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

Antibiotics, Analgesic Sedatives, and Antiseizure Medications Frequently Used in Critically Ill Neonates: A Narrative Review

Antibiotic, analgesic sedative, and antiseizure medications are among the most commonly used medications in preterm/sick neonates, who are at high risk of nosocomial infections, central nervous system complications, and are exposed to numerous painful/stressful procedures. These severe and potentially life-threatening complications may have serious short- and long-term consequences and should be prevented and/or promptly treated. The reported variability in the medications used in neonates indicates the lack of adequate neonatal studies regarding their effectiveness and safety. Important obstacles contributing to inadequate studies in preterm/sick infants include difficulties in obtaining parental consent, physicians' unwillingness to recruit preterm infants, the off-label use of many medications in neonates, and other scientific and ethical concerns. This review is an update on the use of antimicrobials (antifungals), analgesics (sedatives), and antiseizure medications in neonates, focusing on current evidence or knowledge gaps regarding their pharmacokinetics, indications, safety, dosage, and evidence-based guidelines for their optimal use in neonates. We also address the effects of early antibiotic use on the intestinal microbiome and its association with long-term immune-related diseases, obesity, and neurodevelopment (ND). Recommendations for empirical treatment and the emergence of pathogen resistance to antimicrobials and antifungals are also presented. Finally, future perspectives on the prevention, modification, or reversal of antibiotic resistance are discussed.

Accurate prediction of neurologic changes in critically ill infants using pose AI

Infant alertness and neurologic changes can reflect life-threatening pathology but are assessed by exam, which can be intermittent and subjective. Reliable, continuous methods are needed. We hypothesized that our computer vision method to track movement, pose AI, could predict neurologic changes in the neonatal intensive care unit (NICU). We collected 4,705 hours of video linked to electroencephalograms (EEG) from 115 infants. We trained a deep learning pose algorithm that accurately predicted anatomic landmarks in three evaluation sets (ROC-AUCs 0.83-0.94), showing feasibility of applying pose AI in an ICU. We then trained classifiers on landmarks from pose AI and observed high performance for sedation (ROC-AUCs 0.87-0.91) and cerebral dysfunction (ROC-AUCs 0.76-0.91), demonstrating that an EEG diagnosis can be predicted from video data alone. Taken together, deep learning with pose AI may offer a scalable, minimally invasive method for neuro-telemetry in the NICU.

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.

The Development and Implementation of the Fast-Pace Assessment Framework and Tiered Analgesic Orders for Opioid Optimization

BACKGROUND

Within the context of the opioid epidemic, changes needed to be made in the prescription and administration of analgesics. The purpose of this paper is to describe the development and implementation of a project that utilized a holistic pain assessment framework and introduced new order sets to guide the integration of nonopioid, opioid, and co-analgesics in a quaternary care medical center.

METHODS

An interdisciplinary team updated policies and procedures for pain assessment and opioid administration and created new analgesic order sets for both adult and pediatric patients. Following requisite approvals, these order sets were integrated into the electronic health record. Education of clinicians, patients, and caregivers was provided to facilitate implementation of these new clinical practices.

RESULTS

Prescribers' levels of adherence with the use of the pain order sets ranged from 80% to 90% and no adverse effects were reported. Education of nursing staff was incorporated into hospital orientation. Ongoing evaluations are providing insights into how the new policies and procedures can be optimized to ensure reliable, safe, and effective pain management.

CONCLUSIONS

Since the implementation of the opioid optimization project, adherence with the tiered, multimodal approach to analgesic prescribing is high. Next steps include both qualitative and quantitative evaluations of the benefits and challenges associated with this practice change. For example, systems will be developed to monitor nurses' adherence with the implementation of the pain order sets and the use of both pharmacologic and nonpharmacologic pain management interventions.

Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project

Introduction

Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes.

Methods

An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM.

Results

Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM.

Discussion

Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.

Respiratory outcomes and survival after unplanned extubation in the NICU: a prospective cohort study from the SEPREVEN trial

OBJECTIVE

To compare reintubation rates after planned extubation and unplanned extubation (UE) in patients in neonatal intensive care units (NICUs), to analyse risk factors for reintubation after UE and to compare outcomes in patients with and without UE.

DESIGN

Prospective, observational study nested in a randomised controlled trial (SEPREVEN/Study on Epidemiology and PRevention of adverse EVEnts in Neonates). Outcomes were expected to be independent of the intervention tested.

SETTING

12 NICUs in France with a 20-month follow-up, starting November 2015.

PATIENTS

n=2280 patients with a NICU stay >2 days, postmenstrual age ≤42 weeks on admission.

INTERVENTIONS/EXPOSURE

Characteristics of UE (context, timing, sedative administration in the preceding 6 hours, weaning from ventilation at time of UE) and patients.

MAIN OUTCOME MEASURES

Healthcare professional-reported UE rates, reintubation/timing after extubation, duration of mechanical ventilation, mortality and bronchopulmonary dysplasia (BPD).

RESULTS

There were 162 episodes of UE (139 patients, median gestational age (IQR) 27.3 (25.6-31.7) weeks). Cumulative reintubation rates within 24 hours and 7 days of UE were, respectively, 50.0% and 57.5%, compared with 5.5% and 12.3% after a planned extubation. Independent risk factors for reintubation within 7 days included absence of weaning at the time of UE (HR, 95% CI) and sedatives in the preceding 6 hours (HR 1.93, 95% CI 1.04 to 3.60). Mortality at discharge did not differ between patients with planned extubation or UE. UE was associated with a higher risk of BPD.

CONCLUSION

In the SEPREVEN trial, reintubation followed UE in 58% of the cases, compared with 12% after planned extubation.

TRIAL REGISTRATION NUMBER

NCT02598609.

Dangerous Things We Used to Do in Neonatology

Neonatology has been a rapidly growing specialty, starting in the early 1900s with premature infants displayed in incubator shows, to today with complex disease processes treated in state-of-the-art neonatal intensive care units. Along the way evolving knowledge, medications, and technology provided opportunities to learn from mistakes and misguided treatments. The ability to learn from past mistakes improves our care now and illustrates the need for humility and vigilance in everything we do. This article explores errors made in the past as we look forward to the future.

Should secondary pharmacogenomic variants be actively screened and reported when diagnostic genome-wide sequencing is performed in a child?

This white paper was prepared by the Global Alliance for Genomics and Health Regulatory and Ethics Work Stream's Pediatric Task Team to review and provide perspective with respect to ethical, legal, and social issues regarding the return of secondary pharmacogenomic variants in children who have a serious disease or developmental disorder and are undergoing exome or genome sequencing to identify a genetic cause of their condition. We discuss actively searching for and reporting pharmacogenetic/genomic variants in pediatric patients, different methods of returning secondary pharmacogenomic findings to the patient/parents and/or treating clinicians, maintaining these data in the patient's health record over time, decision supports to assist using pharmacogenetic results in future treatment decisions, and sharing information in public databases to improve the clinical interpretation of pharmacogenetic variants identified in other children. We conclude by presenting a series of points to consider for clinicians and policymakers regarding whether, and under what circumstances, routine screening and return of pharmacogenomic variants unrelated to the indications for testing is appropriate in children who are undergoing genome-wide sequencing to assist in the diagnosis of a suspected genetic disease.

Challenges in management of refractory pain and sedation in infants

The survival of preterm infants continues to improve, along with an increased in neonatal intensive care unit (NICU) management of chronic infants who are medically complex infants who have prolonged hospital stays, sometimes up until 2 years of age. Despite advances in neonatal and infant care, the management of pain and sedation in chronic NICU patients continues to be a challenge. Challenges such as development of appropriate pain, sedation, and withdrawal scales along with unfamiliarity of the NICU care team with pediatric disease states and pharmacotherapy complicate management of these patients. Opioid induced hyperalgesia (OIH) and delirium may play a large role in these refractory cases, yet are often not considered in the NICU population. Drug therapy interventions such as gabapentin, ketamine, risperidone, and others have limited data for safety and efficacy in this population. This article summarizes the available literature regarding the evidence for diagnosis and management of infants with refractory pain and sedation along with the challenges that clinicians face when managing these patients.

Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication

Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.

Adverse cardiovascular events are common during dexmedetomidine administration in neonates and infants during intensive care

AIM

This study aimed to assess the safety of a commonly used sedative, dexmedetomidine in neonates and infants during intensive care.

METHODS

A retrospective cohort study was conducted in the paediatric intensive care unit at Oulu University Hospital. The study population consisted of all children from birth up to 6 months of age who received dexmedetomidine during 2010-2016. Adverse cardiovascular outcomes were defined as abnormal heart rates or blood pressure values according to the Paediatric Early Warning Score.

RESULTS

Of the 172 infants, 56% had congenital malformation, and 48% had undergone surgery. Neonates and 1-3-month-olds experienced bradycardia (86% vs. 73% in 1-3-month-olds and 50% in 3-6-month-olds, p = 0.001) and severe bradycardia (17% vs. 14% in 1-3-month-olds and 0% in 3-6-month-olds, p = 0.005) more often than older patients. The median maximum rate of dexmedetomidine infusion was 0.86 μg/kg/h (IQR = 0.60-1.71 μg/kg/h). A dose-dependent increase in bradycardia and severe hypotension was found. Adverse cardiovascular events were managed with additional fluid boluses and discontinuation of the infusion.

CONCLUSION

Adverse cardiovascular events were common during dexmedetomidine administration in neonates and infants. Lower dexmedetomidine doses may be required in sedating neonates.

Use of Dexmedetomidine and Opioids in Hospitalized Preterm Infants

Importance

Dexmedetomidine, an α2-adrenergic agonist, is not approved by the Food and Drug Administration for use in premature infants. However, the off-label use of dexmedetomidine in premature infants has increased 50-fold in the past decade. Currently, there are no large studies characterizing dexmedetomidine use in US neonatal intensive care units (NICUs) or comparing the use of dexmedetomidine vs opioids in infants.

Objectives

To describe dexmedetomidine use patterns in the NICU and examine the association between dexmedetomidine and opioid use in premature infants.

Design, Setting, and Participants

A multicenter, observational cohort study was conducted from November 11, 2022, to April 4, 2023. Participants were inborn infants born between 22 weeks, 0 days, and 36 weeks, 6 days, of gestation at 1 of 383 Pediatrix Medical Group NICUs across the US between calendar years 2010 and 2020.

Main Outcome and Measure

Exposure to medications of interest defined as total days of exposure, timing of use, and changes over time.

Results

A total of 395 122 infants were included in the analysis. Median gestational age was 34 (IQR, 32-35) weeks, and median birth weight was 2040 (IQR, 1606-2440) g. There were 384 infants (0.1% of total; 58.9% male) who received dexmedetomidine. Infants who received dexmedetomidine were born more immature, had lower birth weight, longer length of hospitalization, more opioid exposure, and more days of mechanical ventilation. Dexmedetomidine use increased from 0.003% in 2010 to 0.185% in 2020 (P < .001 for trend), while overall opioid exposure decreased from 8.5% in 2010 to 7.2% in 2020 (P < .001 for trend). The median postmenstrual age at first dexmedetomidine exposure was 31 (IQR, 27-36) weeks, and the median postnatal age at first dexmedetomidine exposure was 3 (IQR, 1-35) days. The median duration of dexmedetomidine receipt was 6 (IQR, 2-14) days.

Conclusion and Relevance

The findings of this multicenter cohort study of premature infants suggest that dexmedetomidine use increased significantly between 2010 and 2020, while overall opioid exposure decreased. Future studies are required to further examine the short- and long-term effects of dexmedetomidine in premature and critically ill infants.

Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture (LP) is a common invasive procedure, most frequently performed to diagnose infection. Physicians perform LP in newborn infants with the help of an assistant using a strict aseptic technique; it is important to monitor the infant during all the steps of the procedure. Without adequate analgesia, LP can cause considerable pain and discomfort. As newborns have increased sensitivity to pain, it is crucial to adequately manage the procedural pain of LP in this population.

OBJECTIVES

To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non-pharmacological interventions, or other pharmacological interventions.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, and three trial registries in December 2022. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs comparing drugs used for pain management, sedation, or both, during LP. We considered the following drugs suitable for inclusion. • Topical anesthetics (e.g. eutectic mixture of local anesthetics [EMLA], lidocaine) • Opioids (e.g. morphine, fentanyl) • Alpha-2 agonists (e.g. clonidine, dexmedetomidine) • N-Methyl-D-aspartate (NMDA) receptor antagonists (e.g. ketamine) • Other analgesics (e.g. paracetamol) • Sedatives (e.g. benzodiazepines such as midazolam) DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) or standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). Our main outcomes were successful LP on first attempt, total number of LP attempts, episodes of bradycardia, pain assessed with validated scales, episodes of desaturation, number of episodes of apnea, and number of infants with one or more episodes of apnea. We used the GRADE approach to evaluate the certainty of the evidence.

MAIN RESULTS

We included three studies (two RCTs and one quasi-RCT) that enrolled 206 newborns. One study included only term infants. All studies assessed topical treatment versus placebo or no intervention. The topical anesthetics were lidocaine 4%, lidocaine 1%, and EMLA. We identified no completed studies on opioids, non-steroidal anti-inflammatory drugs, alpha-2 agonists, NMDA receptor antagonists, other analgesics, sedatives, or head-to-head comparisons (drug A versus drug B). Based on very low-certainty evidence from one quasi-RCT of 100 LPs in 76 infants, we are unsure if topical anesthetics (lidocaine), compared to no anesthesia, has an effect on the following outcomes. • Successful LP on first attempt (first-attempts success in 48% of LPs in the lidocaine group and 42% of LPs in the control group) • Number of attempts per LP (mean 1.9 attempts, [standard error of the mean 0.2] in the lidocaine group, and mean 2.1 attempts [standard error of the mean 2.1] in the control group) • Episodes of bradycardia (0% of LPs in the lidocaine group and 4% of LPs in the control group) • Episodes of desaturation (0% of LPs in the lidocaine group and 8% of LPs in the control group) • Occurrence of apnea (RR 3.24, 95% CI 0.14 to 77.79; risk difference [RD] 0.02, 95% CI -0.03 to 0.08). Topical anesthetics compared to placebo may reduce pain assessed with the Neonatal Facial Coding System (NFCS) score (SMD -1.00 standard deviation (SD), 95% CI -1.47 to -0.53; I² = 98%; 2 RCTs, 112 infants; low-certainty evidence). No studies in this comparison reported total number of episodes of apnea. We identified three ongoing studies, which will assess the effects of EMLA, lidocaine, and fentanyl. Three studies are awaiting classification.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of topical anesthetics (lidocaine) compared to no anesthesia on successful lumbar puncture on first attempt, the number of attempts per lumbar puncture, episodes of bradycardia, episodes of desaturation, and occurrence of apnea. Compared to placebo, topical anesthetics (lidocaine or EMLA) may reduce pain assessed with the NFCS score. One ongoing study will assess the effects of systemic treatment.

The physiology, assessment, and treatment of neonatal pain

Studies have clearly shown that development of pain receptors starts as early as 20-weeks' gestation. Despite contrary belief, the human fetus develops a similar number of receptive pain fibers as seen in adults. These receptors' maturation is based on response to sensory stimuli received after birth which makes the NICU a critical place for developing central nervous system's pain perception. In practice, the assessment of pain relies mostly on bedside staff. In this review we will discuss the various developing features of pain pathways in the neonatal brain and the modification of pain perception secondary to various interactions immediately after birth. We also discuss the various tools utilized in the NICU for pain assessment that rely on physiological and behavioral patterns. Finally, we address the management of pain in the NICU by either pharmacological or non-pharmacological intervention while highlighting potential benefits, disadvantages, and situations where one may be preferred over another.

Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view

In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field.    Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.

Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non‐pharmacological interventions, or other pharmacological interventions.

Iatrogenic Withdrawal Syndrome in Critically Ill Neonates: A Review of Mechanisms, Assessment, Management, and Prevention

Considering that neonatal pain is a relevant matter given its implications and consequences, many neonates, particularly those undergoing critical care, are subjected to analgo-sedation therapies, which commonly includes treatment with opioids and benzodiazepines. These drugs, however, can induce tolerance and dependency, leading to the development of the so-called iatrogenic withdrawal syndrome (IWS) which is observed following discontinuation of these therapeutic agents particularly when utilized for a prolonged period of time (≥5 days). IWS consists of signs and symptoms manifested especially in young children, such as term and premature newborns in the neonatal intensive care unit, who are less capable of metabolizing and eliminating these drugs, compared with older patients. In this study, we review assessment tools that were developed to identify, evaluate, and manage children affected by IWS. The studies reviewed demonstrate that optimal management of IWS includes consideration of alternate routes of drug administration, the need for adequate time for drug tapering, and also the presence of planned rescue therapy when encountering cases refractory to ongoing management. Equally important is prevention of IWS which can be accomplished with the implementation of drug rotation protocols and, adherence to evidenced-based guidelines which facilitate an overall decline in the use and duration of opioids and benzodiazepines. Finally, our review strongly supports the need for more research on IWS in neonates given their increased susceptibility and sparse published data for this age group.

Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia

BACKGROUND

Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life.

OBJECTIVES

To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge.

SEARCH METHODS

We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions.  Primary outcomes were analgesia and sedation, and all-cause mortality to discharge.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data.  MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine.

AUTHORS' CONCLUSIONS

We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.

Clinical Application of Restrictive Brace Combined with Psychological Intervention after Replantation of Severed Fingers in Children

Objective

After replantation of severed fingers in infants, the utility model patent upper limb restrictive brace-assisted bed rest braking, combined with psychological intervention, can alleviate children's anxiety, so as to reduce the occurrence of vascular crisis.

Methods

The study period was from April 2015 to July 2018. In this paper, 30 children with finger injuries in hand surgery in the CIS electronic medical record system of Cangzhou Integrated Traditional Chinese and Western Medicine Hospital were selected as the research objects. Replantation was performed in 30 infants with severed fingers. Among them, 15 cases were applied with the method of aircraft chest arm gypsum splint combined with sedative drug braking and the utility model patented product upper limb restrictive brace fixation-assisted bed rest braking, and the method of psychological intervention was applied at the same time.

Results

Among the 15 fingers in the control group, 6 had vascular crisis and 1 in the experimental group. The incidence of vascular crisis in the experimental group was lower, and the difference between the two groups was statistically significant (P < 0.05). The patients were followed up for 9~18 months, with an average of 9.72 ± 1.07 months. In the control group, 15 cases of severed fingers survived, and there were 13 cases of replantation finger necrosis in 2 cases of intractable arterial crisis. In the experimental group, 14 cases of severed fingers survived in 15 cases and there was 1 case of replanted finger necrosis in intractable arterial crisis after operation. There was no significant difference in the survival rate between the two groups (P > 0.05). In addition, the replanted finger function was evaluated. In the control group, 9 cases were excellent, 4 cases were good, and 1 case was fair. In the experimental group, 14 cases were excellent, 1 case was good, and 0 case was fair. The functional evaluation of the experimental group was better than that of the control group, and the difference between the two groups was statistically significant (P < 0.05).

Conclusion

For infants after replantation of severed fingers, the application of the utility model patented product upper limb restrictive brace can effectively make up for the insufficient fixation of aircraft chest arm gypsum splint, reduce the occurrence of vascular crisis, and assist children in bed. In addition, the application of psychological intervention can reduce children's postoperative crying and is conducive to children's postoperative recovery.

Interventions for the management of Pain and Sedation in Newborns undergoing Therapeutic hypothermia for hypoxic-ischemic encephalopathy (IPSNUT): protocol of a systematic review

BACKGROUND

Clinical research has shown that therapeutic hypothermia after neonatal hypoxic-ischemic injury improves survival without disability. There is no consensus regarding pain relief or sedation during therapeutic hypothermia in newborns; however, therapeutic hypothermia seems to be associated with pain and stress, and adequate analgesia and sedation are central to maximize the effect of therapeutic hypothermia. Pain needs to be adequately managed in all patients, especially the newborn infant due to the potential short- and long-term negative effects of inadequately treated pain in this population.

METHODS

We will perform a systematic review of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy. We will include randomized, quasi-randomized controlled trials and observational studies. The use of pharmacological or non-pharmacological interventions will be compared to other pharmacological and or non-pharmacological interventions or no intervention/placebo. The primary outcomes for this review will be analgesia and sedation assessed with validated pain scales, circulatory instability, mortality to discharge, and moderate-to-severe neurodevelopmental disability. We will search the following databases: CINAHL, ClinicalTrials.gov , Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Two independent researchers will screen the records for inclusion, extract data using a data extraction form, and assess the risk of bias in the included trials.

DISCUSSION

The result of this review will summarize the knowledge regarding the management of pain and sedation in infants treated with therapeutic hypothermia and potentially provide clinicians with guidance on the effective and safe methods.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020205755.