1
|
Aspbury M, Mansfield RC, Baxter L, Bhatt A, Cobo MM, Fitzgibbon SP, Hartley C, Hauck A, Marchant S, Monk V, Pillay K, Poorun R, van der Vaart M, Slater R. Establishing a standardised approach for the measurement of neonatal noxious-evoked brain activity in response to an acute somatic nociceptive heel lance stimulus. Cortex 2024; 179:215-234. [PMID: 39197410 DOI: 10.1016/j.cortex.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/10/2024] [Accepted: 05/15/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND Electroencephalography (EEG) can be used in neonates to measure brain activity changes that are evoked by noxious events, such as clinically required immunisations, cannulation and heel lancing for blood tests. EEG provides an alternative approach to infer pain experience in infants compared with more commonly used behavioural and physiological pain assessments. Establishing the generalisability and construct validity of these measures will help corroborate the use of brain-derived outcomes to evaluate the efficacy of new or existing pharmacological and non-pharmacological methods to treat neonatal pain. This study aimed to test whether a measure of noxious-evoked EEG activity called the noxious neurodynamic response function (n-NRF), that was originally derived in a sample of term-aged infants at the Oxford John Radcliffe Hospital, UK, in 2017, can reliably distinguish noxious from non-noxious events in two independent datasets collected at University College London Hospital and at Royal Devon & Exeter Hospital. We aimed to reproduce three published results that use this measure to quantify noxious-evoked changes in brain activity. We used the n-NRF to quantify noxious-evoked brain activity to test (i) whether significantly larger noxious-evoked activity is recorded in response to a clinical heel lance compared to a non-noxious control heel lance procedure; (ii) whether the magnitude of the activity evoked by a noxious heel lance is equivalent in independent cohorts of infants; and (iii) whether the magnitude of the noxious-evoked brain activity increases with postmenstrual age (PMA) in premature infants up to 37 weeks PMA. Positive replication of these studies will build confidence in the use of the n-NRF as a valid and reliable pain-related outcome which could be used to evaluate analgesic efficacy in neonates. The protocol for this study was published following peer review (https://doi.org/10.17605/OSF.IO/ZY9MS). RESULTS The n-NRF magnitude to a noxious heel lance stimulus was significantly greater than to a non-noxious control heel lance stimulus in both the UCL dataset (n = 60; mean difference .88; 95% confidence interval (CI) .64-1.13; p < .0001) and the Exeter dataset (n = 31; mean difference .31; 95% CI .02-.61; p = .02). The mean magnitude and 90% bootstrap confidence interval of the n-NRF evoked by the heel lance did not meet our pre-defined equivalence bounds of 1.0 ± .2 in either the UCL dataset (n = 72; mean magnitude 1.33; 90% bootstrapped CI 1.18-1.52) or the Exeter dataset (n = 35; mean magnitude .92, 90% bootstrapped CI .74-1.22). The magnitude of the n-NRF to the noxious stimulus was significantly positively correlated with PMA in infants up to 37 weeks PMA (n = 65; one-sided Pearson's R, adjusted for site: .24; 95% CI .06-1.00; p = .03). CONCLUSIONS We have reproduced in independent datasets the findings that the n-NRF response to a noxious stimulus is significantly greater than to a non-noxious stimulus, and that the noxious-evoked EEG response increases with PMA. The pre-defined equivalence bounds for the mean magnitude of the EEG response were not met, though this might be due to either inter-site differences such as the lack of calibration of devices between sites (a true negative) or underpowering (a false negative). This reproducibility study provides robust evidence that supports the use of the n-NRF as an objective outcome for clinical trials assessing acute nociception in neonates. Use of the n-NRF in this way has the potential to transform the way analgesic efficacy studies are performed.
Collapse
Affiliation(s)
| | - Roshni C Mansfield
- Department of Paediatrics, University of Oxford, Oxford, UK; Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, UK; Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y Ambientales, Quito, Ecuador
| | - Sean P Fitzgibbon
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | | | - Annalisa Hauck
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Simon Marchant
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Kirubin Pillay
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ravi Poorun
- Children's Services, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK; College of Medicine & Health, University of Exeter, Exeter, UK
| | | | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| |
Collapse
|
2
|
Bueno M, Rao M, Aujla P, Victor C, Stevens B. A scoping review of the epidemiology and treatment of painful procedures in hospitalized neonates: What has changed in the past three decades? Eur J Pain 2024. [PMID: 38873730 DOI: 10.1002/ejp.2294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Care of newborns hospitalized in the neonatal intensive care unit (NICU) includes multiple painful procedures/day. Epidemiologic studies have reported the frequency and nature of procedures and treatment interventions. However, evidence on the changing trends in the nature and frequency of neonatal pain procedures or treatments over time is absent or inconclusive. We aimed to determine the frequency and nature of painful procedures/neonate/day in the NICU. DATABASES AND DATA TREATMENT MEDLINE and Embase searches were conducted from database inception to July 2023. Studies that reported the nature and frequency of painful procedures and associated pain treatments in neonates were included. Standard inverse-variance random-effects meta-analyses were used to combine studies. Heterogeneity between studies was quantified using the I2 statistic. RESULTS Of 2622 unique citations, 64 full-text articles were reviewed; 23 were included. Six additional studies identified in a previous review, and six publications from reference lists were added, resulting in 35 studies. The mean number of painful procedures/neonate/day was 7.38 (95% CI 5.60, 9.17; range <2 to 17). Although the frequency of painful procedures in more recent studies was reduced, it was not statistically significant (p = 0.16). Painful procedures were more frequent during longer observation periods. Needle-related procedures were most common and did not change over time. Procedure-related treatment was suboptimal and inconsistently reported. CONCLUSIONS Frequency of painful procedures in the NICU has shown a clinically important decrease but has not significantly changed over time. A paradigm shift moving responsibility from providers to systems in changing pain practices in the NICU is required. SIGNIFICANCE STATEMENT The decrease in the daily frequency of painful procedures in hospitalized neonates might be clinically relevant but is not yet statistically significant. Pain treatment is insufficiently documented and reported. This lack of progress in neonatal care might be a result of the complexity of defining pain and stress; inconsistencies in determining the burden of procedural pain; the influence of barriers and facilitators on practice change; and the focus on an individual rather than system responsibility for pain prevention and treatment.
Collapse
Affiliation(s)
- Mariana Bueno
- Peter Gilgan Centre for Research and Learning (PGCRL), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Megha Rao
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | | | | | - Bonnie Stevens
- Peter Gilgan Centre for Research and Learning (PGCRL), The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Vogel A, Ueberbach T, Wilken-Schmitz A, Hahnefeld L, Franck L, Weyer MP, Jungenitz T, Schmid T, Buchmann G, Freudenberg F, Brandes RP, Gurke R, Schwarzacher SW, Geisslinger G, Mittmann T, Tegeder I. Repetitive and compulsive behavior after Early-Life-Pain associated with reduced long-chain sphingolipid species. Cell Biosci 2023; 13:155. [PMID: 37635256 PMCID: PMC10463951 DOI: 10.1186/s13578-023-01106-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/13/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Pain in early life may impact on development and risk of chronic pain. We developed an optogenetic Cre/loxP mouse model of "early-life-pain" (ELP) using mice with transgenic expression of channelrhodopsin-2 (ChR2) under control of the Advillin (Avil) promoter, which drives expression of transgenes predominantly in isolectin B4 positive non-peptidergic nociceptors in postnatal mice. Avil-ChR2 (Cre +) and ChR2-flfl control mice were exposed to blue light in a chamber once daily from P1-P5 together with their Cre-negative mother. RESULTS ELP caused cortical hyperexcitability at P8-9 as assessed via multi-electrode array recordings that coincided with reduced expression of synaptic genes (RNAseq) including Grin2b, neurexins, piccolo and voltage gated calcium and sodium channels. Young adult (8-16 wks) Avil-ChR2 mice presented with nociceptive hypersensitivity upon heat or mechanical stimulation, which did not resolve up until one year of age. The persistent hypersensitivy to nociceptive stimuli was reflected by increased calcium fluxes in primary sensory neurons of aged mice (1 year) upon capsaicin stimulation. Avil-ChR2 mice behaved like controls in maze tests of anxiety, social interaction, and spatial memory but IntelliCage behavioral studies revealed repetitive nosepokes and corner visits and compulsive lickings. Compulsiveness at the behavioral level was associated with a reduction of sphingomyelin species in brain and plasma lipidomic studies. Behavioral studies were done with female mice. CONCLUSION The results suggest that ELP may predispose to chronic "pain" and compulsive psychopathology in part mediated by alterations of sphingolipid metabolism, which have been previously described in the context of addiction and psychiatric diseases.
Collapse
Affiliation(s)
- Alexandra Vogel
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
| | - Timo Ueberbach
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Annett Wilken-Schmitz
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
| | - Lisa Hahnefeld
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 60596, Frankfurt, Germany
- Fraunhofer Cluster of Excellence for Immune Mediated Diseases (CIMD), 60596, Frankfurt, Germany
| | - Luisa Franck
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
| | - Marc-Philipp Weyer
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
| | - Tassilo Jungenitz
- Institute of Clinical Neuroanatomy, Neuroscience Center, Goethe University, Frankfurt, Germany
| | - Tobias Schmid
- Institute of Biochemistry I, Faculty of Medicine, Goethe-University, Frankfurt, Germany
- Partner Site Frankfurt, German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Giulia Buchmann
- Institute of Cardiovascular Physiology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
| | - Florian Freudenberg
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe-University Hospital, Frankfurt, Germany
| | - Ralf P Brandes
- Institute of Cardiovascular Physiology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
| | - Robert Gurke
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 60596, Frankfurt, Germany
- Fraunhofer Cluster of Excellence for Immune Mediated Diseases (CIMD), 60596, Frankfurt, Germany
| | - Stephan W Schwarzacher
- Institute of Clinical Neuroanatomy, Neuroscience Center, Goethe University, Frankfurt, Germany
| | - Gerd Geisslinger
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 60596, Frankfurt, Germany
- Fraunhofer Cluster of Excellence for Immune Mediated Diseases (CIMD), 60596, Frankfurt, Germany
| | - Thomas Mittmann
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Irmgard Tegeder
- Institute of Clinical Pharmacology, Faculty of Medicine, Goethe-University, Frankfurt, Germany.
| |
Collapse
|
4
|
Duff IT, Krolick KN, Mahmoud HM, Chidambaran V. Current Evidence for Biological Biomarkers and Mechanisms Underlying Acute to Chronic Pain Transition across the Pediatric Age Spectrum. J Clin Med 2023; 12:5176. [PMID: 37629218 PMCID: PMC10455285 DOI: 10.3390/jcm12165176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic pain is highly prevalent in the pediatric population. Many factors are involved in the transition from acute to chronic pain. Currently, there are conceptual models proposed, but they lack a mechanistically sound integrated theory considering the stages of child development. Objective biomarkers are critically needed for the diagnosis, risk stratification, and prognosis of the pathological stages of pain chronification. In this article, we summarize the current evidence on mechanisms and biomarkers of acute to chronic pain transitions in infants and children through the developmental lens. The goal is to identify gaps and outline future directions for basic and clinical research toward a developmentally informed theory of pain chronification in the pediatric population. At the outset, the importance of objective biomarkers for chronification of pain in children is outlined, followed by a summary of the current evidence on the mechanisms of acute to chronic pain transition in adults, in order to contrast with the developmental mechanisms of pain chronification in the pediatric population. Evidence is presented to show that chronic pain may have its origin from insults early in life, which prime the child for the development of chronic pain in later life. Furthermore, available genetic, epigenetic, psychophysical, electrophysiological, neuroimaging, neuroimmune, and sex mechanisms are described in infants and older children. In conclusion, future directions are discussed with a focus on research gaps, translational and clinical implications. Utilization of developmental mechanisms framework to inform clinical decision-making and strategies for prevention and management of acute to chronic pain transitions in children, is highlighted.
Collapse
Affiliation(s)
- Irina T. Duff
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21218, USA;
| | - Kristen N. Krolick
- Department of Anesthesia, Cincinnati Children’s Hospital, Cincinnati, OH 45242, USA; (K.N.K.); (H.M.M.)
| | - Hana Mohamed Mahmoud
- Department of Anesthesia, Cincinnati Children’s Hospital, Cincinnati, OH 45242, USA; (K.N.K.); (H.M.M.)
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital, Cincinnati, OH 45242, USA; (K.N.K.); (H.M.M.)
| |
Collapse
|
5
|
Garafova A, Romanova Z, Oravcova H, Izakova L, Hlavacova N, Jezova D. Bridging the mood and stress hormone levels between mothers and their babies: The study design and first preliminary results. Acta Psychol (Amst) 2023; 238:103977. [PMID: 37406587 DOI: 10.1016/j.actpsy.2023.103977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023] Open
Abstract
The neurobiological mechanisms involved in the influence of post-partum maternal mood fluctuations on child development are far from being understood. Here we present the design of an ongoing study aimed to test the hypothesis that the mental state of the mother has an impact on her neonate which is manifested by similarities in the neuroendocrine function of the mother and the child. The hypothesis is being tested under both stress and non-stress conditions in mothers and babies aged 3-4 days and 7-9 months. The focus will be given to correlations with maternal postpartum mood. To confirm the correctness of methodological approaches and the feasibility of the study several preliminary analyses were performed. Salivary alpha-amylase activity as a marker of sympathetic activation and cortisol as the effective hormone of the hypothalamic-pituitary-adrenocortical axis were measured. The obtained results showed the feasibility of saliva sampling in neonates using a sampling time of 120 s. The analysis of cortisol in hair revealed increased concentrations during the third trimester of pregnancy, which is consistent with the knowledge of high cortisol concentrations during pregnancy. A positive correlation was observed between salivary cortisol values before and after the stress test in mother-infant dyads at both the post-partum period and 7-9 months thereafter. Understanding the mechanisms involved in "the bridge" between the mother and her baby will help to develop necessary interventions directed to help mothers in the early postpartum period.
Collapse
Affiliation(s)
- Alexandra Garafova
- Slovak Medical University, Department of Neonatology, University Hospital Bratislava, Antolska 11, 851 07 Bratislava, Slovakia
| | - Zuzana Romanova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia
| | - Henrieta Oravcova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia; Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University Bratislava, Odbojarov 10, 83104 Bratislava, Slovakia
| | - Lubomira Izakova
- Department of Psychiatry, Faculty of Medicine Comenius University and University Hospital Bratislava, Mickiewiczova 13, 81369 Bratislava, Slovakia
| | - Natasa Hlavacova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia
| | - Daniela Jezova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia.
| |
Collapse
|
6
|
Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S, DiLorenzo-Klas M, Racine NM, Ahola Kohut S, Lisi D, Turcotte K, Stevens B, Uman LS. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 2023; 6:CD006275. [PMID: 37314064 PMCID: PMC10265939 DOI: 10.1002/14651858.cd006275.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title. OBJECTIVES To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update. We also searched reference lists and contacted researchers via electronic list-serves. We incorporated 76 new studies into the review. SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis. DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes. MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence. In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements. AUTHORS' CONCLUSIONS Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.
Collapse
Affiliation(s)
| | - Oana Bucsea
- Department of Psychology, York University, Toronto, Canada
| | - Ilana Shiff
- Department of Psychology, York University, Toronto, Canada
| | - Cheryl Chow
- Department of Psychology, York University, Toronto, Canada
| | | | | | | | - Nicole M Racine
- Department of Psychology, University of Calgary, Calgary, Canada
| | - Sara Ahola Kohut
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Diana Lisi
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Kara Turcotte
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Bonnie Stevens
- Nursing Research, The Hospital for Sick Children, Toronto, Canada
| | | |
Collapse
|
7
|
Bucsea O, Rupawala M, Shiff I, Wang X, Meek J, Fitzgerald M, Fabrizi L, Pillai Riddell R, Jones L. Clinical thresholds in pain-related facial activity linked to differences in cortical network activation in neonates. Pain 2023; 164:1039-1050. [PMID: 36633530 PMCID: PMC10108588 DOI: 10.1097/j.pain.0000000000002798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 01/13/2023]
Abstract
ABSTRACT In neonates, a noxious stimulus elicits pain-related facial expression changes and distinct brain activity as measured by electroencephalography, but past research has revealed an inconsistent relationship between these responses. Facial activity is the most commonly used index of neonatal pain in clinical settings, with clinical thresholds determining if analgesia should be provided; however, we do not know if these thresholds are associated with differences in how the neonatal brain processes a noxious stimulus. The objective of this study was to examine whether subclinical vs clinically significant levels of pain-related facial activity are related to differences in the pattern of nociceptive brain activity in preterm and term neonates. We recorded whole-head electroencephalography and video in 78 neonates (0-14 days postnatal age) after a clinically required heel lance. Using an optimal constellation of Neonatal Facial Coding System actions (brow bulge, eye squeeze, and nasolabial furrow), we compared the serial network engagement (microstates) between neonates with and without clinically significant pain behaviour. Results revealed a sequence of nociceptive cortical network activation that was independent of pain-related behavior; however, a separate but interleaved sequence of early activity was related to the magnitude of the immediate behavioural response. Importantly, the degree of pain-related behavior is related to how the brain processes a stimulus and not simply the degree of cortical activation. This suggests that neonates who exhibit clinically significant pain behaviours process the stimulus differently and that neonatal pain-related behaviours reflect just a portion of the overall cortical pain response.
Collapse
Affiliation(s)
- Oana Bucsea
- Psychology, Faculty of Health, York University, Toronto, ON, Canada
| | - Mohammed Rupawala
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Ilana Shiff
- Psychology, Faculty of Health, York University, Toronto, ON, Canada
| | - Xiaogang Wang
- Department of Mathematics and Statistics, York University, Toronto, ON, Canada
| | - Judith Meek
- University College London Hospital, London, United Kingdom
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Rebecca Pillai Riddell
- Psychology, Faculty of Health, York University, Toronto, ON, Canada
- Psychiatry, Hospital for Sick Children, Toronto, ON, Canada
- Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Laura Jones
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| |
Collapse
|
8
|
Rupawala M, Bucsea O, Laudiano-Dray MP, Whitehead K, Meek J, Fitzgerald M, Olhede S, Jones L, Fabrizi L. A developmental shift in habituation to pain in human neonates. Curr Biol 2023; 33:1397-1406.e5. [PMID: 36931271 DOI: 10.1016/j.cub.2023.02.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 11/22/2022] [Accepted: 02/23/2023] [Indexed: 03/18/2023]
Abstract
Habituation to recurrent non-threatening or unavoidable noxious stimuli is an important aspect of adaptation to pain. Neonates, especially if preterm, are exposed to repeated noxious procedures during their clinical care. They can mount strong behavioral, autonomic, spinal, and cortical responses to a single noxious stimulus; however, it is not known whether the developing nervous system can adapt to the recurrence of these inputs. Here, we used electroencephalography to investigate changes in cortical microstates (representing the complex sequential processing of noxious inputs) following two consecutive clinically required heel lances in term and preterm infants. We show that stimulus repetition dampens the engagement of initial microstates and associated behavioral and autonomic responses in term infants, while preterm infants do not show signs of habituation. Nevertheless, both groups engage different longer-latency cortical microstates to each lance, which is likely to reflect changes in higher-level stimulus processing with repeated stimulation. These data suggest that while both age groups are capable of encoding contextual differences in pain, the preterm brain does not regulate the initial cortical, behavioral, and autonomic responses to repeated noxious stimuli. Habituation mechanisms to pain are already in place at term age but mature over the equivalent of the last trimester of gestation and are not fully functional in preterm neonates.
Collapse
Affiliation(s)
- Mohammed Rupawala
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Oana Bucsea
- Faculty of Health, Department of Psychology, York University, Toronto, ON M3J 1P3, Canada
| | | | - Kimberley Whitehead
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London WC1E 6DB, UK
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Sofia Olhede
- Department of Statistical Science, University College London, London WC1E 6BT, UK; Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne 1015, Switzerland
| | - Laura Jones
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK.
| |
Collapse
|
9
|
Meesters NJ, Dilles T, van Rosmalen J, van den Bosch GE, Simons SHP, van Dijk M. COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates? J Perinatol 2023; 43:595-600. [PMID: 36746985 DOI: 10.1038/s41372-023-01628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Naomi J Meesters
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Tinne Dilles
- Nursing and Midwifery Sciences, Centre for Research and Innovation in Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| |
Collapse
|
10
|
Thill B. The fetal pain paradox. FRONTIERS IN PAIN RESEARCH 2023; 4:1128530. [PMID: 37025166 PMCID: PMC10072285 DOI: 10.3389/fpain.2023.1128530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
Controversy exists as to when conscious pain perception in the fetus may begin. According to the hypothesis of cortical necessity, thalamocortical connections, which do not form until after 24-28 weeks gestation, are necessary for conscious pain perception. However, anesthesiologists and neonatologists treat age-matched neonates as both conscious and pain-capable due to observable and measurable behavioral, hormonal, and physiologic indicators of pain. In preterm infants, these multimodal indicators of pain are uncontroversial, and their presence, despite occurring prior to functional thalamocortical connections, has guided the use of analgesics in neonatology and fetal surgery for decades. However, some medical groups state that below 24 weeks gestation, there is no pain capacity. Thus, a paradox exists in the disparate acknowledgment of pain capability in overlapping patient populations. Brain networks vary by age. During the first and second trimesters, the cortical subplate, a unique structure that is present only during fetal and early neonatal development, forms the first cortical network. In the third trimester, the cortical plate assumes this function. According to the subplate modulation hypothesis, a network of connections to the subplate and subcortical structures is sufficient to facilitate conscious pain perception in the fetus and the preterm neonate prior to 24 weeks gestation. Therefore, similar to other fetal and neonatal systems that have a transitional phase (i.e., circulatory system), there is now strong evidence for transitional developmental phases of fetal and neonatal pain circuitry.
Collapse
|
11
|
Bachiller Carnicero L, Antoñón Rodríguez M, de la Huerga López A, Martín Ramos S, Morales Luengo F, Marín Urueña SI, Caserío Carbonero S. Parasympathetic evaluation for procedural pain assessment in neonatology. An Pediatr (Barc) 2022; 97:390-397. [PMID: 36241543 DOI: 10.1016/j.anpede.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/02/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The Newborn Infant Parasympathetic Evaluation (NIPE) index is an instrument that enables continuous, fast and objective assessment of neonatal discomfort. The aim of the study was to analyse changes in NIPE values after performance of blood draws and the factors involved in this variation. MATERIAL AND METHODS We conducted a prospective observational study. We included infants admitted to the neonatal intensive care unit between June and December 2021 who underwent blood draws. We recorded demographic data, aspects related to the procedure, the NIPE index and the heart rate at baseline and 1, 2, 3, 4, 5, 10 and 15 min after the procedure. RESULTS The study included 86 records for 49 patients. In the first 4 min after the procedure, there was a significant decrease in the NIPE index, with a maximum decrease of 22.8% relative to baseline and the nadir at 2.79 min. The decrease in NIPE values was greater in infants born preterm, male, with lower 5-min Apgar scores and following procedures that had been performed previously, after caesarean section or in the morning. There were no differences when the blood draw was obtained during kangaroo care. The correlation between the NIPE index and the heart rate was weak. CONCLUSIONS After a painful procedure, such as a blood draw, the NIPE monitor showed a significant decrease in the first 4 min, which was more pronounced in preterm infants, in repeated procedures or after caesarean delivery. The NIPE index could help identify infants experiencing acute procedural pain, complementing clinical rating scales.
Collapse
Affiliation(s)
| | | | | | - Silvia Martín Ramos
- Unidad de Neonatología, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | | |
Collapse
|
12
|
Wang F, Zhang Q, Ni ZH, Lv HT. Effects of kangaroo care on pain relief in premature infants during painful procedures: A meta-analysis. J SPEC PEDIATR NURS 2022; 27:e12390. [PMID: 35859291 DOI: 10.1111/jspn.12390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/22/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to evaluate effects of kangaroo care on pain relief in premature infants during painful procedures. DESIGN A meta-analysis. METHODS Eight databases (Cochrane Library, PubMed, Embase, Web of Science, China Biology Medicine [CBM], China Science and Technology Journal Database [CSTJ], China National Knowledge Infrastructure [CNKI], and WanFang Data) were systematically reviewed from inception to November 2021 for randomized controlled and crossover trials. RESULTS Thirteen studies, including 2311 infants (kangaroo care: 1153, control: 1158) were analyzed. Kangaroo care had a moderate effect on pain relief during painful procedures in premature infants at a gestational age of 32-36 + 6 weeks but no effect at 28-31 + 6 weeks. Furthermore, 15 or 30 min of kangaroo care had a moderate effect and could markedly relieve pain at the instant of and 30/60 s after, had a small effect at 90 s after, and no effect at 120 s after the procedure. PRACTICE IMPLICATIONS Kangaroo care may be an effective nonpharmacologic alternative therapy to relieve procedural pain in premature infants born at a gestational age of 32-36 + 6 weeks.
Collapse
Affiliation(s)
- Fang Wang
- Neonatal Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Qing Zhang
- Neonatal Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Zhi Hong Ni
- Department of Nursing, Children's Hospital of Soochow University, Suzhou, China
| | - Hai Tao Lv
- Neonatal Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| |
Collapse
|
13
|
PRG-1 prevents neonatal stimuli-induced persistent hyperalgesia and memory dysfunction via NSF/Glu/GluR2 signaling. iScience 2022; 25:104989. [PMID: 36093041 PMCID: PMC9460187 DOI: 10.1016/j.isci.2022.104989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/02/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Neonatal repetitive noxious stimuli (RNS) has been shown to cause long-term harmful effects on nociceptive processing, learning, and memory which persist until adulthood. Plasticity-related gene 1 (PRG-1) regulates synaptic plasticity and functional reorganization in the brain during neuronal development. In this study, neonatal RNS rats were established by repetitive needle pricks to neonatal rats on all four feet to model repetitive pain exposure in infants. Neonatal RNS caused thermal hyperalgesia, mechanical allodynia, learning, and memory impairments which manifested in young rats and persisted until adulthood. Hippocampal PRG-1/N-ethylmaleimide sensitive fusion protein (NSF) interaction was determined to be responsible for the RNS-induced impairment via enhanced extracellular glutamate release and AMPAR GluR2 trafficking deficiency in a cell-autonomous manner. These pathways likely act synergistically to cause changes in dendritic spine density. Our findings suggest that PRG-1 prevents the RNS-induced hyperalgesia, learning, and memory impairment by regulating synaptic plasticity via NSF/Glu/GluR2 signaling. Neonatal RNS induced hyperalgesia, learning, and memory impairment until adulthood. PRG-1 attenuated RNS-induced impairments by dendritic spine regulation. PRG-1 prevents RNS-induced impairments via NSF/Glu/GluR2 signaling.
Collapse
|
14
|
Bachiller Carnicero L, Antoñón Rodríguez M, de la Huerga López A, Martín Ramos S, Morales Luengo F, Marín Urueña SI, Caserío Carbonero S. Evaluación del sistema parasimpático durante procedimientos dolorosos en neonatología. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
|
15
|
Mahdi Z, Marandyuk B, Desnous B, Liet AS, Chowdhury RA, Birca V, Décarie JC, Tremblay S, Lodygensky GA, Birca A, Pinchefsky EF, Dehaes M. Opioid analgesia and temperature regulation are associated with EEG background activity and MRI outcomes in neonates with mild-to-moderate hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia. Eur J Paediatr Neurol 2022; 39:11-18. [PMID: 35598572 DOI: 10.1016/j.ejpn.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/23/2022] [Accepted: 04/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) without sedation may lead to discomfort, which may be associated with adverse consequences in neonates with hypoxic-ischemic encephalopathy (HIE). The aim of this study was to assess the association between level of exposure to opioids and temperature, with electroencephalography (EEG) background activity post-TH and magnetic resonance imaging (MRI) brain injury in neonates with HIE. METHODS Thirty-one neonates with mild-to-moderate HIE who underwent TH were identified. MRIs were reviewed for presence of brain injury. Quantitative EEG background features including EEG discontinuity index and spectral power densities were calculated during rewarming and post-rewarming periods. Dose of opioids administered during TH and temperatures were collected from the medical charts. Multivariable linear and logistic regression analyses were conducted to assess the associations between cumulative dose of opioids and temperature with EEG background and MRI while adjusting for markers of HIE severity. RESULTS Higher opioid doses (β = -0.21, p = 0.02) and reduced skin temperature (β = 0.14, p < 0.01) were associated with lower EEG discontinuity index recorded post-TH. Higher opioid doses (β = 0.75, p = 0.01) and reduced skin temperature (β = -0.39, p = 0.02) were also associated with higher EEG Delta power post-TH. MRI brain injury was observed in 14 patients (45%). In adjusted regression analyses, higher opioid doses (OR = 0.00; 95%CI: 0-0.19; p = 0.01), reduced skin temperature (OR = 41.19; 95%CI: 2.27-747.86; p = 0.01) and reduced cooling device output temperature (OR = 1.91; 95%CI: 1.05-3.48; p = 0.04) showed an association with lower odds of brain injury. CONCLUSIONS Higher level of exposure to opioids and reduced skin temperature during TH in mild-to-moderate HIE were associated with improved EEG background activity post-TH. Moreover, higher exposure to opioids, reduced skin temperature and reduced device output temperature were associated with lower odds of brain injury on MRI.
Collapse
Affiliation(s)
- Zamzam Mahdi
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Bohdana Marandyuk
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Beatrice Desnous
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Anne-Sophie Liet
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Rasheda Arman Chowdhury
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Institute of Biomedical Engineering, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada
| | - Veronica Birca
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Jean-Claude Décarie
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada
| | - Sophie Tremblay
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neonatology, Department of Pediatrics, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Gregory Anton Lodygensky
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neonatology, Department of Pediatrics, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Ala Birca
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Elana F Pinchefsky
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Mathieu Dehaes
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Institute of Biomedical Engineering, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada; Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada.
| |
Collapse
|
16
|
Bellieni CV. Neonatal Infant Pain Scale in assessing pain and pain relief for newborn male circumcision. Int J Impot Res 2022; 35:282-285. [PMID: 35352017 DOI: 10.1038/s41443-022-00551-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/09/2022]
Abstract
Circumcision-partial or total removal of the penile prepuce-requires cutting nerve-laden, sensitive genital tissue and is therefore liable to be painful. The aim of this review is to evaluate the evidence concerning pain felt by newborns during circumcision and to determine whether current analgesic methods can eliminate such pain. I performed a search in medical databases, selecting the trials published in the last 20 years that assessed pain in neonatal circumcision. Twenty-three trials have been retrieved. To get reliable findings, those trials that used validated pain scales were selected; then it was investigated which trials had comparable data for using the same pain scale. The only pain scale that was used in more than two trials was the modified Neonatal Infant Pain Scale (mNIPS) that ranges 0-6. The results of these trials show that none of the analgesic strategies used obtained the absence of pain. Some differences between circumcision techniques can be noticed, but most assessments exceed the score of 3, chosen as the clinically significant pain.
Collapse
Affiliation(s)
- Carlo V Bellieni
- Department of Pediatrics, University of Siena, Viale M Bracci 36, 53100, Siena, Italy.
| |
Collapse
|
17
|
Yuan I, Nelson O, Barr GA, Zhang B, Topjian AA, DiMaggio TJ, Lang SS, Christ LA, Izzetoglu K, Greco CC, Kurth CD, Ganesh A. Functional near-infrared spectroscopy to assess pain in neonatal circumcisions. Paediatr Anaesth 2022; 32:404-412. [PMID: 34747096 DOI: 10.1111/pan.14326] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pain assessment is challenging in neonates. Behavioral and physiological pain scales do not assess neocortical nociception, essential to pain encoding and central pain pathway development. Functional near-infrared spectroscopy (fNIRS) can assess neocortical activation to noxious stimuli from changes in oxy-(HbO) and total-hemoglobin concentrations (HbT). This study aims to assess fNIRS nociceptive functional activation in the prefrontal cortex of neonates undergoing circumcision through changes in HbO and HbT, and the correlation between changes in fNIRS and Neonatal Infant Pain Scale (NIPS), a behavioral pain assessment scale. METHODS In healthy term neonates, HbO, HbT, and NIPS were recorded during sequential circumcision events 1-Prep before local anesthetic injection; 2-Local anesthetic injection; 3-Prep before incision; 4-Oral sucrose; 5-Incision; 6-Gomco (hemostatic device) attached; 7-Gomco twisted on; and 8-Gomco removed. fNIRS and NIPS changes after each event were assessed with Wilcoxon signed-rank test and summarized as median and interquartile range (IQR). Changes in fNIRS vs. NIPS were correlated with Spearman coefficient. RESULTS In 31 neonates fNIRS increased (median [IQR] µmol/L) with noxious events: Local injection (HbO: 1.1 [0.5, 3.1], p < .001; HbT: 2.3 [0.2, 7.6], p < .001), Gomco attached (HbO: 0.7 [0.1, 1.7], p = .002; HbT: 0.7 [-0.2, 2.9], p = .02), and Gomco twisted on (HbO: 0.5 [-0.2, 1.7], p = .03; HbT: 0.8 [-0.1, 3.3], p = .02). fNIRS decreased with non-noxious event: Prep before incision (HbO: -0.6 [-1.2, -0.2] p < .001; HbT: -1 [-1.8, -0.4], p < .001). Local anesthetic attenuated fNIRS increases to subsequent sharp stimuli. NIPS increased with subsequent sharp stimuli despite local anesthetic. Although fNIRS and NIPS changed in the same direction, there was not a strong correlation between them. CONCLUSIONS During neonatal circumcision, changes in fNIRS differed between different types of painful stimuli, which was not the case for NIPS, suggesting that fNIRS may complement NIPS to assess the quality of pain.
Collapse
Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon A Barr
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bingqing Zhang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theresa J DiMaggio
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Department of Neurosurgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lori A Christ
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kurtulus Izzetoglu
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Christine C Greco
- Department of Neonatology, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Charles D Kurth
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
18
|
Latremouille S, Lam J, Shalish W, Sant'Anna G. Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications. BMJ Open 2021; 11:e055209. [PMID: 34933863 PMCID: PMC8710426 DOI: 10.1136/bmjopen-2021-055209] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies. OBJECTIVES To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed. ELIGIBILITY CRITERIA Human neonates ≤1 month of corrected age. SOURCES OF EVIDENCE A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020. CHARTING METHODS A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction). RESULTS Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band. CONCLUSIONS Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.
Collapse
Affiliation(s)
- Samantha Latremouille
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Justin Lam
- Medicine, Griffith University, Nathan, Queensland, Australia
| | - Wissam Shalish
- Division of Neonatology, McGill University Health Center, Montreal, Québec, Canada
| | - Guilherme Sant'Anna
- Division of Neonatology, McGill University Health Center, Montreal, Québec, Canada
| |
Collapse
|
19
|
Schmidt Mellado G, Pillay K, Adams E, Alarcon A, Andritsou F, Cobo MM, Evans Fry R, Fitzgibbon S, Moultrie F, Baxter L, Slater R. The impact of premature extrauterine exposure on infants' stimulus-evoked brain activity across multiple sensory systems. Neuroimage Clin 2021; 33:102914. [PMID: 34915328 PMCID: PMC8683775 DOI: 10.1016/j.nicl.2021.102914] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/10/2021] [Accepted: 12/09/2021] [Indexed: 11/03/2022]
Abstract
Prematurity can result in widespread neurodevelopmental impairment, with the impact of premature extrauterine exposure on brain function detectable in infancy. A range of neurodynamic and haemodynamic functional brain measures have previously been employed to study the neurodevelopmental impact of prematurity, with methodological and analytical heterogeneity across studies obscuring how multiple sensory systems are affected. Here, we outline a standardised template analysis approach to measure evoked response magnitudes for visual, tactile, and noxious stimulation in individual infants (n = 15) using EEG. By applying these templates longitudinally to an independent cohort of very preterm infants (n = 10), we observe that the evoked response template magnitudes are significantly associated with age-related maturation. Finally, in a cross-sectional study we show that the visual and tactile response template magnitudes differ between a cohort of infants who are age-matched at the time of study but who differ according to whether they are born during the very preterm or late preterm period (n = 10 and 8 respectively). These findings demonstrate the significant impact of premature extrauterine exposure on brain function and suggest that prematurity can accelerate maturation of the visual and tactile sensory system in infants born very prematurely. This study highlights the value of using a standardised multi-modal evoked-activity analysis approach to assess premature neurodevelopment, and will likely complement resting-state EEG and behavioural assessments in the study of the functional impact of developmental care interventions.
Collapse
Affiliation(s)
| | - Kirubin Pillay
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ana Alarcon
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Department of Neonatology, Hospital Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | | | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, UK; Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y Ambientales, Quito, Ecuador
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sean Fitzgibbon
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK.
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
| |
Collapse
|
20
|
Hartley C. Toward personalized medicine for pharmacological interventions in neonates using vital signs. PAEDIATRIC AND NEONATAL PAIN 2021; 3:147-155. [PMID: 35372840 PMCID: PMC8937573 DOI: 10.1002/pne2.12065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 10/22/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022]
Abstract
Vital signs, such as heart rate and oxygen saturation, are continuously monitored for infants in neonatal care units. Pharmacological interventions can alter an infant's vital signs, either as an intended effect or as a side effect, and consequently could provide an approach to explore the wide variability in pharmacodynamics across infants and could be used to develop models to predict outcome (efficacy or adverse effects) in an individual infant. This will enable doses to be tailored according to the individual, shifting the balance toward efficacy and away from the adverse effects of a drug. Pharmacological analgesics are frequently not given in part due to the risk of adverse effects, yet this exposes infants to the short‐ and long‐term effects of painful procedures. Personalized analgesic dosing will be an important step forward in providing safer effective pain relief in infants. The aim of this paper was to describe a framework to develop predictive models of drug outcome from analysis of vital signs data, focusing on analgesics as a representative example. This framework investigates changes in vital signs in response to the analgesic (prior to the painful procedure) and proposes using machine learning to examine if these changes are predictive of outcome—either efficacy (with pain response measured using a multimodal approach, as changes in vital signs alone have limited sensitivity and specificity) or adverse effects. The framework could be applied to both preterm and term infants in neonatal care units, as well as older children. Sharing vital signs data are proposed as a means to achieve this aim and bring personalized medicine rapidly to the forefront in neonatology.
Collapse
|
21
|
|
22
|
Espinosa Fernández MG, González-Pacheco N, Sánchez-Redondo MD, Cernada M, Martín A, Pérez-Muñuzuri A, Boix H, Couce ML. Sedoanalgesia in neonatal units. An Pediatr (Barc) 2021; 95:126.e1-126.e11. [PMID: 34332948 DOI: 10.1016/j.anpede.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/09/2020] [Indexed: 12/27/2022] Open
Abstract
Pain recognition and management continues to be a challenge for health professionals in Neonatal Intensive Care Units. Many of the patients are routinely exposed to repeated painful experiences with demonstrated short- and long-term consequences. Preterm babies are a vulnerable high-risk population. Despite international recommendations, pain remains poorly assessed and managed in many Neonatal Intensive Care Units. Due to there being no general protocol, there is significant variability as regards the guidelines for the approach and treatment of pain between the different Neonatal Intensive Care Units. The objective of this article is to review and assess the general principles of pain in the initial stages of development, its recognition through the use of standardised scales. It also includes its prevention and management with the combination of pharmacological and non-pharmacological measures, as well as to establish recommendations that help alleviate pain in daily clinical practice by optimising pain and stress control in the Neonatal Intensive Care Units.
Collapse
Affiliation(s)
| | | | | | - María Cernada
- Servicio de Neonatología, Hospital Universitario y Politécnico La Fe, Grupo de Investigación en Perinatología, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Ana Martín
- Servicio de Neonatología, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Alejandro Pérez-Muñuzuri
- Servicio de Neonatología, Hospital Clínico Universitario de Santiago, IDIS, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Hector Boix
- Servicio de Neonatología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - María L Couce
- Servicio de Neonatología, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| |
Collapse
|
23
|
Yoshida S, Funato H. Physical contact in parent-infant relationship and its effect on fostering a feeling of safety. iScience 2021; 24:102721. [PMID: 34235413 PMCID: PMC8250458 DOI: 10.1016/j.isci.2021.102721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The infant-caregiver relationship involves physical contact for feeding, moving, and other cares, and such contact also encourages the infant to form an attachment, an emotional bond with the caregivers. Physical contact always accompanies somatosensory perception, which is detected by mechanosensory neurons and processed in the brain. Physical contact triggers sensorimotor reflexes such as Transport Response in rodent infants, and calm human infants while being carried. Tactile sensation and deep pressure in physical interactions, such as hugging, can function as emotional communication between infant and caregiver, which can alter the behavior and mood of both the infant and caregiver. This review summarizes the findings related to physical contact between the infant and the caregiver in terms of pleasant, noxious, and neutral somatosensation and discusses how somatosensory perceptions foster a feeling of safety that is important for infant's psychosocial development.
Collapse
Affiliation(s)
- Sachine Yoshida
- Department of Anatomy, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
| | - Hiromasa Funato
- Department of Anatomy, Faculty of Medicine, Toho University, Ota-ku, Tokyo 143-8540, Japan
- International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| |
Collapse
|
24
|
Benoit B, Newman A, Campbell-Yeo M. Challenges and complexities in the electroencephalographic measurement of neonatal pain. Early Hum Dev 2021; 157:105363. [PMID: 33839478 DOI: 10.1016/j.earlhumdev.2021.105363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Britney Benoit
- Rankin School of Nursing, St. Francis Xavier University, Antigonish, Nova Scotia, Canada.
| | - Aaron Newman
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
| | | |
Collapse
|
25
|
Using changes in brain activity to assess pain-relief in infants: Methodological considerations with Benoit et al. (2021). Early Hum Dev 2021; 157:105361. [PMID: 33838455 DOI: 10.1016/j.earlhumdev.2021.105361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023]
|
26
|
An examination of the reciprocal and concurrent relations between behavioral and cardiac indicators of acute pain in toddlerhood. Pain 2021; 161:1518-1531. [PMID: 32107358 DOI: 10.1097/j.pain.0000000000001840] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to examine the concurrent and predictive relations between healthy toddlers' pain behavior and cardiac indicators (ie, heart rate [HR] and respiratory sinus arrhythmia [RSA]) during routine vaccinations. Caregiver-infant dyads were part of a longitudinal cohort observed during their 12- and 18-month vaccinations. Behavioral and cardiac data were simultaneously collected for 1-minute preneedle and 3-minutes postneedle. Videotapes were coded for pain behaviors (FLACC; Merkel et al., 1997), and cardiac data were analyzed (HR, RSA) during sequential 30-second epochs. Four separate cross-lagged path models were estimated using data from the 12- (n = 147) and 18-month (n = 122) vaccinations. Across 12- and 18-month vaccinations, predictive within-measure relations were consistent for FLACC, HR, and RSA, reflecting good stability of these pain indicators. Behavioral indicators predicted subsequent HR and RSA within the immediate postneedle period. Both baseline behavior and HR/RSA predicted future pain scores. Concurrent residual relations between behavioral and cardiac indicators were inconsistent across time and indicators. Results suggest that behavioral and cardiac indicators reflect unique aspects of the nociceptive response. As such, multimodal assessment tools should be used and contextualized by child age, cardiac indicator, baseline behavior/physiology, and pain phase.
Collapse
|
27
|
Baxter L, Moultrie F, Fitzgibbon S, Aspbury M, Mansfield R, Bastiani M, Rogers R, Jbabdi S, Duff E, Slater R. Functional and diffusion MRI reveal the neurophysiological basis of neonates' noxious-stimulus evoked brain activity. Nat Commun 2021; 12:2744. [PMID: 33980860 PMCID: PMC8115252 DOI: 10.1038/s41467-021-22960-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/05/2021] [Indexed: 11/20/2022] Open
Abstract
Understanding the neurophysiology underlying neonatal responses to noxious stimulation is central to improving early life pain management. In this neonatal multimodal MRI study, we use resting-state and diffusion MRI to investigate inter-individual variability in noxious-stimulus evoked brain activity. We observe that cerebral haemodynamic responses to experimental noxious stimulation can be predicted from separately acquired resting-state brain activity (n = 18). Applying this prediction model to independent Developing Human Connectome Project data (n = 215), we identify negative associations between predicted noxious-stimulus evoked responses and white matter mean diffusivity. These associations are subsequently confirmed in the original noxious stimulation paradigm dataset, validating the prediction model. Here, we observe that noxious-stimulus evoked brain activity in healthy neonates is coupled to resting-state activity and white matter microstructure, that neural features can be used to predict responses to noxious stimulation, and that the dHCP dataset could be utilised for future exploratory research of early life pain system neurophysiology.
Collapse
Affiliation(s)
- Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sean Fitzgibbon
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | | | | | - Matteo Bastiani
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Saad Jbabdi
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, UK
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
| |
Collapse
|
28
|
Lavanga M, Bollen B, Caicedo A, Dereymaeker A, Jansen K, Ortibus E, Van Huffel S, Naulaers G. The effect of early procedural pain in preterm infants on the maturation of electroencephalogram and heart rate variability. Pain 2021; 162:1556-1566. [PMID: 33110029 PMCID: PMC8054544 DOI: 10.1097/j.pain.0000000000002125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 01/18/2023]
Abstract
ABSTRACT Preterm infants show a higher incidence of cognitive, social, and behavioral problems, even in the absence of major medical complications during their stay in the neonatal intensive care unit (NICU). Several authors suggest that early-life experience of stress and procedural pain could impact cerebral development and maturation resulting in an altered development of cognition, behavior, or motor patterns in later life. However, it remains very difficult to assess this impact of procedural pain on physiological development. This study describes the maturation of electroencephalogram (EEG) signals and heart rate variability in a prospective cohort of 92 preterm infants (<34 weeks gestational age) during their NICU stay. We took into account the number of noxious, ie, skin-breaking, procedures they were subjected in the first 5 days of life, which corresponded to a median age of 31 weeks and 4 days. Using physiological signal modelling, this study shows that a high exposure to early procedural pain, measured as skin-breaking procedures, increased the level of discontinuity in both EEG and heart rate variability in preterm infants. These findings have also been confirmed in a subset of the most vulnerable preterm infants with a gestational age lower than 29 weeks. We conclude that a high level of early pain exposure in the NICU increases the level of functional dysmaturity, which can ultimately impact preterm infants' future developmental outcome.
Collapse
Affiliation(s)
- Mario Lavanga
- Department of Electrical Engineering (ESAT), Division STADIUS, KU Leuven, Leuven, Belgium
| | - Bieke Bollen
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Applied Mathematics and Computer Science, School of Engineering, Science and Technology, Universidad Del Rosario, Bogota', Colombia
| | - Anneleen Dereymaeker
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Katrien Jansen
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Els Ortibus
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Sabine Van Huffel
- Department of Electrical Engineering (ESAT), Division STADIUS, KU Leuven, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Leuven, Belgium
| |
Collapse
|
29
|
Georgoulas A, Jones L, Laudiano-Dray MP, Meek J, Fabrizi L, Whitehead K. Sleep-wake regulation in preterm and term infants. Sleep 2021; 44:5889156. [PMID: 32770211 PMCID: PMC7819838 DOI: 10.1093/sleep/zsaa148] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/25/2020] [Indexed: 11/19/2022] Open
Abstract
Study Objectives In adults, wakefulness can be markedly prolonged at the expense of sleep, e.g. to stay vigilant in the presence of a stressor. These extra-long wake bouts result in a heavy-tailed distribution (highly right-skewed) of wake but not sleep durations. In infants, the relative importance of wakefulness and sleep are reversed, as sleep is necessary for brain maturation. Here, we tested whether these developmental pressures are associated with the unique regulation of sleep–wake states. Methods In 175 infants of 28–40 weeks postmenstrual age (PMA), we monitored sleep–wake states using electroencephalography and behavior. We constructed survival models of sleep–wake bout durations and the effect of PMA and other factors, including stress (salivary cortisol), and examined whether sleep is resilient to nociceptive perturbations (a clinically necessary heel lance). Results Wake durations followed a heavy-tailed distribution as in adults and lengthened with PMA and stress. However, differently from adults, active sleep durations also had a heavy-tailed distribution, and with PMA, these shortened and became vulnerable to nociception-associated awakenings. Conclusions Sleep bouts are differently regulated in infants, with especially long active sleep durations that could consolidate this state’s maturational functions. Curtailment of sleep by stress and nociception may be disadvantageous, especially for preterm infants given the limited value of wakefulness at this age. This could be addressed by environmental interventions in the future.
Collapse
Affiliation(s)
| | - Laura Jones
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Maria Pureza Laudiano-Dray
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Judith Meek
- Elizabeth Garrett Anderson Wing, University College London Hospitals, London, United Kingdom
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Kimberley Whitehead
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| |
Collapse
|
30
|
Cobo MM, Hartley C, Gursul D, Andritsou F, van der Vaart M, Schmidt Mellado G, Baxter L, Duff EP, Buckle M, Evans Fry R, Green G, Hoskin A, Rogers R, Adams E, Moultrie F, Slater R. Quantifying noxious-evoked baseline sensitivity in neonates to optimise analgesic trials. eLife 2021; 10:e65266. [PMID: 33847561 PMCID: PMC8087440 DOI: 10.7554/elife.65266] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/17/2021] [Indexed: 01/18/2023] Open
Abstract
Despite the high burden of pain experienced by hospitalised neonates, there are few analgesics with proven efficacy. Testing analgesics in neonates is experimentally and ethically challenging and minimising the number of neonates required to demonstrate efficacy is essential. EEG (electroencephalography)-derived measures of noxious-evoked brain activity can be used to assess analgesic efficacy; however, as variability exists in neonate's responses to painful procedures, large sample sizes are often required. Here, we present an experimental paradigm to account for individual differences in noxious-evoked baseline sensitivity which can be used to improve the design of analgesic trials in neonates. The paradigm is developed and tested across four observational studies using clinical, experimental, and simulated data (92 neonates). We provide evidence of the efficacy of gentle brushing and paracetamol, substantiating the need for randomised controlled trials of these interventions. This work provides an important step towards safe, cost-effective clinical trials of analgesics in neonates.
Collapse
Affiliation(s)
- Maria M Cobo
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y AmbientalesQuitoEcuador
| | - Caroline Hartley
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Deniz Gursul
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | | | | | | | - Luke Baxter
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Eugene P Duff
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Wellcome Centre for Integrative Neuroimaging, University of OxfordOxfordUnited Kingdom
| | - Miranda Buckle
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Ria Evans Fry
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Gabrielle Green
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Amy Hoskin
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Richard Rogers
- Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| |
Collapse
|
31
|
Benoit B, Newman A, Martin-Misener R, Latimer M, Campbell-Yeo M. The influence of breastfeeding on cortical and bio-behavioural indicators of procedural pain in newborns: Findings of a randomized controlled trial. Early Hum Dev 2021; 154:105308. [PMID: 33513546 DOI: 10.1016/j.earlhumdev.2021.105308] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 12/17/2022]
Abstract
AIMS The objective of this study was to compare the influence of breastfeeding and 24% oral sucrose on pain-related electrophysiologic activity, bio-behavioural pain scores, physiologic recovery, and adverse events during heel lance. STUDY DESIGN Single-blind randomized controlled trial. SUBJECTS 39 full-term infants were randomized to receive breastfeeding or 0.24 mL of 24% oral sucrose plus offered non-nutritive sucking 2 min prior to heel lance. OUTCOME MEASURES The primary outcome of pain-related potential was recorded on electroencephalogram. Secondary outcomes included Premature Infant Pain Profile - Revised (PIPP-R) score, physiologic recovery, and adverse events. Data were analyzed per protocol (ClinicalTrials.gov: NCT03272594). RESULTS Between November 2017 and January 2019, 20 infants were randomized to breastfeeding and 19 infants to receive oral sucrose. Infants who were breastfeeding had an appreciably smaller, yet not statistically different (F[1,15.9] = 0.58, p = 0.64, SE = 11.79), amplitude pain-related potential (peak amplitude 0.29 μV) following heel lance compared to infants who received oral sucrose (peak amplitude 8.97 μV). Mean PIPP-R scores were not statistically significantly different between groups following heel lance, however, they were indicative of low pain across groups. Mean time in seconds to physiologic recovery was faster in breastfeeding infants (M = 17.5, SD = 31.1) compared to oral sucrose (M = 70.8, SD = 144.3). There were no safety concerns. DISCUSSION Breastfeeding and oral sucrose both reduce bio-behavioural responses to pain, however, may differentially modulate pain response in the infant brain. Further research to understand the neurophysiologic effects of these interventions during acute painful procedures is needed.
Collapse
Affiliation(s)
- Britney Benoit
- Rankin School of Nursing, St. Francis Xavier University, Antigonish, Nova Scotia, Canada.
| | - Aaron Newman
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Margot Latimer
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | | |
Collapse
|
32
|
Shiroshita Y, Kirimoto H, Ozawa M, Watanabe T, Uematsu H, Yunoki K, Sobue I. Can Event-Related Potentials Evoked by Heel Lance Assess Pain Processing in Neonates? A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:58. [PMID: 33498331 PMCID: PMC7909417 DOI: 10.3390/children8020058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/16/2021] [Accepted: 01/16/2021] [Indexed: 01/04/2023]
Abstract
To clarify the possibility of event-related potential (ERP) evoked by heel lance in neonates as an index of pain assessment, knowledge acquired by and problems of the methods used in studies on ERP evoked by heel lance in neonates were systematically reviewed, including knowledge about Aδ and C fibers responding to noxious stimuli and Aβ fibers responding to non-noxious stimuli. Of the 863 reports searched, 19 were selected for the final analysis. The following points were identified as problems for ERP evoked by heel lance in neonates to serve as a pain assessment index: (1) It is possible that the ERP evoked by heel lance reflected the activation of Aβ fibers responding to non-noxious stimuli and not the activation of Aδ or C fibers responding to noxious stimulation; (2) Sample size calculation was presented in few studies, and the number of stimulation trials to obtain an averaged ERP was small. Accordingly, to establish ERP evoked by heel lance as a pain assessment in neonates, it is necessary to perform a study to clarify ERP evoked by Aδ- and C-fiber stimulations accompanied by heel lance in neonates.
Collapse
Affiliation(s)
- Yui Shiroshita
- Division of Nursing Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.O.); (I.S.)
| | - Hikari Kirimoto
- Department of Sensorimotor Neuroscience, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (H.K.); (T.W.); (K.Y.)
| | - Mio Ozawa
- Division of Nursing Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.O.); (I.S.)
| | - Tatsunori Watanabe
- Department of Sensorimotor Neuroscience, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (H.K.); (T.W.); (K.Y.)
| | - Hiroko Uematsu
- School of Nursing, University of Human Environments, Aichi 474-0035, Japan;
| | - Keisuke Yunoki
- Department of Sensorimotor Neuroscience, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (H.K.); (T.W.); (K.Y.)
| | - Ikuko Sobue
- Division of Nursing Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.O.); (I.S.)
| |
Collapse
|
33
|
Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, Birnie KA, Anderson BJ, Chambers CT, Crombez G, Ljungman G, Jordan I, Jordan Z, Roberts C, Schechter N, Sieberg CB, Tibboel D, Walker SM, Wilkinson D, Wood C. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:47-87. [PMID: 33064998 DOI: 10.1016/s2352-4642(20)30277-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK; Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium.
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paula Forgeron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, ON, Canada
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, AB, Canada
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Christine T Chambers
- Department of Psychology and Neuroscience, and Department of Pediatrics, Dalhousie University, Halifax, NS, Canada; Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Geert Crombez
- Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium
| | - Gustaf Ljungman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Neil Schechter
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | - Christine B Sieberg
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suellen M Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Chantal Wood
- Department of Spine Surgery and Neuromodulation, Poitiers University Hospital, Poitiers, France
| |
Collapse
|
34
|
Andersen RD, Olsson E, Eriksson M. The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review. Int J Nurs Stud 2020; 115:103840. [PMID: 33360247 DOI: 10.1016/j.ijnurstu.2020.103840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes. OBJECTIVES To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children. DESIGN Systematic literature review. DATA SOURCES The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020. REVIEW METHODS We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded. RESULTS In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions. CONCLUSIONS Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.
Collapse
Affiliation(s)
- Randi Dovland Andersen
- Department of Child and Adolescent Health Services and Department of Research, Telemark Hospital Trust, P.O. Box 2900 Kjørbekk, Skien 3710, Norway; Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden.
| | - Emma Olsson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden; Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro 701 82, Sweden
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden; Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro 701 82, Sweden
| |
Collapse
|
35
|
Waxman JA, DiLorenzo MG, Pillai Riddell RR, Flora DB, Schmidt LA, Garfield H, Flanders D, Weinberg E, Savlov D. Investigating convergence of cardiac and behavioral indicators of distress during routine vaccinations over the second year of life. Dev Psychobiol 2020; 63:437-451. [PMID: 33043441 DOI: 10.1002/dev.22034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 06/02/2020] [Accepted: 08/14/2020] [Indexed: 11/08/2022]
Abstract
There is considerable variability regarding the convergence between behavioral and biological aspects of distress responses in toddlerhood, and little research has investigated the convergence of these measures in high distress. The aim of the current study was to describe patterns of distress responses to vaccinations as indexed by both pain-related behavioral distress and heart rate (HR) at 12 and 18 months. Caregiver-toddler dyads were part of an ongoing longitudinal cohort observed during 12- (N = 158) and 18-month (N = 122) well-baby vaccinations. Parallel-process growth mixture models discerned two distinct groups at 12 months and three distinct groups at 18 months. All groups had comparable pain-related behavioral distress and HR responses post-vaccination, with most participants displaying high arousal and regulation to baseline levels following the vaccination. However, at 18 months, an important minority had a blunted response or did not regulate to a low level of distress by 3 min post-needle. Post hoc analyses revealed that higher baseline pain-related behavioral distress predicted membership in the majority groups at 12 and 18 months. These results highlight the developmental differences and variability in behavioral and cardiac indicators of distress regulation across the second year of life.
Collapse
Affiliation(s)
| | | | - Rebecca R Pillai Riddell
- York University, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | | | | | - Hartley Garfield
- The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | | | | | | |
Collapse
|
36
|
Mehler K, Giebisch C, Abele J, Roth B, Huenseler C. Pain response to vaccination in newborn infants of diabetic mothers. Early Hum Dev 2020; 149:105139. [PMID: 32763751 DOI: 10.1016/j.earlhumdev.2020.105139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Response to pain is altered in infants who were exposed to pain- and stressful events in the neonatal period. Infants of diabetic mothers receive several heel sticks after birth for measuring blood glucose and thus may show changes in their behavioral and physiologic response to pain. Moreover, maternal hyperglycemia may alter activity of the hypothalamic pituitary adrenal (HPA) axis reactivity. STUDY DESIGN In total, 43 infants of diabetic mothers and 30 control infants were included into the study. Response to pain was assessed at 3 months of age following two intramuscular injections for vaccination. We assessed behavioral (Bernese pain scale), physiologic (heart rate) and hormonal (salivary cortisol) pain response to vaccination as well as spinal sensitization (flexion withdrawal reflex). RESULTS Infants of diabetic mothers received a median number of 5 [4-19] painful events compared to 1 [1-3] in the control group. Heart rate reactivity differed significantly between groups. Infants of diabetic mothers had higher peaks (p = 0.002) and needed more time to recover to baseline (p < 0.001). Moreover, infants of diabetic mothers showed higher peak cortisol (p = 0.001) and a higher relative cortisol increase (p = 0.015). Flexor withdrawal reflex thresholds were significantly lower in infants of diabetic mothers (p = 0.003). CONCLUSION The increase of physiologic and hormonal responses to pain in infants of diabetic mothers is probably caused by repeated painful events and an altered metabolic profile.
Collapse
Affiliation(s)
- Katrin Mehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany.
| | - Christina Giebisch
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| | - Julia Abele
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| | - Bernhard Roth
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| | - Christoph Huenseler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| |
Collapse
|
37
|
Jones L, Laudiano-Dray MP, Whitehead K, Meek J, Fitzgerald M, Fabrizi L, Pillai Riddell R. The impact of parental contact upon cortical noxious-related activity in human neonates. Eur J Pain 2020; 25:149-159. [PMID: 32965725 PMCID: PMC8436758 DOI: 10.1002/ejp.1656] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/13/2020] [Accepted: 08/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neonates display strong behavioural, physiological and cortical responses to tissue-damaging procedures. Parental contact can successfully regulate general behavioural and physiological reactivity of the infant, but it is not known whether it can influence noxious-related activity in the brain. Brain activity is highly dependent upon maternal presence in animal models, and therefore this could be an important contextual factor in human infant pain-related brain activity. METHODS Global topographic analysis was used to identify the presence and inter-group differences in noxious-related activity in three separate parental contexts. EEG was recorded during a clinically required heel lance in three age and sex-matched groups of neonates (a) while held by a parent in skin-to-skin (n = 9), (b) while held by a parent with clothing (n = 9) or (c) not held at all, but in individualized care (n = 9). RESULTS The lance elicited a sequence of 4-5 event-related potentials (ERPs), including the noxious ERP (nERP), which was smallest for infants held skin-to-skin and largest for infants held with clothing (p=0.016). The nERP was then followed by additional and divergent long-latency ERPs (> 750 ms post-lance), not previously described, in each of the groups, suggesting the engagement of different higher level cortical processes depending on parental contact. CONCLUSIONS These results show the importance of considering contextual factors in determining infant brain activity and reveal the powerful influence of parental contact upon noxious-related activity across the developing human brain. SIGNIFICANCE This observational study found that the way in which the neonatal brain processes a noxious stimulus is altered by the type of contact the infant has with their mother. Specifically, being held in skin-to-skin reduces the magnitude of noxious-related cortical activity. This work has also shown that different neural mechanisms are engaged depending on the mother/infant context, suggesting maternal contact can change how a baby's brain processes a noxious stimulus.
Collapse
Affiliation(s)
- Laura Jones
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | | | - Kimberley Whitehead
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London, UK
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, UK
| | | |
Collapse
|
38
|
Lavanga M, Smets L, Bollen B, Jansen K, Ortibus E, Huffel SV, Naulaers G, Caicedo A. A perinatal stress calculator for the neonatal intensive care unit: an unobtrusive approach. Physiol Meas 2020; 41:075012. [PMID: 32521528 DOI: 10.1088/1361-6579/ab9b66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Early experience of pain and stress in the neonatal intensive care unit is known to have an effect on the neurodevelopment of the infant. However, an automated method to quantify the procedural pain or perinatal stress in premature patients does not exist. APPROACH In the current study, EEG and ECG data were collected for more than 3 hours from 136 patients in order to quantify stress exposure. Specifically, features extracted from the EEG and heart-rate variability in both quiet and non-quiet sleep segments were used to develop a subspace linear-discriminant analysis stress classifier. MAIN RESULTS The main novelty of the study lies in the absence of intrusive methods or pain elicitation protocols to develop the stress classifier. Three main findings can be reported. First, we developed different stress classifiers for the different age groups and stress intensities, obtaining an area under the curve in the range [0.78-0.93] for non-quiet sleep and [0.77-0.96] for quiet sleep. Second, a dysmature EEG was found in patients under stress. Third, an enhanced cortical connectivity and increased brain-heart communication was correlated with a higher stress load, while the autonomic activity did not seem to be associated to stress exposure. SIGNIFICANCE The results shed a light on the pain and stress processing in preterm neonates, suggesting that software tools to investigate dysmature EEG might be helpful to assess stress load in premature patients. These results could be the foundation to assess the impact of stress on infants' development and to tune preventive care.
Collapse
Affiliation(s)
- M Lavanga
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Kasteelpark Arenberg 10, box 2446, 3001, Leuven, Belgium. Authors contributed equally to this work
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Lavanga M, Bollen B, Jansen K, Ortibus E, Naulaers G, Van Huffel S, Caicedo A. A Bradycardia-Based Stress Calculator for the Neonatal Intensive Care Unit: A Multisystem Approach. Front Physiol 2020; 11:741. [PMID: 32670096 PMCID: PMC7332774 DOI: 10.3389/fphys.2020.00741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
Early life stress in the neonatal intensive care unit (NICU) can predispose premature infants to adverse health outcomes and neurodevelopment delays. Hands-on-care and procedural pain might induce apneas, hypoxic events, and sleep-wake disturbances, which can ultimately impact maturation, but a data-driven method based on physiological fingerprints to quantify early-life stress does not exist. This study aims to provide an automatic stress detector by investigating the relationship between bradycardias, hypoxic events and perinatal stress in NICU patients. EEG, ECG, and SpO 2 were recorded from 136 patients for at least 3 h in three different monitoring groups. In these subjects, the stress burden was assessed using the Leuven Pain Scale. Different subspace linear discriminant analysis models were designed to detect the presence or the absence of stress based on information in each bradycardic spell. The classification shows an area under the curve in the range [0.80-0.96] and a kappa score in the range [0.41-0.80]. The results suggest that stress seems to increase SpO 2 desaturations and EEG regularity as well as the interaction between the cardiovascular and neurological system. It might be possible that stress load enhances the reaction to respiratory abnormalities, which could ultimately impact the neurological and behavioral development.
Collapse
Affiliation(s)
- Mario Lavanga
- Division STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Bieke Bollen
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Katrien Jansen
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Els Ortibus
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, Faculty of Medicine, KU Leuven, Belgium
| | - Sabine Van Huffel
- Division STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Applied Mathematics and Computer Science, School of Engineering, Science and Technology, Universidad del Rosario, Bogotá, Colombia
| |
Collapse
|
40
|
Laudiano-Dray MP, Pillai Riddell R, Jones L, Iyer R, Whitehead K, Fitzgerald M, Fabrizi L, Meek J. Quantification of neonatal procedural pain severity: a platform for estimating total pain burden in individual infants. Pain 2020; 161:1270-1277. [PMID: 31977932 DOI: 10.1097/j.pain.0000000000001814] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There is increasing evidence that long-term outcomes for infants born prematurely are adversely affected by repeated exposure to noxious procedures. These interventions vary widely, for example, in the extent of damage caused and duration. Neonatal intensive care unit (NICU) procedures are therefore likely to each contribute differently to the overall pain burden of individual neonates, ultimately having a different impact on their development. For researchers to quantify the procedural pain burden experienced by infants on NICU, we aimed to estimate the pain severity of common NICU procedures using published pain scores. We extracted pain scores over the first minute (pain reactivity) from the literature, using 59 randomized controlled trials for 15 different procedures. Hierarchical cluster analysis of average pain scores resulted in 5 discrete severity groups; mild (n = 1), mild to moderate (n = 3), moderate (n = 7), severe (n = 3), and very severe (n = 1). The estimate of the severity of individual procedures provided new insight into infant pain reactivity which is not always directly related to the invasiveness and duration of a procedure; thus, both heel lance and skin tape removal are moderately painful procedures. This estimate of procedural pain severity, based on pain reactivity scores, provides a novel platform for retrospective quantification of an individual neonate's pain burden due to NICU procedures. The addition of measures that reflect the recovery from each procedure, such as brain activity and behavioural regulation, would further improve estimates of the pain burden of neonatal intensive care.
Collapse
Affiliation(s)
- Maria Pureza Laudiano-Dray
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Rebecca Pillai Riddell
- Department of Psychology, Faculty of Health, The O.U.C.H. Lab, York University, Toronto, ON, Canada
- Psychiatry Research, Hospital for Sick Children, Toronto, ON, Canada
| | - Laura Jones
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Rajeshwari Iyer
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Kimberley Whitehead
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Judith Meek
- Neonatal Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London, United Kingdom
| |
Collapse
|
41
|
Schenk K, Stoffel L, Bürgin R, Stevens B, Bassler D, Schulzke S, Nelle M, Cignacco E. Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors. Eur J Pain 2020; 24:1107-1118. [PMID: 32170786 DOI: 10.1002/ejp.1555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/28/2020] [Accepted: 03/11/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered. OBJECTIVES We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN. METHODS We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14 days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models. RESULTS Premature birth (b = -0.721), caffeine (b = -0.302), and the behavioural states quiet and awake (b = -0.283), active and asleep (b = -0.158), and quiet and asleep (b = -0.498) were associated with changes in behavioural pain scores. Premature birth (b = -0.232), mechanical ventilation (b = -0.196), and duration of the heel stick procedure (b = 0.0004) were associated with changes in physiological pain scores. Premature birth (b = -0.907), Caffeine (b = -0.402), the behavioural states quiet and awake (b = -0.274), and quiet and asleep (b = -0.459), and duration of the heel stick procedure (b = 0.001) were associated with changes in the modified BPSN total scores. CONCLUSIONS Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs. SIGNIFICANCE We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.
Collapse
Affiliation(s)
- Karin Schenk
- Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Lilian Stoffel
- Neonatalogy, Children's Hospital, University Hospital of Bern, Bern, Switzerland
| | - Reto Bürgin
- Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Bonnie Stevens
- Lawrence S. Bloomberg Faculty of Nursing and Faculties of Medicine and Dentistry, University of Toronto, Toronto, Canada
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Sven Schulzke
- Department of Neonatology, University Children's Hospital Basel UKBB, Basel, Switzerland
| | - Mathias Nelle
- Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Eva Cignacco
- Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| |
Collapse
|
42
|
Montaldo P, Vakharia A, Ivain P, Mendoza J, Oliveira V, Markati T, Shankaran S, Thayyil S. Pre-emptive opioid sedation during therapeutic hypothermia. Arch Dis Child Fetal Neonatal Ed 2020; 105:108-109. [PMID: 31072966 DOI: 10.1136/archdischild-2019-317050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Paolo Montaldo
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK.,Neonatal Intensive Care Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Anuj Vakharia
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Phoebe Ivain
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Josephine Mendoza
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Vania Oliveira
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Theodora Markati
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| |
Collapse
|
43
|
Battell EE, Lillywhite A, Hathway GJ. The changing role of descending control of spinal nociception over postnatal development. CURRENT OPINION IN PHYSIOLOGY 2019. [DOI: 10.1016/j.cophys.2019.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
44
|
Peña-Bautista C, Escrig R, Lara I, García-Blanco A, Cháfer-Pericás C, Vento M. Non-invasive monitoring of stress biomarkers in the newborn period. Semin Fetal Neonatal Med 2019; 24:101002. [PMID: 30981693 DOI: 10.1016/j.siny.2019.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The neonatal period is a highly sensitive time span during which stressful experiences may have an influence on later health outcomes. Medical procedures applied to newborn babies during hospitalization are stressors that trigger a physiological and psychological stress response. Stress response has been traditionally evaluated using scores based on behavioural signs such as facial expressions, limb movements, crying, etc., which are subjectively interpreted. Only few studies have employed measurable physiological signs to objectively evaluate the stress response to specific interventions. The aim of this review is to inform of recently developed biochemical methods that allow clinicians to evaluate the stress response to medical procedures performed in the neonatal period in biological samples non-invasively obtained. Stress biomarkers are based on the physiological stress response mediated by the hypophysis-pituitary-adrenal axis and the sympathetic-adreno-medullary systems. Cortisol is at present the most widely employed laboratory determination to measure stress levels. In recent years, sequentially determined salivary cortisol levels have allowed non-invasive monitoring of newborn infants under stressful conditions in the NICU.
Collapse
Affiliation(s)
- C Peña-Bautista
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain
| | - R Escrig
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - I Lara
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - A García-Blanco
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain
| | - C Cháfer-Pericás
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain.
| | - M Vento
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain; Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| |
Collapse
|
45
|
Bucsea O, Pillai Riddell R. Non-pharmacological pain management in the neonatal intensive care unit: Managing neonatal pain without drugs. Semin Fetal Neonatal Med 2019; 24:101017. [PMID: 31326301 DOI: 10.1016/j.siny.2019.05.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Premature infants hospitalized after birth are exposed to repeated painful procedures as part of their routine medical care. Early neonatal exposure to unmanaged pain has been linked to numerous negative long-term outcomes, such as the development of pain hypersensitivity, detrimental psychological symptomology, and altered neurodevelopment. These findings emphasize the crucial role of pain management in neonatal care. The aim of this article is to give an overview of evidence-based non-pharmacological pain management techniques for hospitalized neonates. Research supporting the effectiveness of various proximal, distal, and procedural pain management methods in neonates will be presented. Additionally, understanding the larger biopsychosocial context of the infant that underpins the mechanisms of these pain management methods is essential. Therefore, two important models that inform non-pharmacological approaches to infant pain management (DIAPR-R [The Development of Infant Acute Pain Responding-Revised], Attachment Theory) will be discussed.
Collapse
Affiliation(s)
- Oana Bucsea
- York University, Office of the Vice-President Research & Innovation, 509 Kaneff Tower, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Rebecca Pillai Riddell
- York University, Office of the Vice-President Research & Innovation, 509 Kaneff Tower, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada. https://twitter.com/drbeccapr
| |
Collapse
|
46
|
Abstract
Measuring brain activity in infants provides an objective surrogate approach with which to infer pain perception following noxious events. Here we discuss different approaches which can be used to measure noxious-evoked brain activity, and discuss how these measures can be used to assess the analgesic efficacy of pharmacological and non-pharmacological interventions. We review factors that can modulate noxious-evoked brain activity, which may impact infant pain experience, including gestational age, sex, prior pain, stress, and illness.
Collapse
Affiliation(s)
- Deniz Gursul
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom.
| |
Collapse
|
47
|
Tracey I, Woolf CJ, Andrews NA. Composite Pain Biomarker Signatures for Objective Assessment and Effective Treatment. Neuron 2019; 101:783-800. [PMID: 30844399 PMCID: PMC6800055 DOI: 10.1016/j.neuron.2019.02.019] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/05/2019] [Accepted: 02/13/2019] [Indexed: 02/09/2023]
Abstract
Pain is a subjective sensory experience that can, mostly, be reported but cannot be directly measured or quantified. Nevertheless, a suite of biomarkers related to mechanisms, neural activity, and susceptibility offer the possibility-especially when used in combination-to produce objective pain-related indicators with the specificity and sensitivity required for diagnosis and for evaluation of risk of developing pain and of analgesic efficacy. Such composite biomarkers will also provide improved understanding of pain pathophysiology.
Collapse
Affiliation(s)
- Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK.
| | - Clifford J Woolf
- Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, 02115 MA, USA.
| | - Nick A Andrews
- Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, 02115 MA, USA
| |
Collapse
|
48
|
Repeated neonatal needle-prick stimulation increases inflammatory mechanical hypersensitivity in adult rats. Int J Dev Neurosci 2019; 78:191-197. [PMID: 30742972 DOI: 10.1016/j.ijdevneu.2019.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/31/2019] [Accepted: 02/07/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Newborn infants are vulnerable to procedural stress and pain exposure on the first weeks of life that represents a critical period for the development of nociceptive, sensory, emotional, and social functions. We evaluated the nociceptive behavior of adult male and female rats that were submitted to nociceptive experience in the neonatal period and the maternal behavior in the postnatal period. METHODS The animals were submitted to repetitive needle pricking from the second to the fifteenth postnatal day (PND 2-15). Maternal behavior and litter weight were evaluated during this period. Mechanical sensitivity to pain was assessed in offsprings during the adulthood by exposing them to inflammatory stimuli, including formalin test or the Freund's complete adjuvant (CFA) injection followed by the electronic von Frey test at 0, 3, 6 and 24 h later. RESULTS Maternal behavior and litter weight were not altered by pinprick stimuli during PND 2-15. Additionally, pinprick stimulation reduced the paw withdrawal threshold in CFA-injected animals compared to control. In the formalin test, there was a difference between the genders. Female rats are statically more sensitive to formalin stimulation and showed an increased licking time in both the first and second phases and increased number of flinches in second phase. CONCLUSIONS Experiencing early life repetitive pain exposure increased inflammatory pain sensitivity in adult offspring rats and female rats are more sensitive to chemical stimulation. IMPLICATIONS Future investigations of the mechanisms involved in this effect may contribute to the improvement of the understanding of inflammatory pain sensitivity differences.
Collapse
|
49
|
EEG, behavioural and physiological recordings following a painful procedure in human neonates. Sci Data 2018; 5:180248. [PMID: 30422128 PMCID: PMC6233256 DOI: 10.1038/sdata.2018.248] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/21/2018] [Indexed: 02/07/2023] Open
Abstract
We present a dataset of cortical, behavioural, and physiological responses following a single, clinically required noxious stimulus in a neonatal sample. Cortical activity was recorded from 112 neonates (29–47 weeks gestational age at study) using a 20-channel electroencephalogram (EEG), which was time-locked to a heel lance. This data is linked to pain-related behaviour (facial expression), physiology (heart rate, oxygenation) and a composite clinical score (Premature Infant Pain Profile, PIPP). The dataset includes responses to non-noxious sham and auditory controls. The infants’ relevant medical and pain history was collected up to the day of the study and recorded in an extensive database of variables including clinical condition at birth, diagnoses, medications, previous painful procedures, injuries, and selected maternal information. This dataset can be used to investigate the cortical, physiological, and behavioural pain-related processing in human infants and to evaluate the impact of medical conditions and experiences upon the infant response to noxious stimuli. Furthermore, it provides information on the formation of individual pain phenotypes.
Collapse
|
50
|
Verriotis M, Jones L, Whitehead K, Laudiano-Dray M, Panayotidis I, Patel H, Meek J, Fabrizi L, Fitzgerald M. The distribution of pain activity across the human neonatal brain is sex dependent. Neuroimage 2018; 178:69-77. [PMID: 29763673 PMCID: PMC6062722 DOI: 10.1016/j.neuroimage.2018.05.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/30/2018] [Accepted: 05/11/2018] [Indexed: 12/12/2022] Open
Abstract
In adults, there are differences between male and female structural and functional brain connectivity, specifically for those regions involved in pain processing. This may partly explain the observed sex differences in pain sensitivity, tolerance, and inhibitory control, and in the development of chronic pain. However, it is not known if these differences exist from birth. Cortical activity in response to a painful stimulus can be observed in the human neonatal brain, but this nociceptive activity continues to develop in the postnatal period and is qualitatively different from that of adults, partly due to the considerable cortical maturation during this time. This research aimed to investigate the effects of sex and prematurity on the magnitude and spatial distribution pattern of the long-latency nociceptive event-related potential (nERP) using electroencephalography (EEG). We measured the cortical response time-locked to a clinically required heel lance in 81 neonates born between 29 and 42 weeks gestational age (median postnatal age 4 days). The results show that heel lance results in a spatially widespread nERP response in the majority of newborns. Importantly, a widespread pattern is significantly more likely to occur in females, irrespective of gestational age at birth. This effect is not observed for the short latency somatosensory waveform in the same infants, indicating that it is selective for the nociceptive component of the response. These results suggest the early onset of a greater anatomical and functional connectivity reported in the adult female brain, and indicate the presence of pain-related sex differences from birth.
Collapse
Affiliation(s)
- Madeleine Verriotis
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Laura Jones
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Kimberley Whitehead
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Maria Laudiano-Dray
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Ismini Panayotidis
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Hemani Patel
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London, WC1E6DB, United Kingdom
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology, and Pharmacology, University College London, London, WC1E6BT, United Kingdom.
| |
Collapse
|