Patients were asked to self-evaluate using the Wong-Baker Faces Pain Scale (WBFPS).

Statistical Analysis

Mann-Whitney test was used to analyze the data.

Results

There was a statistically significant difference in the WBFPS and the SEM score between the sucrose and the control group (P < 0.05) and the xylitol and control group (P < 0.05). No statistically significant difference was found between the sucrose and xylitol group.

Conclusion

The application of xylitol solution before dental injection was as effective as sucrose solution in minimizing pain during the injection.

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.

The relationship between NICU stress and neurodevelopmental outcomes of preterm infants: A multi-center prospective cohort study in China

PURPOSE

To examine the relationship between NICU stress exposure and the neurodevelopmental outcomes of preterm infants.

DESIGN AND METHODS

A multicenter, prospective cohort study was conducted between May 2021 and June 2022. Preterm infant participants (28-34 weeks gestational age) were recruited at birth from three NICUs of three tertiary hospitals by convenience sampling. The NICU stress includes acute NICU stress and chronic NICU stress which were measured over the total NICU hospitalization for each infant using the Neonatal Infant Stressor Scale (NISS). Neurodevelopmental outcomes of preterm infants were assessed at 3 months corrected age (CA) using the Ages and Stages Questionnaire, Third Edition (ASQ-3).

RESULTS

Of one hundred and thirty preterm infant participants, 108 preterm infants were included into analysis. Results showed that acute NICU stress exposure significantly predicted the neurodevelopmental abnormalities in communication function (RR: 1.001, 95%CI: 1.000-1.001, p = .011), while chronic NICU stress exposure was significantly associated with the problem-solving function (RR: 1.003, 95%CI: 1.001-1.005, p = .002) at 3 months CA. No significant associations were found between NICU stress exposure and other dimensions of neurodevelopmental outcomes, including gross motor, fine motor, and personal-social functions.

CONCLUSION

NICU stress exposure demonstrated a significant predicting relationship with abnormalities in communication and problem-solving functions of preterm infants at 3 months CA.

PRACTICE IMPLICATIONS

During the NICU hospitalization, neonatal health caregivers should systematically monitor the NICU stress exposure to prevent neurodevelopmental problems in preterm infants.

ASSESSMENT OF NEONATAL CARE STANDARD BY THE PREDICTIVE MODEL FOR RETINOPATHY OF PREMATURITY BASED ON WEIGHT GAIN

Care of extremely premature infants is in constant need for evaluation and progress. WINROP, a predictive model based on weight gain, has been developed to reduce the number of stressful examinations for retinopathy for prematurity. Validation studies of WINROP emphasize the difference of applicability in neonatal units of various practice. The aim of the study was to assess the standard of neonatal care by WINROP. Data on extremely premature infants were collected from medical records and entered in WINROP. High- and low-risk WINROP distribution and retinopathy of prematurity outcomes were analyzed. Fifty-four infants, gestational age ≤28 weeks, were included in the study after exclusion of weight related comorbidities. High risk was noted in 74% (n=40) of infants with 24% (n=13) developing retinopathy of prematurity requiring treatment. In low alarm group, there were 3 cases with severe disease. In conclusion, WINROP is not just a provider of predictive information on the severity of retinopathy of prematurity. High-risk alarm indicates the need of adjustment of nutritional strategies. Infants without pathological growth morbidities who develop severe retinopathy of prematurity in low-risk group point to other risk factors for retinopathy of prematurity to be evaluated and changed in future practice.

Sensory processing and sleep characteristics in preterm infants in the early period of life

OBJECTIVE

The present study aimed to investigate the following: (i) differences in sensory processing and sleep characteristics between preterm infants born at < 32 weeks', vs. those born at ≥ 32 weeks' gestation; (ii) differences in sleep characteristics between preterm infants with typical vs. atypical sensory processing; and (iii) relationship between sensory processing and sleep characteristics in preterm infants at 3 months of age.

METHODS

A total of 189 preterm infants, 54 born at < 32 weeks' gestation (26 females; mean gestational age [standard deviation (SD)], 30.1 [1.7] weeks), and 135 born at ≥ 32 weeks' gestation (78 females; mean gestational age [SD], 34.9 [0.9] weeks) were included in the present study. Sleep characteristics were evaluated using the Brief Infant Sleep Questionnaire, and sensory processing was assessed using the Infant Sensory Profile-2.

RESULTS

There were no significant differences in sensory processing (P > 0.05) or sleep characteristics (P > 0.05) between the preterm groups; however, more infants snored in the <32 weeks' gestation group (P = 0.035). Preterm infants with atypical sensory processing showed lower nighttime (P = 0.027) and total sleep durations (P = 0.032), and higher rates of nocturnal wakefulness (P = 0.038) and snoring (P = 0.001) than preterm infants with typical sensory processing. A significant relationship, therefore, was observed between sensory processing and sleep characteristics (P < 0.05).

CONCLUSIONS

Sensory processing patterns may play an important role in understanding sleep problems in preterm infants. The early detection of sleep problems and sensory processing difficulties are necessary for early intervention.

Assessment and management of neonatal pain: a best practice implementation project

BACKGROUND AND AIMS

Neonates are exposed to varying degrees of pain during their hospitalization, which are going to have a profound impact on their lives. Interventions to alleviate neonatal pain are inadequate and inconsistent. The project aims to promote evidence-based practice (EBP) for the assessment and management of neonatal patients with acute pain and to evaluate the impact of these practices on neonatal pain in hospital.

METHODS

The current project was conducted in the neonatal department of a tertiary hospital in China. Five audit criteria were developed for baseline and follow-up audits. The project used the JBI PACES software and JBI's Getting Research into Practice audit and feedback tool to take evidence-based healthcare into practice. A total of 100 neonates with acute pain procedures were evaluated at baseline and follow-up audit.

RESULTS

The results showed a poor compliance of the five audit indicators in the baseline audit and a significantly improved compliance of the five audit indicators in the follow-up audit. Compared to the baseline audit, audit criterion 1 increased from 0% to 86.1%, audit criterion 2 increased from 36.1% to 82.5%, audit criterion 3 increased from 12% to 61%, audit criterion 4 increased from 0% to 66%, and audit criterion 5 increased from 6% at baseline to 71% in the follow-up audit.

CONCLUSION

The project found that EBP can help nursing staff effectively manage neonatal patients who are experiencing acute painful operations. Further studies are necessary to ensure the sustainability of the criteria in the project.

Early-life exposure to analgesia and 18-month neurodevelopmental outcomes in very preterm infants

BACKGROUND

We assessed variability of analgesic use across three tertiary neonatal intensive care units (NICUs) accounting for early-life pain, quantified as number of invasive procedures. We also determined whether analgesia exposure modifies associations between early-life pain and neurodevelopment.

METHODS

Multicenter prospective study of 276 very preterm infants (born <24-32 weeks' gestational age [GA]). Detailed data of number of invasive procedures and duration of analgesia exposure were collected in initial weeks after birth. Eighteen-month neurodevelopmental assessments were completed in 215 children with Bayley Scales for Infant Development-Third edition.

RESULTS

Multivariable linear regressions revealed significant differences in morphine use across sites, for a given exposure to early-life pain (interaction p < 0.001). Associations between early-life pain and motor scores differed by duration of morphine exposure (interaction p = 0.01); greater early-life pain was associated with poorer motor scores in infants with no or long (>7 days) exposure, but not short exposure (≤7 days).

CONCLUSIONS

Striking cross-site differences in morphine exposure in very preterm infants are observed even when accounting for early-life pain. Negative associations between greater early-life pain and adverse motor outcomes were attenuated in infants with short morphine exposure. These findings emphasize the need for further studies of optimal analgesic approaches in preterm infants.

IMPACT

In very preterm neonates, both early-life exposure to pain and analgesia are associated with adverse neurodevelopment and altered brain maturation, with no clear guidelines for neonatal pain management in this population. We found significant cross-site variability in morphine use across three tertiary neonatal intensive care units in Canada. Morphine use modified associations between early-life pain and motor outcomes. In infants with no or long durations of morphine exposure, greater early-life pain was associated with lower motor scores, this relationship was attenuated in those with short morphine exposure. Further trials of optimal treatment approaches with morphine in preterm infants are warranted.

Current pain management practices for preterm infants with necrotizing enterocolitis: a European survey

BACKGROUND

Necrotizing enterocolitis (NEC) is a highly painful intestinal complication in preterm infants that requires adequate pain management to prevent short- and long-term effects of neonatal pain. There is a lack of international guidelines for pain management in NEC patients. Therefore, this study aims to describe current pain management for NEC patients in European neonatal intensive care units (NICUs).

METHODS

An online survey was designed and conducted to assess current practices in pain management for NEC patients in European NICUs. The survey was distributed via neonatal societies, digital platforms, and professional contacts.

RESULTS

Out of the 259 responding unique European NICUs from 36 countries, 61% had a standard protocol for analgesic therapy, 73% assessed pain during NEC, and 92% treated NEC patients with intravenous analgosedatives. There was strong heterogeneity in the used pain scales and initial analgesic therapy, which mainly included acetaminophen (70%), fentanyl (56%), and/or morphine (49%). A third of NICU representatives considered their pain assessment adequate, and half considered their analgesic therapy adequate for NEC patients.

CONCLUSIONS

Various pain scales and analgesics are used to treat NEC patients in European NICUs. Our results provide the first step towards an international guideline to improve pain management for NEC patients.

IMPACT

This study provides an overview of current pain management practices for infants with necrotizing enterocolitis (NEC) in European neonatal intensive care units. Choice of pain assessment tools, analgosedatives, and dosages vary considerably among NICUs and countries. A third of NICU representatives were satisfied with their current pain assessment practices and half of NICU representatives with their analgesic therapy practices in NEC patients in their NICU. The results of this survey may provide a first step towards developing a European pain management consensus guideline for patients with NEC.

The effectiveness of repeated sucrose for procedural pain in neonates in a longitudinal observational study

Goal

To determine the analgesic effectiveness of repeated sucrose administration for skin-breaking (SB) procedures over the Neonatal Intensive Care Unit (NICU) hospitalization of preterm infants.

Methods

Longitudinal observational study, conducted in four level III Canadian NICUs. Eligible infants were <32 weeks gestational age at birth, and <10 days of life at enrollment. Infants received 24% sucrose (0.12 ml) prior to all painful procedures. The Premature Infant Pain Profile - Revised (PIPP-R) was used at 30 and 60 seconds after a medically-required SB procedure as soon as possible after enrollment and weekly up to three additional times for scheduled procedures.

Results

172 infants (57.3% male, gestational age 28.35 (±2.31) weeks) were included. The mean 30 s PIPP-R scores were 6.11 (±3.68), 5.76 (±3.41), 6.48 (±3.67), and 6.81 (±3.69) respectively; there were no statistically significant interactions of study site by time (p = 0.31) or over time (p = 0.15). At 60 s, mean PIPP-R scores were 6.05 (±4.09), 5.74 (±3.67), 6.19 (±3.7), and 5.99 (±3.76) respectively; there were no study site by time interactions (p = 0.14) or differences over time (p = 0.52). There was a statistically significant site difference in the effectiveness of sucrose at 30 and 60 seconds (p < 0.01).

Conclusions

Consistently low PIPP-R scores following a skin-breaking procedure indicated that the analgesic effectiveness of the minimal dose of sucrose was sustained over time in the NICU. Further research is required to determine the optimal combination of sucrose and other pain management strategies to improve clinical practice and the impact of consistent use of repeated use of sucrose on neurodevelopment.

COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates?

OBJECTIVE

We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain.

STUDY DESIGN

This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity.

RESULT

Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively.

CONCLUSION

The COMFORTneo can be used to reliably and validly assess pain in NICU patients.

Quantification of stress exposure in very preterm infants: Development of the NeO-stress score

BACKGROUND

Stress during treatment at the Neonatal Intensive Care Unit (NICU) has long-term negative consequences on preterm infants' development.

AIMS

We developed an instrument suited to validly determine the cumulative stress exposure for preterm infants in a NICU.

STUDY DESIGN

This survey study made use of two consecutive questionnaires.

SUBJECTS

NICU nurses and physicians from the nine NICUs in the Netherlands.

OUTCOME MEASURES

First, respondents rated the relevance of 77 items encompassing potentially stressful procedures, commented on their comprehensibility and the comprehensiveness of the list. We calculated the content validity per item (CVI-I) and included only the relevant items in a second questionnaire in which the participants rated the stressfulness from 0 (not stressful) to 10 (extremely stressful). A stressfulness index - representing the median score - was calculated for each included item.

RESULTS

Based on the CVI-I of the 77 items, step 1 resulted in 38 items considered relevant to quantify stress in preterm infants during the first 28 days of life. This list of 38 items exists of 34 items with a CVI-I if 0.78 or higher, one of these items was split into two items, and three items were added to improve comprehensiveness. The stressfulness index ranged from five to nine.

CONCLUSIONS

The NeO-stress score consists of stressful items including their severity index and was developed to determine cumulative stress exposure of preterm infants. Evaluating the cross-cultural validity, correlating it to behavioural and biological stress responses, and evaluating its ability to predict preterm infants at risk for the negative effects following stress might expand the possibilities for this instrument.

A Bedside Method for Measuring Effects of a Sedative Drug on Cerebral Function in Newborn Infants

BACKGROUND

Data on the cerebral effects of analgesic and sedative drugs are needed for the development of safe and effective treatments during neonatal intensive care. Electroencephalography (EEG) is an objective, but interpreter-dependent method for monitoring cortical activity. Quantitative computerized analyses might reveal EEG changes otherwise not detectable.

METHODS

EEG registrations were retrospectively collected from 21 infants (mean 38.7 gestational weeks; range 27-42) who received dexmedetomidine during neonatal care. The registrations were transformed into computational features and analyzed visually, and with two computational measures quantifying relative and absolute changes in power (range EEG; rEEG) and cortico-cortical synchrony (activation synchrony index; ASI), respectively.

RESULTS

The visual assessment did not reveal any drug effects. In rEEG analyses, a negative correlation was found between the baseline and the referential frontal (rho = 0.612, p = 0.006) and parietal (rho = -0.489, p = 0.035) derivations. The change in ASI was negatively correlated to baseline values in the interhemispheric (rho = -0.753; p = 0.001) and frontal comparisons (rho = -0.496; p = 0.038).

CONCLUSION

Cerebral effects of dexmedetomidine as determined by EEG in newborn infants are related to cortical activity prior to DEX administration, indicating that higher brain activity levels (higher rEEG) during baseline links to a more pronounced reduction by DEX. The computational measurements indicate drug effects on both overall cortical activity and cortico-cortical communication. These effects were not evident in visual analysis.

Effectiveness of parental education about pain in the neonatal period on knowledge, attitudes, and practices: A systematic review and meta-analysis

Background

Despite the availability of effective, safe, and feasible pain management strategies, infant pain remains undertreated. Parents can play a key role in advocating for or delivering pain management strategies if they are educated. To date, a quantitative synthesis of the effectiveness of parental education about pain management in the neonatal period has not been performed.

Objective

To systematically review the effectiveness of parental education during the neonatal period on pain management in infancy.

Methods

MEDLINE, EMBASE, PsycInfo, CINAHL, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) and non-randomized trials (NRTs) that evaluated parental education with respect to pain management during the neonatal period in any setting from inception to February 2021. Screening of article titles and abstracts and data extraction were performed in duplicate. The risk of bias was assessed using the Cochrane Risk Bias Tool 2.0 and the Risk of Bias in Non-randomized Studies of Interventions for RCTs and NRTs, respectively. As per the GRADE methodology, critically important and important outcomes were identified. Critically important outcomes included utilization of pain management strategies and infant pain. Important outcomes included parental knowledge about pain mitigation strategies, parental attitudes, compliance with painful procedures, procedure outcomes, and safety. Data were combined and presented as relative risk (RR) or mean or standardized mean difference (MD or SMD) with 95% confidence interval (CI).

Results

Of the six studies eligible for inclusion, four studies were RCTs and two studies were NRTs. Written information and/or video were used to deliver parental education during the neonatal period in hospital settings in all studies. Four studies (two RCTs and two NRTs) reported on critically important outcomes. The risk of bias was low for the two RCTs and moderate to serious for the two NRTs. Utilization of pain management strategies was assessed for heel lance in the first 48 hours of life in two studies and for vaccine injection at 2 to 6 months of life in two studies. Higher utilization rate for pain management strategies was reported in the pain education group in three studies (RR 1.15, 95% CI 1.04, 1.26; N=2712). There was no difference in the mean number of pain management strategies used in one NRT tracking utilization tracking utilization as continuous data (MD 0.20, 95% CI -0.01, 0.41; N=178). Parent-reported infant pain scores were lower in the pain education group in one RCT (MD -0.16, 95% CI -0.27, -0.06; N=1615). The quality of evidence for the outcome of utilization of pain management strategies was very low while for the outcome of infant pain the quality of evidence was moderate. Five studies (3 RCTs and 2 NRTs) reported on important outcomes. The risk of bias was low for two RCTs and high for one RCT and moderate to serious for the two NRTs. Parental knowledge about pain management strategies (SMD 0.54, 95% CI 0.26, 0.82), parental confidence in their ability to manage pain (SMD 0.24, 95% CI 0.14, 0.34), parental satisfaction with education (MD 1.18, 95% CI 0.84, 1.52) and parental satisfaction with pain management (RR 1.05. 95% CI 1.01, 1.08) were increased in the pain education group. None of the included studies reported on procedural outcomes. No adverse events with the pain education nor the use of pain management interventions were reported in one study.

Conclusions

Parental education in the neonatal period was effective in increasing utilization of pain management strategies during painful procedures. Reduction of pain in infants is based on one study of moderate quality. Furthermore, parental education increased parental knowledge about pain management strategies, confidence in their ability to manage infant pain, and satisfaction with the education and pain management. Parental pain education should be incorporated into postnatal care.

Early-life factors associated with neurobehavioral outcomes in preterm infants during NICU hospitalization

BACKGROUND

The aim of this study was to investigate the influence of early-life pain/stress and medical characteristics on neurobehavioral outcomes in preterm infants.

METHODS

A prospective cohort study was conducted with 92 preterm infants (28-32 weeks gestational age [GA]). Early-life pain/stress was measured via the Neonatal Infant Stressor Scale (NISS) during the first 28 days of NICU hospitalization. Neurobehavioral outcomes were evaluated using the NICU Network Neurobehavioral Scale at 36-38 weeks post-menstrual age. Functional regression and machine learning models were performed to investigate the predictors of neurobehavioral outcomes.

RESULTS

Infants experienced daily acute pain/stress (24.99 ± 7.13 frequencies) and chronic events (41.13 ± 17.81 h). Up to 12 days after birth, both higher acute and chronic NISS scores were associated with higher stress scores; and higher chronic NISS scores were also related to lower self-regulation and quality of movement. Younger GA predicted worse neurobehavioral outcomes; GA < 31.57 weeks predicted worse stress/abstinence, self-regulation, and excitability; GA < 30.57 weeks predicted poor quality of movement. A higher proportion of maternal breastmilk intake predicted better self-regulation, excitability, and quality of movement in older GA infants.

CONCLUSIONS

Preterm infants are vulnerable to the impact of early-life pain/stress. Neurobehavioral outcomes are positively associated with increased GA and higher maternal breastmilk intake.

IMPACT

During the first 12 days of life, preterm infant neurobehavioral outcomes were vulnerable to the negative impact of acute and chronic pain/stress. Future research is warranted to investigate the long-term effects of early-life pain/stress on neurobehavioral outcomes. Gestational age remains one of the critical factors to predict neurobehavioral outcomes in preterm infants; older gestational age significantly predicted better neurobehavioral outcomes. Feeding with a higher proportion of maternal breastmilk predicted better neurobehavioral outcomes. Future research is warranted to investigate how maternal breastmilk may buffer the negative effects of early-life pain/stress on neurobehavioral outcomes.

Grade 3 school performance among children born preterm: a population-based cohort study

OBJECTIVE

To study the association between prematurity and grade 3 school performance in a contemporary cohort of children.

METHODS

Population-based retrospective cohort study in Manitoba, Canada. Children born between 1999 and 2011 who had their grade 3 school performance data available were eligible. Preterm birth (<37 weeks) was the exposure of interest assessed using multivariable logistic regression models. Our primary outcomes were 'needs ongoing help' or 'outside the range' in at least two of each of the (1) four numeracy and (2) three reading competencies.

RESULTS

Of the 186 956 eligible children, 101 436 children (7187 preterm (gestational age, median (IQR) 35 weeks (34, 36)) and 94 249 term (40 weeks (39,40)) were included. Overall, 19% of preterm and 14% of term children had the numeracy outcome (adjusted OR (aOR) 1.38; 95% CI 1.29 to 1.47, p<0.001), while 19% and 13% had the reading outcome (aOR 1.38; 1.29 to 1.48, p<0.001). These differences showed a gestational age gradient. Gestational age (for numeracy, <28 weeks aOR 4.93 (3.45 to 7.03), 28-33 weeks 1.72 (1.50 to 1.98), 34-36 weeks 1.24 (1.15 to 1.34); for reading, <28 weeks 3.51 (2.40 to 5.14), 28-33 weeks 1.72 (1.49 to 1.98), 34-36 weeks 1.24 (1.17-1.37)), male sex, small for gestational age and maternal medical and sociodemographic factors were associated with the numeracy and reading outcomes in this cohort.

CONCLUSIONS AND RELEVANCE

Children born preterm had poorer performance in grade 3 numeracy and reading proficiencies than children born full term. All children born preterm, not just those born extremely preterm, should be screened for reading and numeracy performance in school and strategies implemented to address any deficits.