1
|
Hannan KE, Bourque SL, Ross E, Wymore EM, Kinsella JP, Mandell EW, Houin SS. Successful and Rapid Reduction in Neurosedative and Analgesic Medications in Complex Infants with Severe Bronchopulmonary Dysplasia After Tracheostomy Placement: Experience with 24-hour Propofol Infusions. J Pediatr 2024; 270:114040. [PMID: 38554746 DOI: 10.1016/j.jpeds.2024.114040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
Infants with severe bronchopulmonary dysplasia may require high doses of neurosedative medications to ensure pain control and stability following tracheostomy placement. Subsequent weaning of these medications safely and rapidly is a challenge. We describe a 24-hour propofol infusion to reduce neurosedative medications in 3 high-risk infants following tracheostomy placement.
Collapse
Affiliation(s)
- Kathleen E Hannan
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Stephanie L Bourque
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Emma Ross
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Erica M Wymore
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Erica W Mandell
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Satya S Houin
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
2
|
Selvanathan T, Miller SP. Brain health in preterm infants: importance of early-life pain and analgesia exposure. Pediatr Res 2024:10.1038/s41390-024-03245-w. [PMID: 38806664 DOI: 10.1038/s41390-024-03245-w] [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: 02/13/2024] [Accepted: 03/23/2024] [Indexed: 05/30/2024]
Abstract
"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.
Collapse
Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
| |
Collapse
|
3
|
Keane OA, Ourshalimian S, Lakshmanan A, Lee HC, Hintz SR, Nguyen N, Ing MC, Gong CL, Kaplan C, Kelley-Quon LI. Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US. JAMA Netw Open 2024; 7:e240555. [PMID: 38470421 PMCID: PMC10936113 DOI: 10.1001/jamanetworkopen.2024.0555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024] Open
Abstract
Importance High-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives. Objective To examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants. Design, Setting, and Participants This retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children's hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded. Exposure Any opioid exposure and methadone treatment. Main Outcomes and Measures Regional and institutional variations in opioid exposure. Results Overall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital. Conclusions and Relevance In this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.
Collapse
Affiliation(s)
- Olivia A. Keane
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, California
| | - Henry C. Lee
- Division of Neonatology, University of California San Diego, La Jolla
| | - Susan R. Hintz
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatology, Palo Alto, California
| | - Nam Nguyen
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Division of Pediatric Surgery, Memorial Care Miller Children’s & Women’s Hospital, Long Beach, California
| | - Madeleine C. Ing
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Cynthia L. Gong
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Cameron Kaplan
- USC Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| |
Collapse
|
4
|
Melan N, Pradat P, Godbert I, Pastor-Diez B, Basson E, Picaud JC. Neurodevelopment at 24 months corrected age in extremely preterm infants treated with dexamethasone alternatives during the late postnatal period: a cohort study. Eur J Pediatr 2024; 183:677-687. [PMID: 37955745 PMCID: PMC10912127 DOI: 10.1007/s00431-023-05319-z] [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] [Received: 09/20/2023] [Revised: 10/18/2023] [Accepted: 10/28/2023] [Indexed: 11/14/2023]
Abstract
The administration of dexamethasone has been associated with suboptimal neurodevelopment. We aimed to compare the development of extremely premature infants treated or not with alternatives to dexamethasone: betamethasone, hydrocortisone hemisuccinate. This retrospective cohort study included infants born before 29 weeks of gestational age, treated or not with late (day ≥ 7) postnatal steroids (betamethasone, hydrocortisone hemisuccinate). The neurodevelopment outcome was evaluated at 24 months corrected age, after adjustment on comorbidities of extreme prematurity. In order to analyse their overall development, data about growth and respiratory outcomes were collected. Among the 192 infants included, 59 (30.7%) received postnatal steroids. Suboptimal neurodevelopment concerned 37/59 (62.7%) postnatal steroid-treated and 43/133 (38.1%; p = 0.002) untreated infants. However, in multivariable analysis, only severe neonatal morbidity (p = 0.007) and male gender (p = 0.027) were associated with suboptimal neurodevelopment outcome at 24 months. Conclusions: Betamethasone or hydrocortisone hemisuccinate treatment was not an independent risk for suboptimal neurological development, growth and respiratory outcomes assessed at 24 months corrected age in extremely premature infants. Registration number: The study was registered on the ClinicalTrials.gov register: NCT05055193. What is Known: • Late postnatal steroids are used to treat bronchopulmonary dysplasia • Meta-analyses warned against the neurological risk of dexamethasone use during neonatal period. Early or late hydrocortisone hemisuccinate has been evaluated in multiple studies, none of which have reported an adverse effect on neurodevelopment at least to 2 years. Data about the use of betamethasone are scarce. What is New: • The risk of suboptimal neurodevelopment was higher among extremely premature infants who received postnatal steroids when compared to those who did not. • Betamethasone and hydrocortisone hemisuccinate treatment was not an independent risk factor for suboptimal neurodevelopment at 24 months corrected age.
Collapse
Affiliation(s)
- Nathalie Melan
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Pierre Pradat
- Centre for Clinical Research, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Isabelle Godbert
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Blandine Pastor-Diez
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Eliane Basson
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Jean-Charles Picaud
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France.
- CarMen Laboratory, INSERM, INRA, Université Claude Bernard Lyon 1, Pierre-Bénite, 69310, Lyon, France.
| |
Collapse
|
5
|
Do A, Rorison E, Borucki A, Shibata GS, Pomerantz JH, Hoffman WY. Opioid-free Pain Management after Cleft Lip Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5259. [PMID: 37691705 PMCID: PMC10489184 DOI: 10.1097/gox.0000000000005259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/21/2023] [Indexed: 09/12/2023]
Abstract
Background Side effects of opioid pain management after surgical repair of cleft lips are numerous and affect postoperative course. We compared opioid versus opioid-free pain management regimens for infants who underwent cleft lip repair to evaluate the impact on postoperative recovery. Methods Cleft lip repairs at our institution from December 2016 to February 2021 were retrospectively reviewed, comparing patients who received opioids to patients receiving a nonopioid pain control regimen. Data collected include length of stay, oral morphine equivalents (OME) received on day of surgery (DOS)/postoperative day (POD) 1, time to and volume of first oral feed, and Face/Legs/Activity/Cry/Consolability (FLACC) scores. Results Seventy-three infants were included (47 opioid and 26 nonopioid). The opioid group received average 1.75 mg OME on DOS and 1.04 mg OME on POD1. Average DOS FLACC scores were similar between groups [1.57 ± 1.18 nonopioid versus 1.76 ± 0.94 (SD) opioid; P = 0.46]. Average POD1 FLACC scores were significantly lower for the nonopioid group (0.73 ± 1.05 versus 1.35 ± 1.06; P = 0.022). Median time to first PO (min) was similar [178 (interquartile range [IQR] 66-411) opioid versus 147 (IQR 93-351) nonopioid; P = 0.65]. Median volume of first feed (mL) was twice as high for the nonopioid group [90 (IQR 58-120) versus 45 (IQR 30-60); P = 0.003]. Conclusions Nonopioid postoperative pain management was more effective than opioids for pain management in infants after cleft lip repair, as evidenced by FLACC scores and increased volume of the first oral feed.
Collapse
Affiliation(s)
- Annie Do
- From the Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California San Francisco; San Francisco, Calif
| | - Eve Rorison
- From the Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California San Francisco; San Francisco, Calif
| | - Amber Borucki
- Department of Anesthesia, University of California San Francisco; San Francisco, Calif
| | - Gail S. Shibata
- Department of Anesthesia, University of California San Francisco; San Francisco, Calif
| | - Jason H. Pomerantz
- From the Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California San Francisco; San Francisco, Calif
| | - William Y. Hoffman
- From the Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California San Francisco; San Francisco, Calif
| |
Collapse
|
6
|
Luzzati M, Coviello C, De Veye HS, Dudink J, Lammertink F, Dani C, Koopmans C, Benders M, Tataranno ML. Morphine exposure and neurodevelopmental outcome in infants born extremely preterm. Dev Med Child Neurol 2023; 65:1053-1060. [PMID: 36649164 DOI: 10.1111/dmcn.15510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 01/18/2023]
Abstract
AIM To investigate the association between morphine exposure in the neonatal period and neurodevelopment at 2 and 5 years of age while controlling for potential confounders. METHOD We performed a retrospective, single-centre cohort study on 106 infants (60 males, 46 females; mean gestational age 26 weeks [SD 1]) born extremely preterm (gestational age < 28 weeks). Morphine administration was expressed as cumulative dose (mg/kg) until term-equivalent age. Neurodevelopmental outcome was assessed at 2 years with the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version and at 5 years with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition, Dutch version. Multiple linear regression analysis was used to assess the association between morphine exposure and outcome. RESULTS Sixty-four out of 106 (60.4%) infants included in the study received morphine. Morphine exposure was not associated with poorer motor, cognitive, and language subscores of the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version at 2 years. Morphine exposure was associated with lower Full-Scale IQ scores (p = 0.008, B = -9.3, 95% confidence interval [CI] = -15.6 to -3.1) and Performance IQ scores (p = 0.005, B = -17.5, 95% CI = -27.9 to -7) at 5 years of age. INTERPRETATION Morphine exposure in infants born preterm is associated with poorer Full-Scale IQ and Performance IQ at 5 years. Individualized morphine administration is advised in infants born extremely preterm.
Collapse
Affiliation(s)
- Michele Luzzati
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
- Division of Neonatology, University of Florence, Florence, Italy
| | | | - Henriette Swarenburg De Veye
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Femke Lammertink
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
- Division of Neonatology, University of Florence, Florence, Italy
| | - Corine Koopmans
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Manon Benders
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maria Luisa Tataranno
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
7
|
Testa A, Jacobs B, Zhang L, Jackson D, Ganson K, Nagata J. Adverse Childhood Experiences and Prescription Opioid Use During Pregnancy: An Analysis of the North and South Dakota PRAMS, 2019-2020. RESEARCH SQUARE 2023:rs.3.rs-2547252. [PMID: 37214797 PMCID: PMC10197742 DOI: 10.21203/rs.3.rs-2547252/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Objectives: This study assesses the association between adverse childhood experiences (ACEs) and prescription opioid use during pregnancy. Methods: This study uses data on 2,999 individuals from the 2019 and 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) from North Dakota and South Dakota. The relationship between ACEs and prescription opioid use during pregnancy is examined using multiple logistic regression. Results: The prevalence of prescription opioid use increases alongside accumulating ACEs. Compared to those with no ACEs, recent mothers with three or more ACEs have a 2.4 greater odds of prescription opioid use during pregnancy (aOR [adjusted odds ratio] = 2.437; 95% CI [confidence interval] = 1.319, 4.503). Conclusion: Accumulating ACEs are associated with an increased risk of prescription opioid use during pregnancy. Additional research is needed better understand the mechanisms that link ACEs and prescription opioid use during pregnancy, as well as how to best support those with ACEs exposure in a trauma-informed manner to reduce the risk of substance use.
Collapse
|
8
|
Sensorial saturation improves infants' procedure-related pain behaviour in the cardiac intensive care unit: A quasi-experimental study. Aust Crit Care 2023; 36:232-238. [PMID: 35183430 DOI: 10.1016/j.aucc.2022.01.004] [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: 08/08/2021] [Revised: 01/10/2022] [Accepted: 01/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Painful procedures are unavoidable when providing critical care to infants in intensive care units. These adverse experiences during infancy can lead to later hyperalgesia and poor neurodevelopmental outcomes. Thus, appropriate interventions are required to relieve infant pain during these procedures. OBJECTIVES This study evaluated the effectiveness of sensorial saturation in reducing pain for infants during jugular central venous catheter removal procedures in intensive care units. METHODS This study involved a quasi-experimental, repeated-measures design. Data were collected from participants sequentially recruited from April to June 2019 (control period) and July to September 2019 (experimental period). Participants included 78 infants younger than 1 year with congenital heart disease. The control group (n = 38) received a general nursing intervention using swaddling, a common child-care practice that consists of wrapping infants to restrict movements, whereas the experimental group (n = 40) received sensorial saturation using oral sugar, body massage, and verbal interaction. Infants' physiological reactions to procedural pain were measured by changes in heart rate, oxygen saturation, and respiratory rate. Infants' procedural pain and behavioural indicators were measured using the Modified Behavioural Pain Scale. Data were analysed using descriptive statistics, independent t-tests, χ2 tests, and repeated-measures analysis of variance. RESULTS Compared with the control group, the experimental group had lower heart rates (F = 53.15, p < .001), respiratory rates (F = 15.19, p < .001), and behavioural pain scores (F = 45.21, p < .001), both during and after the procedure. CONCLUSIONS Sensorial saturation can be used as a nursing intervention in infants. Given the many invasive procedures that are part of infant clinical care, sensorial saturation may be a safe analgesic alternative. The findings of this study could lead to the development of evidence-based clinical practice guidelines for the nonpharmacological management of acute pain in infants.
Collapse
|
9
|
Andropoulos DB, Dunbar BS. Neuroprotective Strategies in Anesthesia-Induced Neurotoxicity. Best Pract Res Clin Anaesthesiol 2022. [DOI: 10.1016/j.bpa.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
10
|
Development and Implementation of a Neonatal Pain Management Guideline for Minor Surgeries. Adv Neonatal Care 2022; 22:391-399. [PMID: 34991108 DOI: 10.1097/anc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use. PURPOSE To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time. METHODS An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months. RESULTS The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time. IMPLICATIONS FOR PRACTICE A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse. IMPLICATIONS FOR RESEARCH Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.
Collapse
|
11
|
Vanes LD, Murray RM, Nosarti C. Adult outcome of preterm birth: Implications for neurodevelopmental theories of psychosis. Schizophr Res 2022; 247:41-54. [PMID: 34006427 DOI: 10.1016/j.schres.2021.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
Preterm birth is associated with an elevated risk of developmental and adult psychiatric disorders, including psychosis. In this review, we evaluate the implications of neurodevelopmental, cognitive, motor, and social sequelae of preterm birth for developing psychosis, with an emphasis on outcomes observed in adulthood. Abnormal brain development precipitated by early exposure to the extra-uterine environment, and exacerbated by neuroinflammation, neonatal brain injury, and genetic vulnerability, can result in alterations of brain structure and function persisting into adulthood. These alterations, including abnormal regional brain volumes and white matter macro- and micro-structure, can critically impair functional (e.g. frontoparietal and thalamocortical) network connectivity in a manner characteristic of psychotic illness. The resulting executive, social, and motor dysfunctions may constitute the basis for behavioural vulnerability ultimately giving rise to psychotic symptomatology. There are many pathways to psychosis, but elucidating more precisely the mechanisms whereby preterm birth increases risk may shed light on that route consequent upon early neurodevelopmental insult.
Collapse
Affiliation(s)
- Lucy D Vanes
- Centre for the Developing Brain, Department of Perinatal Imaging and Health, King's College London, UK; Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Chiara Nosarti
- Centre for the Developing Brain, Department of Perinatal Imaging and Health, King's College London, UK; Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| |
Collapse
|
12
|
Xue B, Alipio JB, Kao JPY, Kanold PO. Perinatal Opioid Exposure Results in Persistent Hypoconnectivity of Excitatory Circuits and Reduced Activity Correlations in Mouse Primary Auditory Cortex. J Neurosci 2022; 42:3676-3687. [PMID: 35332087 PMCID: PMC9053845 DOI: 10.1523/jneurosci.2542-21.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/21/2022] [Accepted: 03/14/2022] [Indexed: 11/21/2022] Open
Abstract
Opioid use by pregnant women results in neonatal opioid withdrawal syndrome (NOWS) and lifelong neurobehavioral deficits including language impairments. Animal models of NOWS show impaired performance in a two-tone auditory discrimination task, suggesting abnormalities in sensory processing in the auditory cortex. To investigate the consequences of perinatal opioid exposure on auditory cortex circuits, we administered fentanyl to mouse dams in their drinking water throughout gestation and until litters were weaned at postnatal day (P)21. We then used in vivo two-photon Ca2+ imaging in adult animals of both sexes to investigate how primary auditory cortex (A1) function was altered. Perinatally exposed animals showed fewer sound-responsive neurons in A1, and the remaining sound-responsive cells exhibited lower response amplitudes but normal frequency selectivity and stimulus-specific adaptation (SSA). Populations of nearby layer 2/3 (L2/3) cells in exposed animals showed reduced correlated activity, suggesting a reduction of shared inputs. We then investigated A1 microcircuits to L2/3 cells by performing laser-scanning photostimulation (LSPS) combined with whole-cell patch-clamp recordings from A1 L2/3 cells. L2/3 cells in exposed animals showed functional hypoconnectivity of excitatory circuits of ascending inputs from L4 and L5/6 to L2/3, while inhibitory connections were unchanged, leading to an altered excitatory/inhibitory balance. These results suggest a specific reduction in excitatory ascending interlaminar cortical circuits resulting in decreased activity correlations after fentanyl exposure. We speculate that these changes in cortical circuits contribute to the impaired auditory discrimination ability after perinatal opioid exposure.SIGNIFICANCE STATEMENT This is the first study to investigate the functional effects of perinatal fentanyl exposure on the auditory cortex. Experiments show that perinatal fentanyl exposure results in decreased excitatory functional circuits and altered population activity in primary sensory areas in adult mice. These circuit changes might underlie the observed language and cognitive deficits in infants exposed to opioids.
Collapse
Affiliation(s)
- Binghan Xue
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 20215
- Department of Biology, University of Maryland, College Park, Maryland 20742
| | - Jason B Alipio
- Department of Anatomy and Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Joseph P Y Kao
- Center for Biomedical Engineering and Technology, and Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Patrick O Kanold
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland 20215
- Department of Biology, University of Maryland, College Park, Maryland 20742
| |
Collapse
|
13
|
Morrison TM, MacMillan KDL, Melvin P, Singh R, Murzycki J, Van Vleet MW, Rothstein R, O'Shea TF, Gupta M, Schiff DM, Wachman EM. Neonatal Opioid Withdrawal Syndrome: A Comparison of As-Needed Pharmacotherapy. Hosp Pediatr 2022; 12:530-538. [PMID: 35403199 DOI: 10.1542/hpeds.2021-006301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Methadone and morphine are commonly administered medications for neonatal opioid withdrawal syndrome (NOWS). Infants are increasingly treated with as-needed or "pro re nata" (PRN) medication. The optimal pharmacologic agent for PRN treatment of NOWS has not been examined. This study's objective is to compare NOWS hospital outcomes between infants treated with PRN methadone versus morphine. METHODS We performed a retrospective cohort study of infants pharmacologically treated for NOWS across 4 Massachusetts hospitals between January 2018 and February 2021. Infants born ≥36 weeks gestation with prenatal opioid exposure treated with PRN methadone or morphine were included. Mixed effects logistic and linear regression models were employed to evaluate differences in transition rates to scheduled dosing, length of stay, and number of PRN doses administered depending on PRN treatment agent. RESULTS There were 86 infants in the methadone group and 52 in the morphine group. There were no significant differences in NOWS hospital outcomes between groups in adjusted models: transition to scheduled dosing (methadone 31.6% vs morphine 28.6%, adjusted odds ratio 1.21, 95% confidence interval [CI] 0.87-1.19), mean length of stay (methadone 15.5 vs morphine 14.3 days, adjusted risk ratio 1.06, 95% CI 0.80-1.41), and the mean number of PRN doses (methadone 2.3 vs morphine 3.4, adjusted risk ratio 0.65, 95% CI 0.41-1.02). There was an association with nonpharmacologic care practices and improved NOWS hospital outcomes. CONCLUSIONS There were no significant differences in NOWS hospitalization outcomes based on pharmacologic agent type; nonpharmacologic care practices were most strongly associated with improved NOWS hospitalization outcomes.
Collapse
Affiliation(s)
| | | | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts
| | - Rachana Singh
- Department of Pediatrics, Tufts Children's Hospital, Boston, Massachusetts
| | - Jennifer Murzycki
- Department of Newborn Medicine, Lowell General Hospital, Lowell, Massachusetts
| | - Marcia W Van Vleet
- Department of Newborn Medicine, Baystate Franklin Medical Center, Greenfield, Massachusetts
| | - Robert Rothstein
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts
| | | | - Munish Gupta
- Department of Newborn Medicine, Beth Israel Hospital, Boston, Massachusetts
| | - Davida M Schiff
- Department of Pediatrics, MassGen Hospital for Children, Boston, Massachusetts
| | - Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
14
|
Pavlek LR, Mueller C, Jebbia MR, Kielt MJ, Nelin LD, Shepherd EG, Reber KM, Fathi O. Perspectives on developing and sustaining a small baby program. Semin Perinatol 2022; 46:151548. [PMID: 34895927 DOI: 10.1016/j.semperi.2021.151548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Small Baby Program at Nationwide Children's Hospital was launched in 2004 in response to a need for better care for infants born extremely preterm. Standardization of care, decreased variability, multidisciplinary support, and robust research and quality improvement have allowed us to greatly improve our outcomes. In addition to the numerous medical and technological advances during this time, a strong commitment to kangaroo care and family-centered care have been integral to the growth and success of our program. The following review of the program aims to highlight the above areas while detailing the specific processes that have contributed to its ongoing success. Key areas of focus have been on respiratory management, neurodevelopmental care, and nutritional optimization. The implementation and continued refinement of the Small Baby Program has allowed us to improve the survival of extremely preterm infants, decrease certain morbidities, and improve long-term neurodevelopmental outcomes.
Collapse
Affiliation(s)
- Leeann R Pavlek
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43205, United States.
| | - Clifford Mueller
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Maria R Jebbia
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Matthew J Kielt
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Leif D Nelin
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43205, United States
| | - Edward G Shepherd
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Kristina M Reber
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Omid Fathi
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| |
Collapse
|
15
|
Sindelar R, Shepherd EG, Ågren J, Panitch HB, Abman SH, Nelin LD. Established severe BPD: is there a way out? Change of ventilatory paradigms. Pediatr Res 2021; 90:1139-1146. [PMID: 34012026 DOI: 10.1038/s41390-021-01558-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/04/2023]
Abstract
Improved survival of extremely preterm newborn infants has increased the number of infants at risk for developing bronchopulmonary dysplasia (BPD). Despite efforts to prevent BPD, many of these infants still develop severe BPD (sBPD) and require long-term invasive mechanical ventilation. The focus of research and clinical management has been on the prevention of BPD, which has had only modest success. On the other hand, research on the management of the established sBPD patient has received minimal attention even though this condition poses large economic and health problems with extensive morbidities and late mortality. Patients with sBPD, however, have been shown to respond to treatments focused not only on ventilatory strategies but also on multidisciplinary approaches where neurodevelopmental support, growth promoting strategies, and aggressive treatment of pulmonary hypertension improve their long-term outcomes. In this review we will try to present a physiology-based ventilatory strategy for established sBPD, emphasizing a possible paradigm shift from acute efforts to wean infants at all costs to a more chronic approach of stabilizing the infant. This chronic approach, herein referred to as chronic phase ventilation, aims at allowing active patient engagement, reducing air trapping, and improving ventilation-perfusion matching, while providing sufficient support to optimize late outcomes. IMPACT: Based on pathophysiological aspects of evolving and established severe BPD in premature infants, this review presents some lung mechanical properties of the most severe phenotype and proposes a chronic phase ventilatory strategy that aims at reducing air trapping, improving ventilation-perfusion matching and optimizing late outcomes.
Collapse
Affiliation(s)
- Richard Sindelar
- University Children's Hospital, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Edward G Shepherd
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Johan Ågren
- University Children's Hospital, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Howard B Panitch
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven H Abman
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Leif D Nelin
- University Children's Hospital, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | | |
Collapse
|
16
|
Diffusion Tensor Imaging Changes Do Not Affect Long-Term Neurodevelopment following Early Erythropoietin among Extremely Preterm Infants in the Preterm Erythropoietin Neuroprotection Trial. Brain Sci 2021; 11:brainsci11101360. [PMID: 34679424 PMCID: PMC8533828 DOI: 10.3390/brainsci11101360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to evaluate diffusion tensor imaging (DTI) in infants born extremely preterm, to determine the effect of erythropoietin (Epo) on DTI, and to correlate DTI with neurodevelopmental outcomes at 2 years of age for infants in the Preterm Erythropoietin Neuroprotection (PENUT) Trial. Infants who underwent MRI with DTI at 36 weeks postmenstrual age were included. Neurodevelopmental outcomes were evaluated by Bayley Scales of Infant and Toddler Development (BSID-III). Generalized linear models were used to assess the association between DTI parameters and treatment group, and then with neurodevelopmental outcomes. A total of 101 placebo- and 93 Epo-treated infants underwent MRI. DTI white matter mean diffusivity (MD) was lower in placebo- compared to Epo-treated infants in the cingulate and occipital regions, and occipital white matter fractional isotropy (FA) was lower in infants born at 24-25 weeks vs. 26-27 weeks. These values were not associated with lower BSID-III scores. Certain decreases in clustering coefficients tended to have lower BSID-III scores. Consistent with the PENUT Trial findings, there was no effect on long-term neurodevelopment in Epo-treated infants even in the presence of microstructural changes identified by DTI.
Collapse
|
17
|
Long DA, Fink EL. Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice. Transl Pediatr 2021; 10:2858-2874. [PMID: 34765507 PMCID: PMC8578758 DOI: 10.21037/tp-21-61] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022] Open
Abstract
Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.
Collapse
Affiliation(s)
- Debbie A Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Pediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ericka L Fink
- Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
18
|
Goodstein MH, Stewart DL, Keels EL, Moon RY. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021; 148:peds.2021-052046. [PMID: 34155135 DOI: 10.1542/peds.2021-052046] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.
Collapse
Affiliation(s)
- Michael H Goodstein
- Division of Newborn Services, WellSpan Health, York, Pennsylvania .,Department of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Dan L Stewart
- Department of Pediatrics, Norton Children's and School of Medicine, University of Louisville, Louisville, Kentucky
| | - Erin L Keels
- National Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois.,Neonatal Advanced Practice, Nationwide Children's Hospital, Columbus, Ohio
| | | | | |
Collapse
|
19
|
Puia-Dumitrescu M, Comstock BA, Li S, Heagerty PJ, Perez KM, Law JB, Wood TR, Gogcu S, Mayock DE, Juul SE. Assessment of 2-Year Neurodevelopmental Outcomes in Extremely Preterm Infants Receiving Opioids and Benzodiazepines. JAMA Netw Open 2021; 4:e2115998. [PMID: 34232302 PMCID: PMC8264640 DOI: 10.1001/jamanetworkopen.2021.15998] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Extremely preterm (EP) infants frequently receive opioids and/or benzodiazepines, but these drugs' association with neurodevelopmental outcomes is poorly understood. OBJECTIVES To describe the use of opioids and benzodiazepines in EP infants during neonatal intensive care unit (NICU) hospitalization and to explore these drugs' association with neurodevelopmental outcomes at 2 years' corrected age. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of data from the Preterm Erythropoietin Neuroprotection (PENUT) Trial, which was conducted among infants born between gestational ages of 24 weeks, 0 days, and 27 weeks, 6 days. Infants received care at 19 sites in the United States, and data were collected from December 2013 to September 2016. Data analysis for this study was conducted from March to December 2020. EXPOSURES Short (ie, ≤7 days) and prolonged (ie, >7 days) exposure to opioids and/or benzodiazepines during NICU stay. MAIN OUTCOMES AND MEASURES Cognitive, language, and motor development scores were assessed using the Bayley Scales of Infant Development-Third Edition (BSID-III). RESULTS There were 936 EP infants (448 [48%] female infants; 611 [65%] White infants; mean [SD] gestational age, 181 [8] days) included in the study, and 692 (74%) had neurodevelopmental outcome data available. Overall, 158 infants (17%) were not exposed to any drugs of interest, 297 (32%) received either opioids or benzodiazepines, and 481 (51%) received both. Infants exposed to both had adjusted odds ratios of 9.7 (95% CI, 2.9 to 32.2) for necrotizing enterocolitis and 1.7 (95% CI, 1.1 to 2.7) for severe bronchopulmonary dysplasia; they also had a longer estimated adjusted mean difference in length of stay of 34.2 (95% CI, 26.2 to 42.2) days compared with those who received neither drug. After adjusting for site and propensity scores derived for each exposure category, infants exposed to opioids and benzodiazepines had lower BSID-III cognitive, motor, and language scores compared with infants with no exposure (eg, estimated difference in mean scores on cognitive scale: -5.72; 95% CI, -8.88 to -2.57). Prolonged exposure to morphine, fentanyl, midazolam, or lorazepam was associated with lower BSID-III scores compared with infants without exposure (median [interquartile range] motor score, 85 [73-97] vs 97 [91-107]). In contrast, BSID-III scores for infants with short exposure to both opioids and benzodiazepines were not different than those of infants without exposure. CONCLUSIONS AND RELEVANCE In this study, prolonged combined use of opioids and benzodiazepines was associated with a risk of poorer neurodevelopmental outcomes as measured by BSID-III at 2 years' corrected age.
Collapse
Affiliation(s)
- Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | | | - Sijia Li
- Department of Biostatistics, University of Washington, Seattle
| | | | - Krystle M. Perez
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Janessa B. Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| |
Collapse
|
20
|
Effect of combined pharmacological, behavioral, and physical interventions for procedural pain on salivary cortisol and neurobehavioral development in preterm infants: a randomized controlled trial. Pain 2021; 162:253-262. [PMID: 32773596 DOI: 10.1097/j.pain.0000000000002015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Repeated procedural pain may lead to increased secretion of cortisol and future neurobehavioral development disorders in preterm infants. Changes in the cortisol level may mediate the effect of neonatal repetitive procedural pain on altered childhood neurobehavioral development in preterm infants. However, few studies have investigated the effect of combined pharmacological, behavioral, and physical interventions over repeated painful procedures on pain response, cortisol level, and neurobehavioral development. This study examined (1) the efficacy and safety of sucrose combined with massage, music, non-nutritive sucking, and gentle human touch to treat preterm infants with repeated procedural pain; (2) the cortisol level at discharge from the neonatal intensive care unit (NICU); (3) neurobehavioral development at 40 weeks' corrected gestational age; and (4) the potential mediating effect of the cortisol level in the combined interventions on neurobehavioral development. Stable preterm infants (n = 76) were randomized to receive routine care or combined interventions across repeated painful procedures throughout their NICU stay. The Premature Infant Pain Profile scores in the early, middle, and late periods of the NICU stay were measured, as were the basal salivary cortisol level at admission and discharge, the Neonatal Behavioral Neurological Assessment score at 40 weeks' corrected gestational age, and the incidence of adverse effects during the study period. Our findings indicated that the combined interventions remained efficacious and safe for reducing repeated procedural pain, decreased the cortisol level at discharge, and promoted early neurobehavioral development in preterm infants. This effect may have been mediated through decreased cortisol levels and reduced repeated procedural pain.
Collapse
|
21
|
de Tristan MA, Martin-Marchand L, Roué JM, Anand KJS, Pierrat V, Tourneux P, Kuhn P, Milesi C, Benhammou V, Ancel PY, Carbajal R, Durrmeyer X. Association of Continuous Opioids and/or Midazolam During Early Mechanical Ventilation with Survival and Sensorimotor Outcomes at Age 2 Years in Premature Infants: Results from the French Prospective National EPIPAGE 2 Cohort. J Pediatr 2021; 232:38-47.e8. [PMID: 33395567 DOI: 10.1016/j.jpeds.2020.12.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the association of early continuous infusions of opioids and/or midazolam with survival and sensorimotor outcomes at age 2 years in very premature infants who were ventilated. STUDY DESIGN This national observational study included premature infants born before 32 weeks of gestation intubated within 1 hour after birth and still intubated at 24 hours from the French EPIPAGE 2 cohort. Infants only treated with bolus were excluded. Treated infants received continuous opioid and/or midazolam infusion started before 7 days of life and before the first extubation. Naive infants did not receive these treatments before the first extubation, or received them after the first week of life, or never received them. This study compared treated (n = 450) vs naive (n = 472) infants by using inverse probability of treatment weighting after multiple imputation in chained equations. The primary outcomes were survival and survival without moderate or severe neuromotor or sensory impairment at age 2 years. RESULTS Survival at age 2 years was significantly higher in the treated group (92.5% vs 87.9%, risk difference, 4.7%; 95% CI, 0.3-9.1; P = .037), but treated and naive infants did not significantly differ for survival without moderate or severe neuromotor or sensory impairment (86.6% vs 81.3%; risk difference, 5.3%; 95% CI -0.3 to 11.0; P = .063). These results were confirmed by sensitivity analyses using 5 alternative models. CONCLUSIONS Continuous opioid and/or midazolam infusions in very premature infants during initial mechanical ventilation that continued past 24 hours of life were associated with improved survival without any difference in moderate or severe sensorimotor impairments at age 2 years.
Collapse
Affiliation(s)
- Marie-Amélie de Tristan
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France
| | - Laetitia Martin-Marchand
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France
| | - Jean-Michel Roué
- Neonatal Intensive Care Unit, University Hospital of Brest, Brest, France
| | - Kanwaljeet J S Anand
- Department of Pediatrics, Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Véronique Pierrat
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France; Department of Neonatal Medicine, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Pierre Tourneux
- Neonatal Intensive Care Unit, CHU Amiens - University of Picardie Jules Verne, Amiens, France
| | - Pierre Kuhn
- Neonatal Intensive Care Unit, CHU Strasbourg, France, University of Strasbourg, INSERM Institute of Cellular and Integrative Neurosciences, Strasbourg, France
| | - Christophe Milesi
- Pediatric and Neonatal Intensive Care Unit, University Hospital of Montpellier, Montpellier, France
| | - Valérie Benhammou
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France
| | - Pierre-Yves Ancel
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France
| | - Ricardo Carbajal
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France; Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Armand Trousseau Hospital, Paris, France; Sorbonne University, Faculty of Medecine, Paris, France
| | - Xavier Durrmeyer
- Center of Research in Epidemiology and Statistics, University of Paris, CRESS, INSERM, INRA, Paris, France; Neonatal Intensive Care Unit, Hospital Center Intercommunal Créteil, Créteil, France; University of Paris East Créteil, Faculty of Medecine, Mondor Biomedical Research Institute, Clinical Research Group Cardiovascular and Respiratory Manifestations of Acute Lung Injury and Sepsis, Créteil, France.
| |
Collapse
|
22
|
Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
Collapse
Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
| |
Collapse
|
23
|
Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
Collapse
Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| |
Collapse
|
24
|
Puthoff TD, Veneziano G, Kulaylat AN, Seabrook RB, Diefenbach KA, Ryshen G, Hastie S, Lane A, Renner L, Bapat R. Development of a Structured Regional Analgesia Program for Postoperative Pain Management. Pediatrics 2021; 147:peds.2020-0138. [PMID: 33602800 DOI: 10.1542/peds.2020-0138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019. METHODS A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time. RESULTS There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups. CONCLUSIONS We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program.
Collapse
Affiliation(s)
| | - Giorgio Veneziano
- Nationwide Children's Hospital, Columbus, Ohio; and.,The Ohio State University, Columbus, Ohio
| | | | - Ruth B Seabrook
- Nationwide Children's Hospital, Columbus, Ohio; and.,The Ohio State University, Columbus, Ohio
| | - Karen A Diefenbach
- Nationwide Children's Hospital, Columbus, Ohio; and.,The Ohio State University, Columbus, Ohio
| | - Greg Ryshen
- Nationwide Children's Hospital, Columbus, Ohio; and
| | - Sarah Hastie
- Nationwide Children's Hospital, Columbus, Ohio; and
| | - Autumn Lane
- Nationwide Children's Hospital, Columbus, Ohio; and
| | | | - Roopali Bapat
- Nationwide Children's Hospital, Columbus, Ohio; and .,The Ohio State University, Columbus, Ohio
| |
Collapse
|
25
|
Davis NL, Akinmboni TO, Mooney SM. Quantifying Medication Exposure in Very Low Birth Weight Neonates. Am J Perinatol 2021; 38:383-391. [PMID: 31683322 DOI: 10.1055/s-0039-1697669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Very low birth weight (VLBW) infants are exposed to medications with insufficient evidence describing pharmacokinetics and safety. Objective was to quantify and identify risk factors associated with the highest quartile of medication exposure. STUDY DESIGN Retrospective record review of VLBW infants admitted to a level-IV neonatal intensive care unit (NICU). We obtained baseline clinical and demographic characteristics, as well as data on all medications received during admission. Characteristics of patients within the upper quartile of medication use were compared with remaining patients. RESULTS Identified 106 infants, mean birth weight (BW) = 961 g, gestational age = 27.3 weeks. Infants received a median = 20 medications (range, 4-72). Those in the top quartile of medication use received ≥30 medications while in the NICU and had higher odds of being male sex, lower BW, longer length of hospital stay (LOHS), and bronchopulmonary dysplasia. Sepsis did not affect medication exposure. Antibiotics, opiates, and reflux medications were among the top prescribed. CONCLUSION Infants are exposed to a large number of medications during NICU hospitalization, including potentially unnecessary antibiotics and reflux medications. Male sex, the presence of certain comorbidities such as necrotizing enterocolitis, and LOHS, are associated with higher exposure. Increased awareness of this issue may assist in decreasing medication exposure in VLBW populations.
Collapse
Affiliation(s)
- Natalie L Davis
- Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Temitope O Akinmboni
- Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sandra M Mooney
- Department of Nutrition, University of North Carolina Nutrition Research Institute, University of North Carolina Chapel Hill, Kannapolis, North Carolina
| |
Collapse
|
26
|
Gao H, Gao H, Li M, Zhang H, Wang D, Wang B. Morphine use in the neonatal period and later neuropsychological development: a systematic review. Dev Med Child Neurol 2021; 63:22-28. [PMID: 33078421 DOI: 10.1111/dmcn.14703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 01/31/2023]
Abstract
AIM To identify and evaluate the evidence documenting the association between neonatal morphine and later childhood neuropsychological development. METHOD We conducted a systematic literature search of eight electronic databases from inception until June 2019. We included all randomized controlled trials (RCTs) and cohort studies recruiting neonates who received morphine treatment, and measuring neuropsychological development outcomes with a minimum follow-up of 6 months. RESULTS Twelve separate reports from three RCTs and five cohort studies met our inclusion criteria. Owing to the small number of the included trials and the variable study designs, a meta-analysis was not performed. The findings from this review indicated that neonatal morphine use had no adverse effects on behaviour, cognition, motor, and executive function development at 8 to 9 years and earlier; except for the inconsistent conclusions on internalizing behavioural problems at 5 to 7 years and cognitive and motor developments at 18 months. INTERPRETATION Why a child needs morphine may have a more profound impact on later neuropsychological development than morphine itself. The small number, high heterogeneity, and limitations of the included studies limit confidence in the result of this systematic review.
Collapse
Affiliation(s)
- Haixia Gao
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Honglian Gao
- Binzhou Medical University Hospital, Binzhou, China
| | - Mei Li
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hua Zhang
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Danwen Wang
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Bin Wang
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
| |
Collapse
|
27
|
Abstract
The entire field of medicine, not just anesthesiology, has grown comfortable with the risks posed by opioids; but these risks are unacceptably high. It is time for a dramatic paradigm shift. If used at all for acute or chronic pain management, they should be used only after consideration and maximizing the use of nonopioid pharmacologic agents, regional analgesia techniques, and nonpharmacologic methods. Opioids poorly control pain, their intraoperative use may increase the risk of recurrence of some types of cancer, and they have a large number of both minor and serious side effects. Furthermore, there are a myriad of alternative analgesic strategies that provide superior analgesia, decrease recovery time, and have fewer side effects and risks associated with their use. In this article the negative consequences of opioid use for pain, appropriate alternatives to opioids for analgesia, and the available evidence in pediatric populations for both are described.
Collapse
|
28
|
Al-Mouqdad MM, Khalil TM, Asfour SS. Retrospective study of short-term complications associated with early morphine use in intubated premature infants. Sci Rep 2020; 10:10874. [PMID: 32616894 PMCID: PMC7331726 DOI: 10.1038/s41598-020-67891-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/10/2020] [Indexed: 11/15/2022] Open
Abstract
Relieving neonatal pain is essential for the management of premature infants. Morphine is the most frequently used analgesic in neonatal intensive care. Here we report the relationship between early morphine infusion and the composite outcome of intraventricular hemorrhage and/or death in intubated premature infants. Infants (gestational age ≤ 32 weeks and birth weight < 1,500 g) intubated on admission were retrospectively evaluated in a large tertiary neonatal intensive care unit. Modified log-Poisson regression with robust variance estimator and Cox regression was applied to adjust the relative risk for infants’ outcomes. Of 420 premature infants, 230 (54.7%) received continuous morphine infusion in the first 72 h. Of these, 153 were < 28 gestational weeks; of the 190 patients who did not receive morphine, 63 were < 28 gestational weeks. The analysis revealed that infants < 28 gestational weeks who received morphine were significantly associated with an increased risk for IVH and/or death [adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.1–1.71)], and mortality (aRR 1.83, 95% CI 1.17–2.89). Moreover, in infants < 28 gestational weeks, survival was low in those infants who were exposed to morphine infusion in the first 72 h (hazard ratio 2.11; 95% CI 1.19–3.73). Early morphine infusion is associated with an increased risk for IVH and/or death; however, further studies are required to verify our findings.
Collapse
Affiliation(s)
- Mountasser M Al-Mouqdad
- Neonatal Intensive Care, NICU Department, Hospital of Paediatrics, King Saud Medical City, Al Imam Abdul Aziz Ibn Muhammad Ibn Saud, Riyadh, 12746, Saudi Arabia.
| | - Thanaa M Khalil
- Obstetric and Gynecology Department, Maternity Hospital, King Saud Medical City, Riyadh, Saudi Arabia
| | - Suzan S Asfour
- Clinical Pharmacy Department, Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
29
|
Dallefeld SH, Smith PB, Crenshaw EG, Daniel KR, Gilleskie ML, Smith DS, Balevic S, Greenberg RG, Chu V, Clark R, Kumar KR, Zimmerman KO. Comparative safety profile of chloral hydrate versus other sedatives for procedural sedation in hospitalized infants. J Neonatal Perinatal Med 2020; 13:159-165. [PMID: 32538879 DOI: 10.3233/npm-190214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Given the limited available evidence on chloral hydrate safety in neonatal populations and the discrepancy in chloral hydrate acceptance between the US and other countries, we sought to clarify the safety profile of chloral hydrate compared to other sedatives in hospitalized infants. METHODS We included all infants <120 days of life who underwent a minor procedure and were administered chloral hydrate, clonidine, clonazepam, dexmedetomidine, diazepam, ketamine, lorazepam, midazolam, propofol, or pentobarbital on the day of the procedure. We characterized the distribution of infant characteristics and evaluated the relationship between drug administration and any adverse event. We performed propensity score matching, regression adjustment (RA), and inverse probability weighting (IPW) to ensure comparison of similar infants and to account for confounding by indication and residual bias. Results were assessed for robustness to analytical technique by reanalyzing the main outcomes with multivariate logistic regression, a doubly robust IPW with RA model, and a doubly robust augmented IPW model with bias-correction. RESULTS Of 650 infants, 497 (76%) received chloral hydrate, 79 (12%) received midazolam, 54 (8%) received lorazepam, and 15 (2%) received pentobarbital. Adverse events occurred in 41 (6%) infants. Using propensity score matching, chloral hydrate was associated with a decreased risk of an adverse event compared to other sedatives, risk difference (95% confidence interval) of -12.79 (-18.61, -6.98), p < 0.001. All other statistical methods resulted in similar findings. CONCLUSION Administration of chloral hydrate to hospitalized infants undergoing minor procedures is associated with a lower risk for adverse events compared to other sedatives.
Collapse
Affiliation(s)
- S H Dallefeld
- Pediatric Intensive Care Unit, Dell Children's Medical Center of Central Texas, Austin, TX, USA.,Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - P B Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - E G Crenshaw
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - K R Daniel
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - M L Gilleskie
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - D S Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - S Balevic
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - R G Greenberg
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Vivian Chu
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - R Clark
- Pediatrix Medical Group, Inc, Sunrise, FL, USA
| | - K R Kumar
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - K O Zimmerman
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| |
Collapse
|
30
|
The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery. Plast Reconstr Surg 2020; 145:507-516. [PMID: 31985649 DOI: 10.1097/prs.0000000000006471] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population. METHODS After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores. RESULTS The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924). CONCLUSIONS Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
|
31
|
Guo W, Liu X, Zhou X, Wu T, Sun J. Efficacy and safety of combined nonpharmacological interventions for repeated procedural pain in preterm neonates: A systematic review of randomized controlled trials. Int J Nurs Stud 2020; 102:103471. [DOI: 10.1016/j.ijnurstu.2019.103471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
|
32
|
Mesek I, Nellis G, Lass J, Metsvaht T, Varendi H, Visk H, Turner MA, Nunn AJ, Duncan J, Lutsar I. Medicines prescription patterns in European neonatal units. Int J Clin Pharm 2019; 41:1578-1591. [PMID: 31625122 DOI: 10.1007/s11096-019-00923-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
Background Hospitalized neonates receive the highest number of drugs compared to all other age groups, but consumption rates vary between studies depending on patient characteristics and local practices. There are no large-scale international studies on drug use in neonatal units. Objective We aimed to describe drug use in European neonatal units and characterize its associations with geographic region and gestational age. Setting A one-day point prevalence study was performed as part of the European Study of Neonatal Exposure to Excipients from January to June 2012. Method All neonatal prescriptions and demographic data were registered in a web-based database. The impact of gestational age and region on prescription rate were analysed with logistic regression. Main outcome measure The number and variety of drugs prescribed to hospitalized neonates in different gestational age groups and geographic regions. Results In total, 21 European countries with 89 neonatal units participated. Altogether 2173 prescriptions given to 726 neonates were registered. The 10 drugs with the highest prescription rate were multivitamins, vitamin D, caffeine, gentamicin, amino acids for parenteral nutrition, phytomenadione, ampicillin, benzylpenicillin, fat emulsion for parenteral nutrition and probiotics. The six most commonly prescribed ATC groups (alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous, respiratory and cardiovascular system) covered 98% of prescriptions. Gestational age significantly affected the use of all commonly used drug groups. Geographic region influenced the use of alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous and respiratory system drugs. Conclusion While gestational age-dependent differences in neonatal drug use were expected, regional variations (except for systemic anti-infectives) indicate a need for cooperation in developing harmonized evidence-based guidelines and suggest priorities for collaborative work.
Collapse
Affiliation(s)
- Inge Mesek
- Department of Microbiology, University of Tartu, Tartu, Estonia.
| | - Georgi Nellis
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Jana Lass
- Department of Microbiology, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Clinic of Anaesthesiology and Intensive Care, Paediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Heili Varendi
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Helle Visk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anthony J Nunn
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jennifer Duncan
- Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| |
Collapse
|
33
|
Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach. Clin Ther 2019; 41:1701-1713. [PMID: 31431300 DOI: 10.1016/j.clinthera.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain. FINDINGS After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking. IMPLICATIONS The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.
Collapse
|
34
|
Ryan M, Lacaze-Masmonteil T, Mohammad K. La neuroprotection contre les lésions cérébrales aiguës chez les nouveau-nés prématurés. Paediatr Child Health 2019. [DOI: 10.1093/pch/pxz057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michelle Ryan
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | | | - Khorshid Mohammad
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| |
Collapse
|
35
|
Ryan M, Lacaze-Masmonteil T, Mohammad K. Neuroprotection from acute brain injury in preterm infants. Paediatr Child Health 2019; 24:276-290. [PMID: 31239818 DOI: 10.1093/pch/pxz056] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Infants born at ≤32+6 weeks gestation are at higher risk for intracranial ischemic and hemorrhagic injuries, which often occur in the first 72 hours postbirth. Antenatal strategies to reduce the incidence of acute brain injuries include administering maternal corticosteroids and prompt antibiotic treatment for chorioamnionitis. Perinatal strategies include delivery within a tertiary centre, delayed cord clamping, and preventing hypothermia. Postnatal strategies include empiric treatment with antibiotics when chorioamnionitis is suspected, the cautious use of inotropes, the avoidance of blood PCO2 fluctuation, and neutral head positioning. Clinicians should be aware of the policies and procedures that, especially when combined, can provide neuroprotection for preterm infants.
Collapse
Affiliation(s)
- Michelle Ryan
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | | | - Khorshid Mohammad
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| |
Collapse
|
36
|
Early Developmental Exposure to Repetitive Long Duration of Midazolam Sedation Causes Behavioral and Synaptic Alterations in a Rodent Model of Neurodevelopment. J Neurosurg Anesthesiol 2019; 31:151-162. [PMID: 30767941 DOI: 10.1097/ana.0000000000000541] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is a large body of preclinical literature suggesting that exposure to general anesthetic agents during early life may have harmful effects on brain development. Patients in intensive care settings are often treated for prolonged periods with sedative medications, many of which have mechanisms of action that are similar to general anesthetics. Using in vivo studies of the mouse hippocampus and an in vitro rat cortical neuron model we asked whether there is evidence that repeated, long duration exposure to midazolam, a commonly used sedative in pediatric intensive care practice, has the potential to cause lasting harm to the developing brain. We found that mice that underwent midazolam sedation in early postnatal life exhibited deficits in the performance on Y-maze and fear-conditioning testing at young adult ages. Labeling with a nucleoside analog revealed a reduction in the rate of adult neurogenesis in the hippocampal dentate gyrus, a brain region that has been shown to be vulnerable to developmental anesthetic neurotoxicity. In addition, using immunohistochemistry for synaptic markers we found that the number of presynaptic terminals in the dentate gyrus was reduced, while the number of excitatory postsynaptic terminals was increased. These findings were replicated in a midazolam sedation exposure model in neurons in culture. We conclude that repeated, long duration exposure to midazolam during early development has the potential to result in persistent alterations in the structure and function of the brain.
Collapse
|
37
|
Ferraz P, Barros M, Miyoshi M, Davidson J, Guinsburg R. Bundle to reduce unplanned extubation in a neonatal intensive care unit. J Matern Fetal Neonatal Med 2019; 33:3077-3085. [DOI: 10.1080/14767058.2019.1568981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Priscila Ferraz
- Pediatric Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Marina Barros
- Pediatric Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Milton Miyoshi
- Pediatric Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Josy Davidson
- Pediatric Department, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | |
Collapse
|
38
|
Rubenstein E, Young JC, Croen LA, DiGuiseppi C, Dowling NF, Lee LC, Schieve L, Wiggins LD, Daniels J. Brief Report: Maternal Opioid Prescription from Preconception Through Pregnancy and the Odds of Autism Spectrum Disorder and Autism Features in Children. J Autism Dev Disord 2019; 49:376-382. [PMID: 30132098 PMCID: PMC6331251 DOI: 10.1007/s10803-018-3721-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Opioid use during pregnancy is associated with suboptimal pregnancy outcomes. Little is known about child neurodevelopmental outcomes. We examined associations between maternal opioid prescriptions preconception to delivery (peri-pregnancy) and child's risk of ASD, developmental delay/disorder (DD) with no ASD features, or ASD/DD with autism features in the Study to Explore Early Development, a case-control study of neurodevelopment. Preconception opioid prescription was associated with 2.43 times the odds of ASD [95% confidence interval (CI) 0.99, 6.02] and 2.64 times the odds of ASD/DD with autism features (95% CI 1.10, 6.31) compared to mothers without prescriptions. Odds for ASD and ASD/DD were non-significantly elevated for first trimester prescriptions. Work exploring mechanisms and timing between peri-pregnancy opioid use and child neurodevelopment is needed.
Collapse
Affiliation(s)
- Eric Rubenstein
- Waisman Center, University of Wisconsin-Madison, Rm 529, 1500 Highland Avenue, Madison, WI, 53705, USA.
| | - Jessica C Young
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Lisa A Croen
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Carolyn DiGuiseppi
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus School of Public Health, 13001 E. 17th Place, Aurora, CO, 80045, USA
| | - Nicole F Dowling
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Li-Ching Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Laura Schieve
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Lisa D Wiggins
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Julie Daniels
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| |
Collapse
|
39
|
Oda A, Kamei Y, Hiroma T, Nakamura T. Neurally adjusted ventilatory assist in extremely low-birthweight infants. Pediatr Int 2018; 60:844-848. [PMID: 29944776 DOI: 10.1111/ped.13646] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 05/28/2018] [Accepted: 06/22/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is expected to improve respiratory outcomes in preterm infants, but it has not yet been evaluated. We investigated whether NAVA could improve respiratory outcomes and reduce sedation use in extremely low-birthweight infants (ELBWI). METHODS A retrospective cohort study was conducted based on patient charts at the Nagano Children's Hospital neonatal intensive care unit, Japan. Infants who were born at <27 weeks' gestation were included. We assessed the prevalence of bronchopulmonary dysplasia (BPD), home oxygen therapy (HOT), duration of intubation, and sedation use. RESULTS The NAVA group consisted of 14 ELBWI who were born at <27 weeks' gestation between September 2013 and September 2015. A total of 21 ELBWI born between September 2011 and September 2013, before NAVA implementation, served as the control group. There were no significant differences in the perinatal background characteristics between the two groups. For respiratory outcomes, no significant between-group differences were found in the prevalence of BPD and HOT or the duration of intubation. The total duration of sedation use was not significantly different between the two groups, but in the NAVA group, midazolam was discontinued in all cases after the infants were switched to NAVA. CONCLUSIONS NAVA was safe in preterm infants and had a similar effect to conventional mechanical ventilation with regard to respiratory outcomes and sedation use in the chronic phase; thus, NAVA could be used in the early phase, at least before BPD worsens to improve respiratory outcomes in ELBWI.
Collapse
Affiliation(s)
- Arata Oda
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan.,Division of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Yoshiya Kamei
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan
| | - Takehiko Hiroma
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan.,Division of Neonatology, Shinshu University, Nagano, Japan
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan.,Division of Neonatology, Shinshu University, Nagano, Japan
| |
Collapse
|
40
|
|
41
|
Effect of non-nutritive sucking and sucrose alone and in combination for repeated procedural pain in preterm infants: A randomized controlled trial. Int J Nurs Stud 2018; 83:25-33. [DOI: 10.1016/j.ijnurstu.2018.04.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/13/2022]
|
42
|
Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Schwerdtle T, Vollmer G, Wallace H, Benford D, Calò G, Dahan A, Dusemund B, Mulder P, Németh-Zámboriné É, Arcella D, Baert K, Cascio C, Levorato S, Schutte M, Vleminckx C. Update of the Scientific Opinion on opium alkaloids in poppy seeds. EFSA J 2018; 16:e05243. [PMID: 32625895 PMCID: PMC7009406 DOI: 10.2903/j.efsa.2018.5243] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.
Collapse
|
43
|
Shapiro MC, Henderson CM, Hutton N, Boss RD. Defining Pediatric Chronic Critical Illness for Clinical Care, Research, and Policy. Hosp Pediatr 2017; 7:236-244. [PMID: 28351944 DOI: 10.1542/hpeds.2016-0107] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronically critically ill pediatric patients represent an emerging population in NICUs and PICUs. Chronic critical illness has been recognized and defined in the adult population, but the same attention has not been systematically applied to pediatrics. This article reviews what is currently known about pediatric chronic critical illness, highlighting the unique aspects of chronic critical illness in infants and children, including specific considerations of prognosis, outcomes, and decision-making. We propose a definition that incorporates NICU versus PICU stays, recurrent ICU admissions, dependence on life-sustaining technology, multiorgan dysfunction, underlying medical complexity, and the developmental implications of congenital versus acquired conditions. We propose a research agenda, highlighting existing knowledge gaps and targeting areas of improvement in clinical care, research, and policy.
Collapse
Affiliation(s)
- Miriam C Shapiro
- Johns Hopkins University School of Medicine, Baltimore, Maryland; .,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- University of Mississippi Medical Center, Jackson, Mississippi; and.,Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Nancy Hutton
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
| |
Collapse
|
44
|
Zuzarte I, Indic P, Barton B, Paydarfar D, Bednarek F, Bloch-Salisbury E. Vibrotactile stimulation: A non-pharmacological intervention for opioid-exposed newborns. PLoS One 2017; 12:e0175981. [PMID: 28426726 PMCID: PMC5398650 DOI: 10.1371/journal.pone.0175981] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/03/2017] [Indexed: 02/03/2023] Open
Abstract
Objective To examine the therapeutic potential of stochastic vibrotactile stimulation (SVS) as a complementary non-pharmacological intervention for withdrawal in opioid-exposed newborns. Study design A prospective, within-subjects single-center study was conducted in 26 opioid-exposed newborns (>37 weeks; 16 male) hospitalized since birth and treated pharmacologically for Neonatal Abstinence Syndrome. A specially-constructed mattress delivered low-level SVS (30-60Hz, 10–12μm RMS), alternated in 30-min intervals between continuous vibration (ON) and no vibration (OFF) over a 6–8 hr session. Movement activity, heart rate, respiratory rate, axillary temperature and blood-oxygen saturation were calculated separately for ON and OFF. Results There was a 35% reduction in movement activity with SVS (p<0.001), with significantly fewer movement periods >30 sec duration for ON than OFF (p = 0.003). Incidents of tachypneic breaths and tachycardic heart beats were each significantly reduced with SVS, whereas incidents of eupneic breaths and eucardic heart beats each significantly increased with SVS (p<0.03). Infants maintained body temperature and arterial-blood oxygen level independent of stimulation condition. Conclusions SVS reduced hyperirritability and pathophysiological instabilities commonly observed in pharmacologically-managed opioid-exposed newborns. SVS may provide an effective complementary therapeutic intervention for improving autonomic function in newborns with Neonatal Abstinence Syndrome.
Collapse
Affiliation(s)
- Ian Zuzarte
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Premananda Indic
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Bruce Barton
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - David Paydarfar
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts, United States of America
| | - Francis Bednarek
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Elisabeth Bloch-Salisbury
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
45
|
Zimmerman KO, Smith PB, Benjamin DK, Laughon M, Clark R, Traube C, Stürmer T, Hornik CP. Sedation, Analgesia, and Paralysis during Mechanical Ventilation of Premature Infants. J Pediatr 2017; 180:99-104.e1. [PMID: 27522446 PMCID: PMC5183489 DOI: 10.1016/j.jpeds.2016.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 07/01/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To characterize administration of sedatives, analgesics, and paralytics in a large cohort of mechanically ventilated premature infants. STUDY DESIGN Retrospective cohort study including all infants <1500 g birth weight and <32 weeks gestational age (GA) mechanically ventilated at 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. The primary outcome is the proportion of mechanically ventilated days in which infants were administered drugs of interest. Multivariable logistic regression was used to evaluate the predictors of administration of drugs of interest. RESULTS We identified 85 911 mechanically ventilated infants. Infants received a drug of interest (opioids, benzodiazepines, other sedatives, and paralytics) on 433 587/1 305 413 (33%) of mechanically ventilated infant days. The administration of opioids increased during the study period from 5% of infant days in 1997 to 32% in 2012. The administration of benzodiazepines increased during the study period from 5% of infant days in 1997 to 24% in 2012. Use of paralytics and other drugs remained ≤1% throughout the study period. Predictors of drug administration included younger GA, small for GA status, male sex, presence of a major congenital anomaly, older postnatal age at intubation, exposure to high-frequency ventilation, exposure to inotropes, more recent year of discharge, and neonatal intensive care unit site. CONCLUSIONS Administration of opioids and benzodiazepines in mechanically ventilated premature infants increased over time. Because infant characteristics were unchanged, site-specific differences in practice likely explain our observations. Increased administration over time is concerning given limited evidence of benefit and potential for harm.
Collapse
Affiliation(s)
- Kanecia O Zimmerman
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Matthew Laughon
- Department of Pediatrics, Division of Neonatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC.
| |
Collapse
|
46
|
Neurally adjusted ventilatory assist (NAVA) in preterm newborn infants with respiratory distress syndrome-a randomized controlled trial. Eur J Pediatr 2016; 175:1175-1183. [PMID: 27502948 DOI: 10.1007/s00431-016-2758-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/11/2016] [Accepted: 07/29/2016] [Indexed: 12/17/2022]
Abstract
UNLABELLED Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator synchrony during invasive ventilation and leads to lower peak inspiratory pressures (PIP) and oxygen requirements. The aim of this trial was to compare NAVA with current standard ventilation in preterm infants in terms of the duration of invasive ventilation. Sixty infants born between 28 + 0 and 36 + 6 weeks of gestation and requiring invasive ventilation due to neonatal respiratory distress syndrome (RDS) were randomized to conventional ventilation or NAVA. The median durations of invasive ventilation were 34.7 h (quartiles 22.8-67.9 h) and 25.8 h (15.6-52.1 h) in the NAVA and control groups, respectively (P = 0.21). Lower PIPs were achieved with NAVA (P = 0.02), and the rapid reduction in PIP after changing the ventilation mode to NAVA made following the predetermined extubation criteria challenging. The other ventilatory and vital parameters did not differ between the groups. Frequent apneas and persistent pulmonary hypertension were conditions that limited the use of NAVA in 17 % of the patients randomized to the NAVA group. Similar cumulative doses of opiates were used in both groups (P = 0.71). CONCLUSIONS NAVA was a safe and feasible ventilation mode for the majority of preterm infants suffering from RDS, but the traditional extubation criteria were not clinically applicable during NAVA. WHAT IS KNOWN • NAVA improves patient-ventilator synchrony during invasive ventilation. • Lower airway pressures and oxygen requirements are achieved with NAVA during invasive ventilation in preterm infants by comparison with conventional ventilation. What is new: • Infants suffering from PPHN did not tolerate NAVA in the acute phase of their illness. • The traditional extubation criteria relying on inspiratory pressures and spontaneous breathing efforts were not clinically applicable during NAVA.
Collapse
|