Long-term effects of neonatal pain

Exploring implementation processes of a parent-targeted educational video for improving newborn pain treatment: A sequential exploratory mixed-methods study

Despite known analgesic effects of breastfeeding (BF), skin-to-skin care (SSC), and sweet solutions (sucrose) for newborns, these interventions remain underutilized. Our team produced a five-minute parent-targeted video (BSweet2Babies) demonstrating BF, SSC, and sucrose during newborn blood sampling. We conducted a sequential exploratory mixed-methods study with eight maternal-newborn units across Ontario, Canada to identify barriers and facilitators to implementing the video and the three pain management strategies.Over a 6-month period, data collection included 15 telephone interviews, two email communications, and three community of practice teleconferences with the participating sites (n = 8). We used the Theoretical Domains Framework as the coding matrix. Participants discussed integrating the video in prenatal education and the importance of involving leadership when planning for practice change. Key barriers included lack of comfort with parental presence, perception of high complexity of the strategies, short postpartum stays, competing priorities, and interprofessional challenges. Key facilitators included alignment with the Baby-Friendly Hospital Initiative, modeling by Lactation Consultants, and frequent reminders.

Sedation and Pain Management in Neonates Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy

Hypoxic-ischemic encephalopathy (HIE) is a common cause of significant neonatal morbidity and mortality. The stronghold of the treatment for moderate-to-severe HIE is therapeutic hypothermia (TH) which provides a neuroprotective effect. However, it also is associated with pain and stress. Moreover, neonates with HIE are subjected to a significant number of painful procedures. Untreated pain during the early neonatal period may entail future challenges such as impaired brain growth and development as well as impaired pain sensitivity later in life. Hereby, the provision of adequate sedation and alleviation of pain and discomfort is essential. There are currently no universally accepted guidelines for sedation and pain management for this patient population. In this review, we highlight non-pharmacologic and pharmacologic methods currently in use to provide comfort and sedation to patients with HIE undergoing TH.

Does birth weight or preterm birth predict worse pain prognosis in adulthood? A Northern Finland Birth Cohort study followed up to 46 years of age

Although pain is a highly common symptom, only a subset of individuals develops chronic and disabling conditions. Delving into the predictors for poor musculoskeletal pain (MSK) outcomes in adulthood may help identify those needing early prevention and intervention. This study aimed to evaluate whether birth weight or preterm birth predicts worse prognosis of MSK pain in adulthood. Participants in the Northern Finland Birth Cohort 1966 were followed from birth to 46 years of age. Associations of birth weight (measured using corrections to gestational age) and preterm birth (<37 completed weeks) with high-risk classification for worse pain using three prognostic tools: the Örebro Musculoskeletal Pain Screening Questionnaire-Short Form (ÖMPSQ-SF), STartT Back Tool (SBT), and Risk of Pain Spreading (ROPS) assessed at 46 years among people reporting MSK pain (n=3200-4525). Log-binomial regression models for dummy outcomes (ÖMPSQ-SF and SBT) and generalized linear regression models for continuous outcomes (ROPS) were employed. Birth weight did not predict high-risk classification by any tool. Compared to full-term participants, those born preterm had higher risk of being classified into the high-risk group only according to ÖMPSQ-SF (relative risk 1.61, 95% confidence interval 1.00-2.59) and SBT (1.61, 1.14-2.28). Adjustments did not change these results. Preterm birth appeared to predict allocation to the group with poorer prognosis of MSK outcomes as measured by ÖMPSQ-SF and SBT, but not by ROPS. This highlights the need for further research into the role of preterm birth in the development or accumulation of adverse pain-related thoughts and experiences in mid-life. PERSPECTIVE: Preterm birth tended to predict allocation to the high-risk group for worse pain prognosis in adulthood. Similar was not observed concerning birth weight. Further research is warranted to validate the results and delve into explanatory pathways.

Use of Mothers Milk Odor and White Noise on Pain Management in Preterm Infants: A Randomized Controlled Trial

BACKGROUND

Recurrent pain experienced by preterm infants during hospitalization is significant due to its short and long-term negative consequences.

PURPOSE

This randomized controlled trial examined the effect of the mother's own milk odor and white noise on pain management during heel lance in preterms.

METHODS

The data were collected in the neonatal intensive care unit and postpartum services between May and October 2022. The study included 66 infants born between 34 and 37 weeks. Infants were randomly assigned to either the mother's own milk odor, white noise, or control groups. Data were collected using the Premature Infant Pain Profile-Revised Form, Descriptive Information Form, and Follow-Up Chart. Pain was evaluated 5 and 2 minutes before the procedure, at the time and 5 minutes after the procedure by 2 independent nursing academicians/lecturers through video recordings. Frequency, mean, standard deviation, chi-square test, one-way ANOVA and repeated measures were used for data analysis.

RESULTS

All groups were similar regarding the descriptive characteristics. The control group had higher heart rates before and after the procedure than the mother's own milk odor and white noise group. Oxygen saturation was higher and pain scores were lower in the white noise and mother's own milk odor group compared to the control group during and after the procedure. There was no difference between the mother's milk odor and white noise groups at any time.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The odor of the mother's milk and white noise may effectively manage pain during heel lance in preterms. Neonatal nurses can adopt these methods as effective non-pharmacological pain management methods.

Individualized developmental care interventions for promoting development and preventing morbidity in preterm infants

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of individualized developmental care interventions for promoting development and preventing morbidity in preterm infants.

Depression of cortical neuronal activity after a low-dose fentanyl in preterm infants

AIM

Opioids might be harmful to the developing brain and dosing accuracy is important. We aimed at investigating fentanyl effects on cortical activity in infants using computational re-analysis of bedside recorded EEG signals.

METHODS

Fifteen infants born at median 26.4 gestational weeks (range 23.3-34.1), with a birth weight 740 grams (530-1420) and postnatal age 7 days (5-11) received fentanyl 0.5 or 2 μg/kg intravenously before a skin-breaking procedure or tracheal intubation, respectively. Cortical activity was continuously recorded using amplitude-integrated electroencephalography (aEEG).  Analyses using three computational EEG features representing cortical synchrony and signal power, were conducted five minutes pre- and 10 minutes post the drug administration.

RESULTS

Visual assessment of trends displayed from the EEG metrics did not indicate systematic changes. However, the magnitude of the changes in the parietal and right hemisphere signals after the dose was significantly correlated (ρ < -0.5, p < 0.05) to the EEG amplitude and frequency power level before drug administration. This effect started after 3-4 min.

CONCLUSION

Fentanyl, even in small doses, may affect cortical activity in the preterm brain. The effect is robustly related to the state of cortical activity prior to drug treatment, which must be taken into account when analysing the effects of sedative drugs.

Deep proteomics and network pharmacology reveal sex- and age-shared neuropathic pain signatures in mouse dorsal root ganglia

Our understanding of how sex and age influence chronic pain at the molecular level is still limited with wide-reaching consequences for adolescent patients. Here, we leveraged deep proteome profiling of mouse dorsal root ganglia (DRG) from adolescent (4-week-old) and adult (12-week-old) male and female mice to investigate the establishment of neuropathic pain in the spared nerve injury (SNI)-model in parallel. We quantified over 12,000 proteins, including notable ion channels involved in pain, highlighting the sensitivity of our approach. Differential expression revealed sex- and age-dependent proteome changes upon nerve injury. In contrast to most previous studies, our comprehensive dataset enabled us to determine differentially expressed proteins (DEPs), which were shared between male and female mice of both age groups. Among these, the vast majority (94 %) were also expressed and, in part, altered in human DRG of neuropathic pain patients, indicating evolutionary conservation. Proteome signatures represented numerous targets of FDA-approved drugs comprising both (i) known pain therapeutics (e.g. Pregabalin and opioids) and, importantly, (ii) compounds with high potential for future re-purposing, e.g. Ptprc-modulators and Epoetins. Protein network and multidimensional analysis uncovered distinct hubs of sex- and age-shared biological pathways impacted by neuropathic pain, such as neuronal activity and synaptic function, DNA-damage, and neuroimmune interactions. Taken together, our results capture the complexity of nerve injury-associated DRG alterations in mice at the network level, moving beyond single-candidate studies. Consequently, we provide an innovative resource of the molecular landscape of neuropathic pain, enabling novel opportunities for translational pain research and network-based drug discovery.

The effects of white noise and swaddling methods on orogastric tube insertion-related pain in preterm infants: A randomized controlled trial

AIM

This study aims to investigate the effects of the white noise, swaddling and white noise + swaddling methods on pain and physiological parameters associated with orogastric tube insertion procedure.

METHODS

This was a randomized controlled trial. A total of 132 preterm infants were randomly assigned to four groups as white noise group (n = 33), swaddling group (n = 33), white noise + swaddling group (n = 33) and control group (n = 33). Interventions were initiated 5 min before the orogastric tube insertion procedure and continued during and up to 5 min after the procedure.

RESULTS

White noise intervention alone did not have a significant effect on reducing pain associated with orogastric tube insertion (p > 0.05). Compared with the control group, the preterm infants in the swaddling group experienced 0.587 times less pain, and those in the white noise + swaddling group experienced 0.473 times less pain.

CONCLUSIONS

Findings indicate the swaddling and the combination of white noise + swaddling may be a useful intervention in reducing the invasive pain experienced by preterm infants during and after orogastric tube insertion and in improving the physiological parameters associated with pain.

Pain Assessment in the Patient Unable to Self- Report: Clinical Practice Recommendations in Support of the ASPMN 2024 Position Statement

Recognizing and managing pain is especially challenging for vulnerable populations who cannot communicate their discomfort. Because there is no valid and reliable objective measure of pain, the American Society for Pain Management Nursing advocates for comprehensive assessment practices articulated in a Hierarchy of Pain Assessment. These practices must gather relevant information to infer the presence of pain and evaluate a patient's response to treatment. Nurses and other healthcare providers must be advocates for those who cannot communicate their pain experience.

Neonatal paw pricking alters adolescent behavior in a sex-dependent manner and sucrose partially remediates the effects

Neonatal exposure to noxious stimuli such as repeated heel lances can cause behavior changes. In the NICU sucrose given prior to procedures attenuates the immediate behavioral response to noxious stimuli but may not ameliorate the long-term consequences, and treatment with 24 % sucrose can brain structure and behavior in adult rodents. We used a rat model to determine whether paw pricks during the neonatal period alter social interaction and/or paw withdrawal thresholds (PWT) in adolescence, and if 7 % sucrose mitigates these effects. One male and one female pup per litter was assigned to each of six experimental groups (no paw prick (control), 1 paw prick (1PP), or 2PP, ± sucrose). Hind paws were pricked once or twice each day between postnatal day (P)3 and P10. Social behavior and PWT were tested in adolescence using the modified social interaction test and von Frey filaments, respectively. Social behavior was altered in the 2PP group; total time interacting was lower in 2PP rats, primarily due to less time sniffing a play partner. Sucrose did not mitigate effects of paw prick but trended to alter social behaviors in males; it decreased time in contact but increased social motivation (movement toward a play partner). PWTs were higher in 2PP animals, this was not altered by sucrose. Thus, rat pups exposed to paw pricks in the neonatal period have some altered behaviors in adolescence. The nature of the behavioral changes is sex-dependent, but sucrose did not mitigate these changes.

Parenting pain away: Quasi-experimental study of an eHealth learning platform to evaluate acceptability, feasibility, and utilisation of parent-led pain management

AIM

To evaluate the impact of an eHealth educational resource about infant procedural pain management, given during the prenatal period, on feasibility, acceptability, knowledge, self-efficacy, and involvement.

BACKGROUND

Routine health care requires newborns to have painful procedures (e.g., intramuscular injection). The impacts of untreated pain in neonates are widely recognised but adoption of effective procedural pain management strategies in clinical practice varies. There is clear evidence supporting the effectiveness of parent-led pain management during procedures (e.g., skin-to-skin care) and reputable resources to raise awareness among parents are warranted. Our team co-created Parenting Pain Away, a website to equip parents with evidence to assist with managing the pain of procedures and empower them to be involved.

METHODS

A quasi-experimental evaluation using a pre/post intervention design with low-risk expectant parents.

RESULTS

Of the 41 participants, before intervention exposure participants were familiar or had used skin-to-skin care (n = 33), breastfeeding (n = 30) and sucrose (n = 13) as pain management. Most participants (n = 38) desired more information on how to be involved. Providing access to Parenting Pain Away during pregnancy was supported and participants ranked the website above average using the System Usability Scale. Parenting Pain Away did not have a statistically significant influence on outcomes. Participants reported variation in clinical support with parent-led pain management.

CONCLUSION

A multifaceted approach is recommended to maintain infant procedural pain management.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Equipping parents with knowledge related to infant pain management using an eHealth approach satisfied their information desires. The study findings are important considerations for perinatal care providers, policy makers, and families to finally achieve adequate procedural pain management.

REPORTING METHOD

This study used the STROBE checklist, adhering to EQUATOR guidelines.

PATIENT AND PUBLIC CONTRIBUTION

A stakeholder group (expectant parents, parents, perinatal researchers, clinicians, and administrators) was created to inform the study design and intervention.

Quality Improvement Intervention Decreases Pain and Adverse Events Due to Heel Lances in Infants

BACKGROUND

Studies have investigated ways to reduce infants' pain during heel lancing, but research on preventing adverse events is scarce. This study investigated whether or not the number of infants with normal comfort (>8 and ≤14), distress (≤4), and pain (≤4) scores increased and whether or not the number of adverse events (blue and/or edematous heels and improperly placed incisions) decreased during and after heel lancing following an intervention.

METHODS

A pre- and post-quality improvement intervention including 189 and 186 heel lances, respectively, in infants (postmenstrual age ≥ 28 + 0 to ≤ 43 + 6 weeks) was conducted in May to July 2020 and April to July 2022. The intervention comprised five initiatives: skin-to-skin contact, comforting, sucrose/breastfeeding, warming cold heels, and ergonomics for staff. ComfortNeo score, along with distress and pain scores assessed the infants' pain and discomfort before, during, and after heel lancing. Adverse events were assessed visually.

RESULTS

Post-intervention, there was a significant increase in the number of infants with normal pain and distress scores during (86% to 95%, p = 0.01, and 82% to 93%, p = 0.01, respectively) and after (95% to 99%, p = 0.04, and 90% to 99%, p < 0.01, respectively) heel lancing compared to the pre-intervention. A non-significant reduction in the number of adverse events was observed (41 to 30, p = 0.17).

CONCLUSIONS

Cost-free procedural changes can decrease pain, discomfort, and adverse events in infants undergoing heel lancing. Painful procedures should be evaluated and optimized. Staff and parents should collaborate to manage pain and adverse events.

Barriers and facilitators to using procedural pain treatments in pediatric patients (under 1 year old): protocol for a mixed studies systematic review with a narrative synthesis

BACKGROUND

The management of procedural pain in pediatric patients under 1 year old is crucial but often inadequately addressed in clinical practice. Despite proven evidence-based interventions like skin-to-skin contact, sweet solutions, and breastfeeding, their implementation remains sporadic. This systematic review aims to uncover the barriers and facilitators to adopting these interventions, leveraging the Consolidated Framework for Implementation Research (CFIR) to provide a structured analysis.

METHODS

This review will examine primary studies identifying barriers or facilitators to the use of procedural pain treatments in pediatric patients under 1 year old, imposing no restrictions on the publication year or language. A thorough search will cover databases such as MEDLINE (Ovid), Embase, CINAHL, PsycINFO, Web of Science, and Scopus. The Mixed Methods Appraisal Tool (MMAT) will be utilized for quality assessment. The CFIR framework will serve to categorize and analyze the identified barriers and facilitators, using narrative synthesis for data integration.

DISCUSSION

Applying the CFIR framework allows for a comprehensive and systematic review of the factors influencing the implementation of procedural pain management strategies in pediatric care. By identifying key barriers and facilitators through this lens, the review will guide the development of targeted interventions aimed at enhancing the adoption of evidence-based pain treatments. Such strategic interventions are essential for bridging the gap between research findings and clinical practice, potentially improving the effectiveness and efficiency of pain management for pediatric patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022322319.

Short-term effects of opioids during therapeutic hypothermia for neonatal encephalopathy

Objective

To examine the effects of opioids during therapeutic hypothermia (TH) on short-term outcomes in neonates with neonatal encephalopathy (NE).

Methods

Multicenter retrospective study of neonates with moderate/severe NE from Jan. 2013-Feb 2021. Opioid exposure was classified as positive (>0.1 mg/kg) or negative (no exposure or ≤0.1 mg/kg) based on cumulative morphine milligram equivalents (MME). Negative binomial regression models were used to evaluate clinical outcomes.

Results

One hundred and twenty neonates were included. Adjusted analyses indicated that opioid exposure was associated with an increase in (1) length of hospitalization, (2) hypotension/use of vasopressors, and (3) need for and longer duration of mechanical ventilation. Many findings persisted even after adjusting for site and the presence of confirmed seizures (a marker of disease severity).

Discussion

Opioid use during TH was associated with adverse effects on short-term outcomes. Caution should be exercised when using opioids during TH until longer-term neurodevelopmental outcome studies can be conducted in larger cohorts.

Impact of breast milk on cortical pain response in newborns during the heel prick procedure: a randomized controlled trial

OBJECTIVE

To investigate the effects of breast milk on cortical pain response and behavioral response in newborns during heel-prick procedure.

STUDY DESIGN

A prospective, randomized controlled trial was conducted on healty-term newborns, undergoing heel blood sampling. Infants were randomly assigned to study group with receive orally 2 ml breast milk (n = 45) or a control group with no intervention (n = 45). A near-infrared spectroscopy device was used to monitor regional cerebral oxygen saturation (rScO2), while neonatal pain expression was assessed by Neonatal Pain, Agitation, and Sedation Scale (N-PASS).

RESULTS

The N-PASS score (p = 0.001) and the crying time (p = 0.017) were significantly lower in the study group compared to the control group. Although the mean rScO2 values decreased in both groups during the procedure, the percent change in rScO2 was not significant difference between two groups.

CONCLUSION

Breast milk administration decreases behavioral responses to a noxious stimulus without reducing the cortical response to pain.

CLINICAL TRIAL REGISTRATION

This trial was registered under ClinicalTrials.gov identifier no. NCT05961904.

On the relation of injury to pain-an infant perspective

ABSTRACT

Forty-five years ago, Patrick Wall published his John J Bonica lecture "On the relation of injury to pain."90 In this lecture, he argued that pain is better classified as an awareness of a need-state than as a sensation. This need state, he argued, serves more to promote healing than to avoid injury. Here I reframe Wall's prescient proposal to pain in early life and propose a set of different need states that are triggered when injury occurs in infancy. This paper, and my own accompanying Bonica lecture, is dedicated to his memory and to his unique contribution to the neuroscience of pain. The IASP definition of pain includes a key statement, "through their life experiences, individuals learn the concept of pain."69 But the relation between injury and pain is not fixed from birth. In early life, the links between nociception (the sense) and pain (the need state) are very different from those of adults, although no less important. I propose that injury evokes three pain need states in infancy, all of which depend on the state of maturity of the central nervous system: (1) the need to attract maternal help; (2) the need to learn the concept of pain; and (3) the need to maintain healthy activity dependent brain development.

Functional connectivity of the pediatric brain

PURPOSE

This review highlights the importance of functional connectivity in pediatric neuroscience, focusing on its role in understanding neurodevelopment and potential applications in clinical practice. It discusses various techniques for analyzing brain connectivity and their implications for clinical interventions in neurodevelopmental disorders.

METHODS

The principles and applications of independent component analysis and seed-based connectivity analysis in pediatric brain studies are outlined. Additionally, the use of graph analysis to enhance understanding of network organization and topology is reviewed, providing a comprehensive overview of connectivity methods across developmental stages, from fetuses to adolescents.

RESULTS

Findings from the reviewed studies reveal that functional connectivity research has uncovered significant insights into the early formation of brain circuits in fetuses and neonates, particularly the prenatal origins of cognitive and sensory systems. Longitudinal research across childhood and adolescence demonstrates dynamic changes in brain connectivity, identifying critical periods of development and maturation that are essential for understanding neurodevelopmental trajectories and disorders.

CONCLUSION

Functional connectivity methods are crucial for advancing pediatric neuroscience. Techniques such as independent component analysis, seed-based connectivity analysis, and graph analysis offer valuable perspectives on brain development, creating new opportunities for early diagnosis and targeted interventions in neurodevelopmental disorders, thereby paving the way for personalized therapeutic strategies.

Prongs or Mask for Nasal Continuous Positive Airway Pressure in Neonates: Which One Is More Comfortable?

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is a common mode of respiratory support in neonatal intensive care units. Our objective was to compare whether NCPAP given with nasal prongs compared with a nasal mask reduces the pain scores in preterm infants with respiratory distress.

METHODS

Preterm infants on NCPAP due to respiratory distress were included in the study. All infants received NCPAP via the Infant Flow SiPAP. The COVERS pain scale was used to score the infants' pain. Each infant was studied alternating between nasal prongs and a nasal mask. Heart rate, respiratory rate, oxygen saturation, and transcutaneous CO 2 (tcCO 2 ) were monitored. Blood pressure and the infants' pain scores were determined every 30 minutes and the average of measurements was taken.

RESULTS

The median (interquartile range) values of pain scores, respiratory rates, oxygen saturations, tcCO 2 levels, and systolic blood pressures differed significantly and favored the nasal mask.

CONCLUSIONS

This study demonstrates that continuous positive airway pressure via a nasal mask leads to a significant reduction in pain scores without altering the respiratory parameters of babies. On the basis of this study, it is possible to conclude that NCPAP applied via nasal mask may be a good alternative to NCPAP applied via nasal prongs.

Effectiveness of non-pharmacological interventions in reducing pain in preterm infants: A systematic review and network meta-analysis

OBJECTIVE

To identify the most effective non-pharmacological measures for pain control in preterm infants in the Neonatal Intensive Care Unit (NICU).

METHODS

A Systematic review and network meta-analysis of randomized clinical trials published in English, Portuguese, and Spanish from April 2020 to December 2023. The data sources used were MedLine via PubMed, LILACS, EMBASE, The Cochrane Central Register of Controlled Trials, and Pedro. We performed the risk of bias analysis with Rob 2 and the certainty of the evidence and strength of the recommendation using the Grading of Recommendations Assessment, Development, and Evaluation system. We assessed heterogeneity using the Higgins and Thompson I2 test, the classification of interventions using the P-score, and inconsistencies using the Direct Evidence Plot.

RESULTS

From 210 publications identified, we utilized 12 studies in analysis with 961 preterm infants, and we combined ten studies in network meta-analysis with 716 preterm infants, and 12 combinations of non-pharmacological measures. With moderate confidence, sensory saturation, sugars, non-nutritive sucking, maternal heart sound, lullaby, breast milk odor/taste, magnetic acupuncture, skin-to-skin contact, and facilitated tucking have been shown to reduce pain in preterm infants when compared to no intervention, placebo, proparacaine or standard NICU routine: sensory saturation [SMD 5,25 IC 95%: -8,98; -1,53], sugars [SMD 2,32 IC 95%: -3,86; -0,79], pacifier [SMD 3,74 IC 95%: -7,30; 0,19], and sugars and pacifier SMD [3,88 IC 95% -7,72; -0,04].

CONCLUSION

Non-pharmacological measures are strongly recommended for pain management in preterm infants in the NICU.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings of this study have important implications for policy and practice. This is the only systematic review that compared the effectiveness of non-pharmacological measures, thus making it possible to identify which measure presents the best results and could be the first choice in clinical decision making.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Genital Modifications in Prepubescent Minors: When May Clinicians Ethically Proceed?

When is it ethically permissible for clinicians to surgically intervene into the genitals of a legal minor? We distinguish between voluntary and nonvoluntary procedures and focus on nonvoluntary procedures, specifically in prepubescent minors ("children"). We do not address procedures in adolescence or adulthood. With respect to children categorized as female at birth who have no apparent differences of sex development (i.e., non-intersex or "endosex" females) there is a near-universal ethical consensus in the Global North. This consensus holds that clinicians may not perform any nonvoluntary genital cutting or surgery, from "cosmetic" labiaplasty to medicalized ritual "pricking" of the vulva, insofar as the procedure is not strictly necessary to protect the child's physical health. All other motivations, including possible psychosocial, cultural, subjective-aesthetic, or prophylactic benefits as judged by doctors or parents, are seen as categorically inappropriate grounds for a clinician to proceed with a nonvoluntary genital procedure in this population. We argue that the main ethical reasons capable of supporting this consensus turn not on empirically contestable benefit-risk calculations, but on a fundamental concern to respect the child's privacy, bodily integrity, developing sexual boundaries, and (future) genital autonomy. We show that these ethical reasons are sound. However, as we argue, they do not only apply to endosex female children, but rather to all children regardless of sex characteristics, including those with intersex traits and endosex males. We conclude, therefore, that as a matter of justice, inclusivity, and gender equality in medical-ethical policy (we do not take a position as to criminal law), clinicians should not be permitted to perform any nonvoluntary genital cutting or surgery in prepubescent minors, irrespective of the latter's sex traits or gender assignment, unless urgently necessary to protect their physical health. By contrast, we suggest that voluntary surgeries in older individuals might, under certain conditions, permissibly be performed for a wider range of reasons, including reasons of self-identity or psychosocial well-being, in keeping with the circumstances, values, and explicit needs and preferences of the persons so concerned. Note: Because our position is tied to clinicians' widely accepted role-specific duties as medical practitioners within regulated healthcare systems, we do not consider genital procedures performed outside of a healthcare context (e.g., for religious reasons) or by persons other than licensed healthcare providers working in their professional capacity.

Costs and outcomes associated with the administration of Intravenous Acetaminophen in neonates after esophageal atresia and tracheoesophageal fistula repair

BACKGROUND

Over the last decade, the intravenous (IV) formulation of acetaminophen (APAP) has gained popularity as a safe and effective first-line analgesic in the neonatal intensive care unit and it is especially useful in peri-operative settings where oral agents are contraindicated. The primary objective was to examine the outcomes and costs associated with the use of IV APAP in combination with opioids versus opioids alone as a pain management strategy after neonatal esophageal atresia (EA) and tracheoesophageal fistula (TEF) repair.

METHODS

Data from the Pediatric Health Information System was used to examine 1137 hospitalizations for EA/TEF repair from October 2015 to September 2018. Neonates administered opioids only, or IV APAP in combination with opioids as pain management, were included.

RESULTS

Neonates receiving IV APAP experienced a longer median LOS, but a significantly lower mortality rate, a decreased mean daily cost, and reduced opioid use compared to neonates given only opioids. The two groups had no significant differences in pharmacy and total costs.

CONCLUSION

Our findings suggest that the use of IV APAP alongside opioids in EA/TEF repair is associated with reduced mortality and opioid use, as well as longer LOS.

Analgesic utility of automatic lancing device for heel prick in neonates: a systematic review and meta-analysis

Background: This systematic review and meta-analysis assessed the benefits of an automatic lancing device compared with a manual lancet or a hypodermic needle in neonates.Materials & methods: We followed the Cochrane Handbook methodology, used the RoB-2 tool for risk of bias assessment, RevMan 4.1 for meta-analysis and GRADE framework for certainty assessment. We searched the databases and gray literature on 15 November 2023.Results: Six eligible studies enrolling 539 neonates were included. An automatic lancing device reduced pain scores during and after heel prick, sampling time and the need for repeat puncture. The certainty of evidence was very low to moderate.Conclusion: An automatic lancing device is preferred for heel pricks in neonates, given less pain and higher efficiency.PROSPERO registration number: CRD42023483189.

Dexmedetomidine as a Short-Use Analgesia for the Immature Nervous System

Pain management in neonates continues to be a challenge. Diverse therapies are available that cause loss of pain sensitivity. However, because of side effects, the search for better options remains open. Dexmedetomidine is a promising drug; it has shown high efficacy with a good safety profile in sedation and analgesia in the immature nervous system. Though dexmedetomidine is already in use for pain control in neonates (including premature neonates) and infants as an adjunct to other anesthetics, the question remains whether it affects the neuronal activity patterning that is critical for development of the immature nervous system. In this study, using the neonatal rat as a model, the pharmacodynamic effects of dexmedetomidine on the nervous and cardiorespiratory systems were studied. Our results showed that dexmedetomidine has pronounced analgesic effects in the neonatal rat pups, and also weakly modified both the immature network patterns of cortical and hippocampal activity and the physiology of sleep cycles. Though the respiration and heart rates were slightly reduced after dexmedetomidine administration, it might be considered as the preferential independent short-term therapy for pain management in the immature and developing brain.

Pain in Neonates: Perceptions and Current Practices

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

A Spatiotemporal Deep Learning Framework for Scalp EEG-Based Automated Pain Assessment in Children

OBJECTIVE

Common pain assessment approaches such as self-evaluation and observation scales are inappropriate for children as they require patients to have reasonable communication ability. Subjective, inconsistent, and discontinuous pain assessment in children may reduce therapeutic effectiveness and thus affect their later life.

METHODS

To address the need for suitable assessment measures, this paper proposes a spatiotemporal deep learning framework for scalp electroencephalogram (EEG)-based automated pain assessment in children. The dataset comprises scalp EEG data recorded from 33 pediatric patients with an arterial puncture as a pain stimulus. Two electrode reduction plans in line with clinical findings are proposed. Combining three-dimensional hand-crafted features and preprocessed raw signals, the proposed transformer-based pain assessment network (STPA-Net) integrates both spatial and temporal information.

RESULTS

STPA-Net achieves superior performance with a subject-independent accuracy of 87.83% for pain recognition, and outperforms other state-of-the-art approaches. The effectiveness of electrode combinations is explored to analyze pain-related cortical activities and correspondingly reduce cost. The two proposed electrode reduction plans both demonstrate competitive pain assessment performance qualitatively and quantitatively.

CONCLUSION AND SIGNIFICANCE

This study is the first to develop a scalp EEG-based automated pain assessment for children adopting a method that is objective, standardized, and consistent. The findings provide a potential reference for future clinical research.

Reducing Procedural Pain and Avoiding Peripheral Intravenous Catheters by Implementing a Feeding Protocol for Late Preterm Infants: A Quality Improvement Project

BACKGROUND

Late preterm births account for a large portion of preterm births, yet the optimal method of nutrition and enteral feeding in this population remains unclear and often involves intravenous (IV) fluids.

PURPOSE

To develop and implement a late preterm feeding protocol in order to decrease the necessity of IV access, decrease the use of starter parenteral nutrition (PN), and reduce the pain endured by an infant in the neonatal intensive care unit.

METHODS

The Plan-Do-Study-Act quality improvement model was utilized as a framework for the implementation of this quality improvement project. A literature review was conducted and subsequently, a feeding protocol was developed and included the more judicious use of starter PN. This protocol was implemented, evaluated, and adopted. A second Plan-Do-Study-Act cycle was completed with the addition of an auto-text reminder incorporated into admission notes in the electronic medical record.

RESULTS

The implementation of the protocol significantly reduced placement of IV access and the use of starter (PN) in late preterm infants without considerable differences in balancing measures. The percentage of infants who received peripheral IV access declined considerably from 70% to 42% ( P = .0017) subsequently, less pain endured by the infants. There was a decrease in the initiation of starter PN from 55% to 7% ( P < .00001).

IMPLICATIONS FOR PRACTICE

Administering enteral feedings on admission to stable, late preterm infants reduced the need for peripheral IV access and thus decreased pain from this procedure.

Performance Evaluation of a Supervised Machine Learning Pain Classification Model Developed by Neonatal Nurses

BACKGROUND

Early-life pain is associated with adverse neurodevelopmental consequences; and current pain assessment practices are discontinuous, inconsistent, and highly dependent on nurses' availability. Furthermore, facial expressions in commonly used pain assessment tools are not associated with brain-based evidence of pain.

PURPOSE

To develop and validate a machine learning (ML) model to classify pain.

METHODS

In this retrospective validation study, using a human-centered design for Embedded Machine Learning Solutions approach and the Neonatal Facial Coding System (NFCS), 6 experienced neonatal intensive care unit (NICU) nurses labeled data from randomly assigned iCOPEvid (infant Classification Of Pain Expression video) sequences of 49 neonates undergoing heel lance. NFCS is the only observational pain assessment tool associated with brain-based evidence of pain. A standard 70% training and 30% testing split of the data was used to train and test several ML models. NICU nurses' interrater reliability was evaluated, and NICU nurses' area under the receiver operating characteristic curve (AUC) was compared with the ML models' AUC.

RESULTS

Nurses weighted mean interrater reliability was 68% (63%-79%) for NFCS tasks, 77.7% (74%-83%) for pain intensity, and 48.6% (15%-59%) for frame and 78.4% (64%-100%) for video pain classification, with AUC of 0.68. The best performing ML model had 97.7% precision, 98% accuracy, 98.5% recall, and AUC of 0.98.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The pain classification ML model AUC far exceeded that of NICU nurses for identifying neonatal pain. These findings will inform the development of a continuous, unbiased, brain-based, nurse-in-the-loop Pain Recognition Automated Monitoring System (PRAMS) for neonates and infants.

Macrophage memories of early-life injury drive neonatal nociceptive priming

The developing peripheral nervous and immune systems are functionally distinct from those of adults. These systems are vulnerable to early-life injury, which influences outcomes related to nociception following subsequent injury later in life (i.e., "neonatal nociceptive priming"). The underpinnings of this phenomenon are unclear, although previous work indicates that macrophages are trained by inflammation and injury. Our findings show that macrophages are both necessary and partially sufficient to drive neonatal nociceptive priming, possibly due to a long-lasting remodeling in chromatin structure. The p75 neurotrophic factor receptor is an important effector in regulating neonatal nociceptive priming through modulation of the inflammatory profile of rodent and human macrophages. This "pain memory" is long lasting in females and can be transferred to a naive host to alter sex-specific pain-related behaviors. This study reveals a mechanism by which acute, neonatal post-surgical pain drives a peripheral immune-related predisposition to persistent pain following a subsequent injury.

The relationship between neonatal stress in preterm infants and developmental outcomes at the corrected age of 24-30 months

Aim

The aim of research was to study the relationship between the stress experienced by preterm infants in the neonatal intensive care unit (NICU) and developmental status in the follow up, and to establish factors, associated with their neurodevelopment.

Methods

The first stage of research involved measuring stress markers (cortisol, melatonin) in infants (n = 56) during their NICU stay; the second phase assessed the developmental status at the corrected age of 24-30 months.

Results

The total ASQ-3 score, communication, problem solving, and personal-social skills scores at the corrected age of 24-30 months were positively correlated with melatonin level determined in the neonatal period (r = 0.31, p = 0.026; r = 0.36, p = 0.009; r = 0.30, p = 0.033, and r = 0.32; p = 0.022 respectively). In the same time, ASQ-3 communication and personal-social scores were negatively correlated with cortisol level (r = -0.31, p = 0.043; r = -0.35, p = 0.022). The ROC-curve analysis revealed that a decrease of melatonin below 3.44 ng/mL and 3.71 ng/mL during the neonatal period could predict communication and problem-solving delay, respectively. An increase in cortisol above 0.64 mcg/dl is predictive in personal-social delay. Negative correlation was identified between the NICU and total hospital stay duration and ASQ-3 communication scores in the follow-up (r = -0.27; p = 0.049 and r = -0.41; p = 0.002, respectively). The duration of mechanical ventilation was negatively correlated with gross motor scores (r = -0.46; p = 0.043). Apgar score was positively correlated with ASQ-3 communication (r = 0.29; p = 0.032) and personal-social scores (r = 0.28; p = 0.034); maternal age-with ASQ-3 total (r = 0.29; p = 0.034), communication (r = 0.37; p = 0.006), and personal-social scores (r = 0.29; p = 0.041). Positive correlations were observed between gestational age and communication scores (r = 0.28; p = 0.033). Infants who suffered neonatal sepsis had significantly often delay of communication (p = 0.014) and gross motor skills (p = 0.016). Children who required mechanical ventilation were more likely to have communication delay (p = 0.034).

Conclusion

Developmental outcomes in preterm infants at the corrected age of 24-30 months were associated with neonatal stress. Correlations between the communication, problem-solving and personal-social development in the follow up and cortisol and melatonin levels determined in the neonatal period supported this evidence. Factors as low gestational age, duration of hospital and NICU stay, mechanical ventilation, and sepsis were associated with more frequent delays in communication, gross motor and problems-solving skills.

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

Introduction

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

Methods

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

Results

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

Discussion

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

The Bayliss-Starling Prize Lecture: The developmental physiology of spinal cord and cortical nociceptive circuits

When do we first experience pain? To address this question, we need to know how the developing nervous system processes potential or real tissue-damaging stimuli in early life. In the newborn, nociception preserves life through reflex avoidance of tissue damage and engagement of parental help. Importantly, nociception also forms the starting point for experiencing and learning about pain and for setting the level of adult pain sensitivity. This review, which arose from the Bayliss-Starling Prize Lecture, focuses on the basic developmental neurophysiology of early nociceptive circuits in the spinal cord, brainstem and cortex that form the building blocks of our first pain experience.

A developmental framework for understanding the influence of sex and gender on health: Pediatric pain as an exemplar

Sex differences are a robust finding in many areas of adult health, including cardiovascular disease, psychiatric disorders, and chronic pain. However, many sex differences are not consistently observed until after the onset of puberty. This has led to the hypothesis that hormones are primary contributors to sex differences in health outcomes, largely ignoring the relative contributions of early developmental influences, emerging psychosocial factors, gender, and the interaction between these variables. In this paper, we argue that a comprehensive understanding of sex and gender contributions to health outcomes should start as early as conception and take an iterative biopsychosocial-developmental perspective that considers intersecting social positions. We present a conceptual framework, informed by a review of the literature in basic, clinical, and social science that captures how critical developmental stages for both sex and gender can affect children's health and longer-term outcomes. The literature on pediatric chronic pain is used as a worked example of how the framework can be applied to understanding different chronic conditions.

The effect of the simulated intrauterine sound on behavioral and physiological indices of pain during capillary blood sampling for screening preterm infants: a randomized clinical trial study

INTRODUCTION

Due to medical procedures, preterm infants are at high risk for side effects of pain. In this regard, heel lancing for capillary blood sampling is a common painful procedure. The present study was conducted to assess the effectiveness of a simulated intrauterine sound on behavioral and physiological indices of pain due to heel-prick blood sampling in preterm infants.

METHODS

A double‑blind randomized clinical trial (RCT) was conducted. The data were collected from September 23 to December 22, 2019. We measured the effect of a simulated intrauterine sound on changes in the behavioral and physiological parameters of pain (heart rate, SPO2) caused by heel lance that was measured 5 min before the intervention, during the sampling, and 5 min after the procedure. We measured behavioral pain by video recording the infants' faces and then the scoring neonatal infant pain scale (NIPS). Heart rate and SPO2 were measured using a pulse oximeter device. The data were analyzed using analysis of variance (ANOVA) and independent t‑test in SPSS software version 20.0.

RESULTS

Eighty infants were randomized (40 in each group). Mean scores NIPS during and after intervention were in the intervention group (3.55 ± 0.84, 95% CI: 3.30-3.80(, and (1.15 ± 0.84, 95%: 0.95-1.35) and in the control group (5.57 ± 0.95, 95% CI:5.30-5.85) and (3.00 ± 0.98) respectively. There were significant differences in scores of NIPS between the two study groups during (p < 0.001) and five min after heel lancing (p < 0.001). Mean scores of heart rate in the three phases of before, during, and five min after the intervention were respectively in the intervention group (127.57 ± 4.45, 95% CI:126.27-128.99), (131.07 ± 6.54, 95% CI:129.20-133.22), (128.45 ± 5.15, 95% CI:127.02-130.07) and in the control group (128.67 ± 4.57, 95% CI:127.32-130.07), (136.07 ± 7.24, 95% CI:133.90-138.37), and (132.42 ± 6.47, 95% CI:130.37-134.49). There were significant differences in heart rate between the intervention and the control group during (p = 0.002) and five min after the heel lance (p = 0.003). Mean scores of SPO2 in the three phases of baseline, during, and five min after the intervention were respectively in the intervention group (96.72 ± 0.93, 95% CI:96.42-97.00), (91.47 ± 1.46, 95% CI:91.05-91.92), (94.17 ± 1.03, 95% CI:93.22-94.00) and in the control group (96.6 ± 0.84, 95% CI:96.35-96.85), (91.5 ± 1.24, 95% CI:91.12-91.87), and (93.60 ± 1.27, 95% CI:93.85-94.50).

CONCLUSION

This study showed that the simulated intrauterine sound reduces the behavioral pain and heart rate in the intervention group during and after heel lance. These results suggest using the method during the painful heel lancing to reduce pain parameters in preterm infants.

Neonatal Intensive Care Nurses' Knowledge of Neonatal Pain Assessment in Private and Public Hospitals in Jeddah, Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Neonatal Intensive Care Unit (NICU) nurses with adequate neonatal pain assessment knowledge are crucial in effective neonatal pain management. There is limited research that assessed the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

OBJECTIVE

To assess the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

DESIGN AND METHODS

 A cross-sectional design using an online survey was conducted to capture information regarding neonatal pain assessment knowledge from 125 NICU nurses in Saudi Arabia. Knowledge of pain assessment was assessed using a modified version of the knowledge, attitudes, and practice scale. Knowledge scores were classified as high, average, and low.

RESULTS

Participants' knowledge regarding neonatal pain assessment was inadequate (Mean = 63/100). The majority of the participants had a low to average level of knowledge (n= 97, 78%).

CONCLUSION

A significant proportion of NICU nurses had inadequate knowledge regarding neonatal pain assessment, which can be improved. Educational interventions are needed to boost these nurses' knowledge regarding neonatal pain assessment.

Macrophage epigenetic memories of early life injury drive neonatal nociceptive priming

The developing peripheral nervous and immune systems are functionally distinct from adults. These systems are vulnerable to early life injury, which influences outcomes related to nociception following subsequent injury later in life (neonatal nociceptive priming). The underpinnings of this phenomenon are largely unknown, although previous work indicates that macrophages are epigenetically trained by inflammation and injury. We found that macrophages are both necessary and partially sufficient to drive neonatal nociceptive priming possibly due to a long-lasting epigenetic remodeling. The p75 neurotrophic factor receptor (NTR) was an important effector in regulating neonatal nociceptive priming through modulation of the inflammatory profile of rodent and human macrophages. This pain memory was long lasting in females and could be transferred to a naive host to alter sex-specific pain-related behaviors. This study reveals a novel mechanism by which acute, neonatal post-surgical pain drives a peripheral immune-related predisposition to persistent pain following a subsequent injury.

Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review

BACKGROUND

Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress.

OBJECTIVE

This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes.

METHODS

We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied.

RESULTS

The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism.

CONCLUSIONS

No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.

Parents' experiences with interprofessional collaboration in neonatal pain management: A descriptive qualitative study

AIM

To describe parents' experiences with interprofessional collaboration (IPC) in neonatal pain management.

BACKGROUND

Neonatal care should be based on IPC, and non-pharmacological pain-relieving methods are recommended to be used primarily that enables parental participation. However, there is a lack of knowledge about pain management on IPC from the parent's viewpoint.

DESIGN

A descriptive qualitative study.

METHOD

The research involved a purposive sample of parents (n = 16) whose infant had been treated at a neonatal intensive care unit in Finland. Interviews were conducted with participants from all over Finland who were recruited through the national association for premature infants. Parents discussed their experiences during semi-structured interviews which were guided by the subareas of IPC, partnership, cooperation and coordination. The data were analysed using deductive-inductive content analysis. The reporting of results followed COREQ guidelines.

RESULTS

Based on the parent's experiences the partnership involved themes of understanding the neonatal pain management context, being able to influence the pain management, and feeling valued. Cooperation included themes of identifying different roles and equality. Coordination was described through the sharing of knowledge, skills and expertise, as well as feeling supported by professionals.

CONCLUSION

Parental involvement on IPC should be developed through interventions that involve training around pain assessment and non-pharmacological pain-relief methods.

RELEVANCE FOR CLINICAL PRACTICE

Professionals involved in neonatal care should act in a goal-oriented and unified manner to promote a culture of care that allows for active parental participation.

NO PATIENT OR PUBLIC CONTRIBUTION

The research has been carried out in accordance with good scientific practice. Only the research team has been involved in the design, conduct, analysis and drafting of the manuscript.

Evaluation of Pain Prevalence in Children Who Experienced Perinatal Hypoxia-Ischemia Events: Characteristics and Associations With Sociodemographic Factors

INTRODUCTION

Pain in children who suffer from hypoxia-ischemia (HI) events is still not widely studied. Hypoxia-ischemia is characterized by the momentary or permanent cessation of blood flow and, consequently, of oxygen supply, becoming the main cause of encephalopathy in children. Hyperalgesia was identified in animals undergoing prenatal hypoxia-ischemia by researchers from the Universidade do Estado do Rio de Janeiro (UERJ). Premature and asphyxiated newborns have been admitted to the neonatal intensive care unit (NICU) of Pedro Ernesto University Hospital (HUPE) in Brazil and are monitored by the Outpatient Follow-up of High-Risk Newborns Project (SARAR), but no pain assessment was performed.

OBJECTIVE

To assess pain in children born in high-risk situations, such as prematurity and perinatal asphyxia, with higher chances of perinatal HI, discharged from the NICU/HUPE, and followed by SARAR.

METHODOLOGY

The study was approved by the HUPE Research Ethics Committee. The epidemiological, descriptive, cross-sectional study started in 2021 and finished in 2023, with the application of the pain assessment tool or instrument adapted from the Lübeck Pain-Screening Questionnaire to the caregivers and with the collection of growth and development data. The population consisted of asphyxiated infants born with a gestational age greater than 35 weeks and submitted to the Therapeutic Hypothermia protocol and premature infants discharged from the NICU between two (gestational age 1 (GA1)) and 12 years old. For most of them, pain prevalence was assessed according to its frequency and intensity, as were sociodemographic variables of the child and mother, neural alterations, and the Children's Developmental Scale (DENVER II). The percentage differences between the evaluated factors and the presence of pain were performed using Fisher's exact test and medians using the non-parametric Wilcoxon rank-sum test, both appropriate for the small sample of children. Significance levels of 10% were considered for trends and 5% for statistically significant differences.

RESULTS

Of the 86 children included in our search, 26 (30%) were born with a gestational age greater than 35 weeks and diagnosed with perinatal asphyxia (hereinafter referred to as the asphyxiation group), and 60 (70%) were premature. Pain was reported by 22 (25%) children, of whom 54.4% reported moderate or severe pain. The head and abdomen were the most reported sites (36%). Differences were observed in the percentage distribution of pain between asphyxiates and premature infants (11% vs. 32%; p-value 0.061 on the Fisher test) and between females and males (34% vs. 17%; p-value 0.085 on the Fisher test). Black and Brown children had higher median pain scale values than White children (p-value < 0.027, Wilcoxon rank sum test).

CONCLUSION

There is a higher prevalence of pain in girls, in the head, in premature infants, and greater intensity among Black and Brown children. Therefore, knowing the pain profile can help improve their quality of life by offering treatments.

Developmental impact of peripheral injury on neuroimmune signaling

A peripheral injury drives neuroimmune interactions at the level of the injury and throughout the neuraxis. Understanding these systems will be beneficial in the pursuit to target persistent pain that involves both neural and immune components. In this review, we discuss the impact of injury on the development of neuroimmune signaling, along with data that suggest a possible cellular immune memory. We also discuss the parallel effects of injury in the nervous system and immune related areas including bone marrow, lymph node and central nervous system-related cells. Finally, we relate these findings to patient populations and current research that evaluates human tissue.

Wound healing and pain sensitivity following caustic paste disbudding in dairy calves

Caustic paste disbudding is increasing in popularity on commercial dairy farms in the United States, but little research has explored the pain and welfare implications beyond the acute period of this procedure. In contrast, researchers have reported it takes 7 to 9 wk, on average, for hot-iron disbudding wounds to re-epithelialize in dairy calves. Our objective was to describe wound healing and sensitivity following caustic paste disbudding. Jersey and Holstein female calves were disbudded using caustic paste (H. W. Naylor Company Inc.) at 3 d of age (n = 18), and control calves received a sham procedure (n = 15). Before disbudding, calves received a local block and a nonsteroidal anti-inflammatory drug. Calves ≥34 kg and <34 kg at birth had 0.3 or 0.25 mL of paste applied per unshaved horn bud, respectively. Following disbudding, wounds were scored 2×/wk for the presence or absence of 8 tissue categories, including the final stages: new epithelium and fully healed. Control calves were removed from the experiment after 6 wk to be hot-iron disbudded. Mechanical nociceptive threshold (MNT) measures were collected weekly to evaluate wound sensitivity until calves were removed from the study or healed. Wounds were slow to re-epithelialize (16.2 ± 5.7 wk, mean ± SD; range: 6.2-32.5 wk) and contract to be considered fully healed (18.8 ± 6 wk, mean ± SD; range: 8.7-34.1 wk). Compared with non-disbudded controls, paste calves exhibited lower MNT values for all 6 wk (mean ± SE; control: 1.46 ± 0.16; paste: 1.18 ± 0.12 N). These data indicate that wounds from caustic paste disbudding are more sensitive than undamaged tissue for at least 6 wk and take twice as long to heal compared with cautery methods described in the literature. In conclusion, caustic paste disbudding wounds took 18.8 wk to fully heal and were more sensitive than intact horn buds for 6 wk. Future work should examine whether aspects of paste application (e.g., amount used, time rubbed in, calf age, pain mitigation) could improve healing time and sensitivity.

Video-Based versus On-Site Neonatal Pain Assessment in Neonatal Intensive Care Units: The Impact of Video-Based Neonatal Pain Assessment in Real-World Scenario on Pain Diagnosis and Its Artificial Intelligence Application

BACKGROUND

Neonatal pain assessment (NPA) represents a huge global problem of essential importance, as a timely and accurate assessment of neonatal pain is indispensable for implementing pain management.

PURPOSE

To investigate the consistency of pain scores derived through video-based NPA (VB-NPA) and on-site NPA (OS-NPA), providing the scientific foundation and feasibility of adopting VB-NPA results in a real-world scenario as the gold standard for neonatal pain in clinical studies and labels for artificial intelligence (AI)-based NPA (AI-NPA) applications.

SETTING

A total of 598 neonates were recruited from a pediatric hospital in China.

METHODS

This observational study recorded 598 neonates who underwent one of 10 painful procedures, including arterial blood sampling, heel blood sampling, fingertip blood sampling, intravenous injection, subcutaneous injection, peripheral intravenous cannulation, nasopharyngeal suctioning, retention enema, adhesive removal, and wound dressing. Two experienced nurses performed OS-NPA and VB-NPA at a 10-day interval through double-blind scoring using the Neonatal Infant Pain Scale to evaluate the pain level of the neonates. Intra-rater and inter-rater reliability were calculated and analyzed, and a paired samples t-test was used to explore the bias and consistency of the assessors' pain scores derived through OS-NPA and VB-NPA. The impact of different label sources was evaluated using three state-of-the-art AI methods trained with labels given by OS-NPA and VB-NPA, respectively.

RESULTS

The intra-rater reliability of the same assessor was 0.976-0.983 across different times, as measured by the intraclass correlation coefficient. The inter-rater reliability was 0.983 for single measures and 0.992 for average measures. No significant differences were observed between the OS-NPA scores and the assessment of an independent VB-NPA assessor. The different label sources only caused a limited accuracy loss of 0.022-0.044 for the three AI methods.

CONCLUSION

VB-NPA in a real-world scenario is an effective way to assess neonatal pain due to its high intra-rater and inter-rater reliability compared to OS-NPA and could be used for the labeling of large-scale NPA video databases for clinical studies and AI training.

Early-Life Iron Deficiency Persistently Alters Nociception in Developing Mice

Clinical association studies have identified early-life iron deficiency (ID) as a risk factor for the development of chronic pain. While preclinical studies have shown that early-life ID persistently alters neuronal function in the central nervous system, a causal relationship between early-life ID and chronic pain has yet to be established. We sought to address this gap in knowledge by characterizing pain sensitivity in developing male and female C57Bl/6 mice that were exposed to dietary ID during early life. Dietary iron was reduced by ∼90% in dams between gestational day 14 and postnatal day (P)10, with dams fed an ingredient-matched, iron-sufficient diet serving as controls. While cutaneous mechanical and thermal withdrawal thresholds were not altered during the acute ID state at P10 and P21, ID mice were more sensitive to mechanical pressure at P21 independent of sex. During adulthood, when signs of ID had resolved, mechanical and thermal thresholds were similar between early-life ID and control groups, although male and female ID mice displayed increased thermal tolerance at an aversive (45 °C) temperature. Interestingly, while adult ID mice showed decreased formalin-induced nocifensive behaviors, they showed exacerbated mechanical hypersensitivity and increased paw guarding in response to hindpaw incision in both sexes. Collectively, these results suggest that early-life ID elicits persistent changes in nociceptive processing and appears capable of priming developing pain pathways. PERSPECTIVE: This study provides novel evidence that early-life ID evokes sex-independent effects on nociception in developing mice, including an exacerbation of postsurgical pain during adulthood. These findings represent a critical first step towards the long-term goal of improving health outcomes for pain patients with a prior history of ID.

Opioids for procedural pain in neonates

BACKGROUND

Neonates might be exposed to numerous painful procedures due to diagnostic reasons, therapeutic interventions, or surgical procedures. Options for pain management include opioids, non-pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported.

OBJECTIVES

To evaluate the benefits and harms of opioids in term or preterm neonates exposed to procedural pain, compared to placebo or no drug, non-pharmacological intervention, other analgesics or sedatives, other opioids, or the same opioid administered by a different route.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was December 2021.

SELECTION CRITERIA

We included randomized controlled trials conducted in preterm and term infants of a postmenstrual age (PMA) up to 46 weeks and 0 days exposed to procedural pain where opioids were compared to 1) placebo or no drug; 2) non-pharmacological intervention; 3) other analgesics or sedatives; 4) other opioids; or 5) the same opioid administered by a different route.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods and any harms. We used a fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, and their confidence intervals (CI). We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 13 independent studies (enrolling 823 newborn infants): seven studies compared opioids to no treatment or placebo (the main comparison in this review), two studies to oral sweet solution or non-pharmacological intervention, and five studies (of which two were part of the same study) to other analgesics and sedatives. All studies were performed in a hospital setting. Opioids compared to placebo or no drug Compared to placebo, opioids probably reduce pain score assessed with the Premature Infant Pain Profile (PIPP)/PIPP-Revised (PIPP-R) scale during the procedure (MD -2.58, 95% CI -3.12 to -2.03; 199 participants, 3 studies; moderate-certainty evidence); may reduce Neonatal Infant Pain Scale (NIPS) during the procedure (MD -1.97, 95% CI -2.46 to -1.48; 102 participants, 2 studies; low-certainty evidence); and may result in little to no difference in pain score assessed with the Douleur Aiguë du Nouveau-né (DAN) scale one to two hours after the procedure (MD -0.20, 95% CI -2.21 to 1.81; 42 participants, 1 study; low-certainty evidence). The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R scale up to 30 minutes after the procedure (MD 0.14, 95% CI -0.17 to 0.45; 123 participants, 2 studies; very low-certainty evidence) or one to two hours after the procedure (MD -0.83, 95% CI -2.42 to 0.75; 54 participants, 2 studies; very low-certainty evidence). The evidence is very uncertain about the effect of opioids on episodes of bradycardia (RR 3.19, 95% CI 0.14 to 72.69; 172 participants, 3 studies; very low-certainty evidence). Opioids may result in an increase in episodes of apnea compared to placebo (RR 3.15, 95% CI 1.08 to 9.16; 199 participants, 3 studies; low-certainty evidence): with one study reporting a concerning increase in severe apnea (RR 7.44, 95% CI 0.42 to 132.95; 31 participants, 1 study; very low-certainty). The evidence is very uncertain about the effect of opioids on episodes of hypotension (RR not estimable, risk difference 0.00, 95% CI -0.06 to 0.06; 88 participants, 2 studies; very low-certainty evidence). No studies reported parent satisfaction with care provided in the neonatal intensive care unit (NICU). Opioids compared to non-pharmacological intervention The evidence is very uncertain about the effect of opioids on pain score assessed with the Crying Requires oxygen Increased vital signs Expression Sleep (CRIES) scale during the procedure when compared to facilitated tucking (MD -4.62, 95% CI -6.38 to -2.86; 100 participants, 1 study; very low-certainty evidence) or sensorial stimulation (MD 0.32, 95% CI -1.13 to 1.77; 100 participants, 1 study; very low-certainty evidence). The other main outcomes were not reported. Opioids compared to other analgesics or sedatives The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R during the procedure (MD -0.29, 95% CI -1.58 to 1.01; 124 participants, 2 studies; very low-certainty evidence); up to 30 minutes after the procedure (MD -1.10, 95% CI -2.82 to 0.62; 12 participants, 1 study; very low-certainty evidence); and one to two hours after the procedure (MD -0.17, 95% CI -2.22 to 1.88; 12 participants, 1 study; very low-certainty evidence). No studies reported any harms. The evidence is very uncertain about the effect of opioids on episodes of apnea during (RR 3.27, 95% CI 0.85 to 12.58; 124 participants, 2 studies; very low-certainty evidence) and after the procedure (RR 2.71, 95% CI 0.11 to 64.96; 124 participants, 2 studies; very low-certainty evidence) and on hypotension (RR 1.34, 95% CI 0.32 to 5.59; 204 participants, 3 studies; very low-certainty evidence). The other main outcomes were not reported. We identified no studies comparing different opioids (e.g. morphine versus fentanyl) or different routes for administration of the same opioid (e.g. morphine enterally versus morphine intravenously).

AUTHORS' CONCLUSIONS

Compared to placebo, opioids probably reduce pain score assessed with PIPP/PIPP-R scale during the procedure; may reduce NIPS during the procedure; and may result in little to no difference in DAN one to two hours after the procedure. The evidence is very uncertain about the effect of opioids on pain assessed with other pain scores or at different time points. The evidence is very uncertain about the effect of opioids on episodes of bradycardia, hypotension or severe apnea. Opioids may result in an increase in episodes of apnea. No studies reported parent satisfaction with care provided in the NICU. The evidence is very uncertain about the effect of opioids on any outcome when compared to non-pharmacological interventions or to other analgesics. We identified no studies comparing opioids to other opioids or comparing different routes of administration of the same opioid.

The impact of gender medicine on neonatology: the disadvantage of being male: a narrative review

This narrative non-systematic review addresses the sex-specific differences observed both in prenatal period and, subsequently, in early childhood. Indeed, gender influences the type of birth and related complications. The risk of preterm birth, perinatal diseases, and differences on efficacy for pharmacological and non-pharmacological therapies, as well as prevention programs, will be evaluated. Although male newborns get more disadvantages, the physiological changes during growth and factors like social, demographic, and behavioural reverse this prevalence for some diseases. Therefore, given the primary role of genetics in gender differences, further studies specifically targeted neonatal sex-differences will be needed to streamline medical care and improve prevention programs.

Parents' perceptions of their child's pain assessment in hospital care: A cross-sectional study

PURPOSE

A prerequisite for successful pain management is identifying the pain and assessing its intensity. The aim of this study was to describe parents' perceptions of their child's pain assessment in hospital care.

DESIGN AND METHODS

This study was a descriptive cross-sectional study. A questionnaire was completed by parents (n = 261) whose child was hospitalized in one of the pediatric units (n = 6) of the University Hospital in Finland. Quantitative data were analyzed using statistical methods; open-ended data were analyzed using inductive content analysis.

RESULTS

Parents reported that their children experienced moderate (36%) to severe pain (42%) during hospitalization. The most intense pain experienced by the children was associated with needle-related procedures (41%). A large proportion of parents (83%) were involved in their child's pain assessment. Parents were satisfied with their child's pain assessment but perceived some shortcomings. Parents hoped that a variety of methods would be used to assess their child's pain and that the parents' and child's views on pain would be taken into account.

CONCLUSIONS

Most children experience moderate to severe pain during hospitalization. Parents are often involved in pain assessment but are rarely instructed to use pain scales.

PRACTICE IMPLICATIONS

Child's pain should be assessed regularly and frequently enough. It is important that the child and parents are involved in shared decision-making about pain assessment and treatment, and they have opportunities to ask questions. Guidance should be offered to parents about the use of pain assessment scales.

Opioids for procedural pain in neonates

BACKGROUND

Neonates might be exposed to numerous painful procedures due to diagnostic reasons, therapeutic interventions, or surgical procedures. Options for pain management include opioids, non-pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported.

OBJECTIVES

To evaluate the benefits and harms of opioids in term or preterm neonates exposed to procedural pain, compared to placebo or no drug, non-pharmacological intervention, other analgesics or sedatives, other opioids, or the same opioid administered by a different route.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was December 2021.

SELECTION CRITERIA

We included randomized controlled trials conducted in preterm and term infants of a postmenstrual age (PMA) up to 46 weeks and 0 days exposed to procedural pain where opioids were compared to 1) placebo or no drug; 2) non-pharmacological intervention; 3) other analgesics or sedatives; 4) other opioids; or 5) the same opioid administered by a different route.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods and any harms. We used a fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, and their confidence intervals (CI). We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 13 independent studies (enrolling 823 newborn infants): seven studies compared opioids to no treatment or placebo (the main comparison in this review), two studies to oral sweet solution or non-pharmacological intervention, and five studies (of which two were part of the same study) to other analgesics and sedatives. All studies were performed in a hospital setting. Opioids compared to placebo or no drug Compared to placebo, opioids probably reduce pain score assessed with the Premature Infant Pain Profile (PIPP)/PIPP-Revised (PIPP-R) scale during the procedure (MD -2.58, 95% CI -3.12 to -2.03; 199 participants, 3 studies; moderate-certainty evidence); may reduce Neonatal Infant Pain Scale (NIPS) during the procedure (MD -1.97, 95% CI -2.46 to -1.48; 102 participants, 2 studies; low-certainty evidence); and may result in little to no difference in pain score assessed with the Douleur Aiguë du Nouveau-né (DAN) scale one to two hours after the procedure (MD -0.20, 95% CI -2.21 to 1.81; 42 participants, 1 study; low-certainty evidence). The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R scale up to 30 minutes after the procedure (MD 0.14, 95% CI -0.17 to 0.45; 123 participants, 2 studies; very low-certainty evidence) or one to two hours after the procedure (MD -0.83, 95% CI -2.42 to 0.75; 54 participants, 2 studies; very low-certainty evidence). No studies reported any harms. The evidence is very uncertain about the effect of opioids on episodes of bradycardia (RR 3.19, 95% CI 0.14 to 72.69; 172 participants, 3 studies; very low-certainty evidence). Opioids may result in an increase in episodes of apnea compared to placebo (RR 3.15, 95% CI 1.08 to 9.16; 199 participants, 3 studies; low-certainty evidence). The evidence is very uncertain about the effect of opioids on episodes of hypotension (RR not estimable, risk difference 0.00, 95% CI -0.06 to 0.06; 88 participants, 2 studies; very low-certainty evidence). No studies reported parent satisfaction with care provided in the neonatal intensive care unit (NICU). Opioids compared to non-pharmacological intervention The evidence is very uncertain about the effect of opioids on pain score assessed with the Crying Requires oxygen Increased vital signs Expression Sleep (CRIES) scale during the procedure when compared to facilitated tucking (MD -4.62, 95% CI -6.38 to -2.86; 100 participants, 1 study; very low-certainty evidence) or sensorial stimulation (MD 0.32, 95% CI -1.13 to 1.77; 100 participants, 1 study; very low-certainty evidence). The other main outcomes were not reported. Opioids compared to other analgesics or sedatives The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R during the procedure (MD -0.29, 95% CI -1.58 to 1.01; 124 participants, 2 studies; very low-certainty evidence); up to 30 minutes after the procedure (MD -1.10, 95% CI -2.82 to 0.62; 12 participants, 1 study; very low-certainty evidence); and one to two hours after the procedure (MD -0.17, 95% CI -2.22 to 1.88; 12 participants, 1 study; very low-certainty evidence). No studies reported any harms. The evidence is very uncertain about the effect of opioids on episodes of apnea during (RR 3.27, 95% CI 0.85 to 12.58; 124 participants, 2 studies; very low-certainty evidence) and after the procedure (RR 2.71, 95% CI 0.11 to 64.96; 124 participants, 2 studies; very low-certainty evidence) and on hypotension (RR 1.34, 95% CI 0.32 to 5.59; 204 participants, 3 studies; very low-certainty evidence). The other main outcomes were not reported. We identified no studies comparing different opioids (e.g. morphine versus fentanyl) or different routes for administration of the same opioid (e.g. morphine enterally versus morphine intravenously).

AUTHORS' CONCLUSIONS

Compared to placebo, opioids probably reduce pain score assessed with PIPP/PIPP-R scale during the procedure; may reduce NIPS during the procedure; and may result in little to no difference in DAN one to two hours after the procedure. The evidence is very uncertain about the effect of opioids on pain assessed with other pain scores or at different time points. No studies reported if any harms occurred. The evidence is very uncertain about the effect of opioids on episodes of bradycardia or hypotension. Opioids may result in an increase in episodes of apnea. No studies reported parent satisfaction with care provided in the NICU. The evidence is very uncertain about the effect of opioids on any outcome when compared to non-pharmacological interventions or to other analgesics. We identified no studies comparing opioids to other opioids or comparing different routes of administration of the same opioid.

Group B Streptococcus Early-Onset Disease: New Preventive and Diagnostic Tools to Decrease the Burden of Antibiotic Use

The difficulty in recognizing early-onset neonatal sepsis (EONS) in a timely manner due to non-specific symptoms and the limitations of diagnostic tests, combined with the risk of serious consequences if EONS is not treated in a timely manner, has resulted in a low threshold for starting empirical antibiotic treatment. New guideline strategies, such as the neonatal sepsis calculator, have been proven to reduce the antibiotic burden related to EONS, but lack sensitivity for detecting EONS. In this review, the potential of novel, targeted preventive and diagnostic methods for EONS is discussed from three different perspectives: maternal, umbilical cord and newborn perspectives. Promising strategies from the maternal perspective include Group B Streptococcus (GBS) prevention, exploring the virulence factors of GBS, maternal immunization and antepartum biomarkers. The diagnostic methods obtained from the umbilical cord are preliminary but promising. Finally, promising fields from the newborn perspective include biomarkers, new microbiological techniques and clinical prediction and monitoring strategies. Consensus on the definition of EONS and the standardization of research on novel diagnostic biomarkers are crucial for future implementation and to reduce current antibiotic overexposure in newborns.

Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.