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Agakidou E, Kontou A, Stathopoulou T, Farini M, Thomaidou A, Tsoni K, Chotas W, Sarafidis K. Intertemporal Improvement in Physicians' Perceptions of the Short-Term Adverse Outcomes of Neonatal Pain: Results of a Two-Time-Point National Survey. CHILDREN (BASEL, SWITZERLAND) 2024; 11:471. [PMID: 38671688 PMCID: PMC11049171 DOI: 10.3390/children11040471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
Pain in early life may seriously impact neonatal outcomes. This study aimed to evaluate whether the perceptions of physicians working in neonatal intensive care units (NICUs) of the short-term adverse outcomes associated with neonatal pain have changed over a 20-year period. Self-administered questionnaires were distributed to 117 and 145 neonatologists, pediatricians, and fellows working in level III NICUs in 2000 (T1) and 2019 (T2), respectively. The questionnaire consisted of four domains, including the central nervous, cardiovascular, and respiratory systems, as well as "other systems" (metabolic/endocrine system, growth, and general condition), with 21 total items overall. Although the proportion of positive (correct) responses to the total and system-specific domain scores was significantly higher at T2 than T1, the knowledge of certain short-term adverse outcomes was suboptimal even at T2. Adjustment for cofactors confirmed the independent association of the survey time-point with the total and system-specific domain scores. Moreover, NICU type was an independent significant factor associated with the adjusted total and central nervous system scores, while young doctors had a better knowledge of adverse cardiovascular effects. Conclusions: The perceptions of NICU physicians concerning the short-term outcomes associated with neonatal pain have significantly improved over the past 20 years, although remaining knowledge gaps mandate ongoing efforts to achieve an improvement in neonatal care.
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Affiliation(s)
- Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Angeliki Kontou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Theodora Stathopoulou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Maria Farini
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Agathi Thomaidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Konstantina Tsoni
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
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ten Barge JA, Baudat M, Meesters NJ, Kindt A, Joosten EA, Reiss IK, Simons SH, van den Bosch GE. Biomarkers for assessing pain and pain relief in the neonatal intensive care unit. FRONTIERS IN PAIN RESEARCH 2024; 5:1343551. [PMID: 38426011 PMCID: PMC10902154 DOI: 10.3389/fpain.2024.1343551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
Newborns admitted to the neonatal intensive care unit (NICU) regularly undergo painful procedures and may face various painful conditions such as postoperative pain. Optimal management of pain in these vulnerable preterm and term born neonates is crucial to ensure their comfort and prevent negative consequences of neonatal pain. This entails accurate and timely identification of pain, non-pharmacological pain treatment and if needed administration of analgesic therapy, evaluation of treatment effectiveness, and monitoring of adverse effects. Despite the widely recognized importance of pain management, pain assessment in neonates has thus far proven to be a challenge. As self-report, the gold standard for pain assessment, is not possible in neonates, other methods are needed. Several observational pain scales have been developed, but these often rely on snapshot and largely subjective observations and may fail to capture pain in certain conditions. Incorporation of biomarkers alongside observational pain scores holds promise in enhancing pain assessment and, by extension, optimizing pain treatment and neonatal outcomes. This review explores the possibilities of integrating biomarkers in pain assessment in the NICU.
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Affiliation(s)
- Judith A. ten Barge
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Mathilde Baudat
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Naomi J. Meesters
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Alida Kindt
- Metabolomics and Analytics Center, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Elbert A. Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Irwin K.M. Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Sinno H.P. Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Gerbrich E. van den Bosch
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
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Latremouille S, Lam J, Shalish W, Sant'Anna G. Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications. BMJ Open 2021; 11:e055209. [PMID: 34933863 PMCID: PMC8710426 DOI: 10.1136/bmjopen-2021-055209] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies. OBJECTIVES To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed. ELIGIBILITY CRITERIA Human neonates ≤1 month of corrected age. SOURCES OF EVIDENCE A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020. CHARTING METHODS A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction). RESULTS Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band. CONCLUSIONS Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.
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Affiliation(s)
- Samantha Latremouille
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Justin Lam
- Medicine, Griffith University, Nathan, Queensland, Australia
| | - Wissam Shalish
- Division of Neonatology, McGill University Health Center, Montreal, Québec, Canada
| | - Guilherme Sant'Anna
- Division of Neonatology, McGill University Health Center, Montreal, Québec, Canada
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Walas W, Halaba Z, Latka-Grot J, Piotrowski A. Available Instruments to Assess Pain in Infants. Neoreviews 2021; 22:e644-e652. [PMID: 34599062 DOI: 10.1542/neo.22-10-e644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.
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Affiliation(s)
- Wojciech Walas
- Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Zenon Halaba
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Julita Latka-Grot
- Neonatal Department, Children's Memorial Health Institute, Warszawa, Poland
| | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
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Walas W, Latka-Grot J, Maroszyńska I, Malinowska E, Rutkowska M, Piotrowski A, Wrońska M, Szczapa T, Kubiaczyk A, Skrzypek M, De Jonckheere J, Halaba ZP. Newborn Infant Parasympathetic Evaluation Index for the Assessment of Procedural Pain in Nonanesthetized Infants: A Multicenter Pilot Study. Am J Perinatol 2021; 38:e224-e230. [PMID: 32276281 DOI: 10.1055/s-0040-1709458] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the ability of the Newborn Infant Parasympathetic Evaluation (NIPE) index to detect the response to nociceptive stimuli in nonanesthetized infants and to compare these results to simultaneous scoring by behavioral scales. STUDY DESIGN Thirty-six nonanesthetized infants admitted to neonatal/pediatric intensive care unit (N/PICUs) were enrolled to the study. Due to faulty records of the data, three patients had to be excluded. To detect pain caused by noxious stimuli, the heart-rate-variability-derived NIPE index and behavioral pain scales designed for measuring procedural pain in nonverbal children were used. RESULTS Forty-one painful events were available for analysis. We observed in the whole group a statistically significant decrease in NIPE values at 1, 2, and 3 minutes after a painful stimulus, in comparison to the NIPE value at rest and the statistically significant differences between the minimum NIPE value within 3 minutes after the stimulus in comparison to NIPE value at rest in the whole group, as well as in the subgroups of moderate and severe pain. Receiver operating characteristic (ROC) analysis has shown the strong sensitivity and specificity of the NIPE in detecting the noxious stimuli (ROC AUC: 0.767). We also found that the stronger the sensation of pain was, the more rapidly NIPE reached its lowest value. DISCUSSION Our study indicates that the painful procedures are associated with a significant decrease in the NIPE value within 3 minutes after a noxious stimulus. Based on our observation, the minimum value within 3 minutes from the painful procedure seems to be the most distinctive value.
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Affiliation(s)
- Wojciech Walas
- Paediatric and Neonatal Intensive Care Unit, University Hospital in Opole, Opole, Poland
| | - Julita Latka-Grot
- Department of Neonatal, Children's Memorial Health Institute, Warszawa, Poland
| | - Iwona Maroszyńska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Ewelina Malinowska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | | | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
| | - Monika Wrońska
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
| | - Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznań University of Medical Sciences, Poznań, Poznań, Poland
| | - Agata Kubiaczyk
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznań University of Medical Sciences, Poznań, Poznań, Poland
| | - Michał Skrzypek
- Department of Biostatistics, School of Public Health in Bytom, Medical University of Silesia, Bytom, Poland
| | - Julien De Jonckheere
- Clinical Investigation Center-Technological Innovation (CIC-IT) 1403, University Hospital Center (UHC) Lille, Lille, France
| | - Zenon P Halaba
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
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Gendras J, Lavenant P, Sicard-Cras I, Consigny M, Misery L, Anand KJS, Sizun J, Roué JM. The newborn infant parasympathetic evaluation index for acute procedural pain assessment in preterm infants. Pediatr Res 2021; 89:1840-1847. [PMID: 32961546 DOI: 10.1038/s41390-020-01152-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Accurate assessments of pain in hospitalized preterm infants present a major challenge in improving the short- and long-term consequences associated with painful experiences. We evaluated the ability of the newborn infant parasympathetic evaluation (NIPE) index to detect acute procedural pain in preterm infants. METHODS Different painful and stressful interventions were prospectively observed in preterm infants born at 25 + 0 to 35 + 6 weeks gestation. Pain responses were measured using the composite Premature Infant Pain Profile Revised (PIPP-R) scale, the NIPE index, and skin conductance responses (SCR). Outcome measures were correlations between the NIPE index, the PIPP-R score, and the SCR. Sensitivity/specificity analyses tested the accuracy of the NIPE index and SCR. RESULTS Two hundred and fifty-four procedures were recorded in 90 preterm infants. No significant correlation was found between PIPP-R and the NIPE index. PIPP-R and SCR were positively correlated (r = 0.27, P < 0.001), with stronger correlations for painful procedures (r = 0.68, P < 0.001) and especially for skin-breaking procedures (r = 0.82, P < 0.001). The NIPE index and SCR had high sensitivity and high negative predictive values to predict PIPP-R > 10, especially for skin-breaking painful procedures. CONCLUSIONS We found no significant correlation between the NIPE index and PIPP-R during routine painful or stressful procedures in preterm infants. IMPACT Exposure to repetitive pain can lead to neurodevelopmental sequelae. Behavior-based pain scales have limited clinical utility, especially for preterm infants. New devices for monitoring physiological responses to pain have not been validated sufficiently in preterm infants. This study found that the NIPE index was not significantly correlated to the validated PIPP-R scale during acute procedural pain. Secondary analysis of this study showed that NIPE index and SCRs may help to exclude severe pain in preterm infants. In clinical practice, measurements of physiological parameters should be combined with behavior-based scales for multidimensional pain assessments.
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Affiliation(s)
- Julie Gendras
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Pauline Lavenant
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Iona Sicard-Cras
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Maëlys Consigny
- Centre d'Investigation Clinique 0502, Inserm, Brest, 29200, France
| | - Laurent Misery
- Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Kanwaljeet J S Anand
- Pain/Stress Neurobiology Lab, Maternal and Child Health Research Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Jacques Sizun
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France.,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France
| | - Jean-Michel Roué
- Pôle de Femme, de la Mère et de l'Enfant, Centre Hospitalier Régional Universitaire, Brest, France. .,Laboratoire Interactions Epithéliums Neurones, EA 4685, Faculté de médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, 29200, France. .,Pain/Stress Neurobiology Lab, Maternal and Child Health Research Institute, Stanford University School of Medicine, Stanford, CA, USA.
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Lim BG. Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients. Anesth Pain Med (Seoul) 2019; 14:380-392. [PMID: 33329766 PMCID: PMC7713809 DOI: 10.17085/apm.2019.14.4.380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/03/2022] Open
Abstract
Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.
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Affiliation(s)
- Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
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8
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Shahid S, Florez ID, Mbuagbaw L. Efficacy and Safety of EMLA Cream for Pain Control Due to Venipuncture in Infants: A Meta-analysis. Pediatrics 2019; 143:peds.2018-1173. [PMID: 30587535 DOI: 10.1542/peds.2018-1173] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5852339542001PEDS-VA_2018-1173Video Abstract CONTEXT: The eutectic mixture of lidocaine (EMLA) cream has been used to reduce the pain during venipuncture in infants. OBJECTIVE To determine the efficacy and safety of EMLA in infants <3 months of age requiring venipuncture in comparison with nonpharmacological interventions in terms of pain reduction, change in physiologic variables, and methemoglobinemia. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and gray literature were searched from inception to August 2017, without language restrictions. STUDY SELECTION We selected randomized controlled trials in which researchers compared EMLA with nonpharmacological interventions. DATA EXTRACTION Two reviewers independently performed abstract screening and full-text review, and extracted the data and assessed the risk of bias. RESULTS Ten randomized controlled trials (907 infants) were included. EMLA revealed little or no effect in reduction of pain (standardized mean difference: 0.14; 95% confidence interval [CI]: -0.17 to 0.45; 6 trials, n = 742; moderate-quality evidence) when EMLA was compared with sucrose, breastfeeding, or placebo. In comparison with placebo, EMLA revealed a small-to-moderate effect on increasing methemoglobin levels (mean difference: 0.35; 95% CI: 0.04 to 0.66; 2 trials, n = 134; low-quality evidence). There was an increased risk of blanching of the skin in the EMLA group (relative risk: 2.63; 95% CI: 1.58 to 4.38; 2 trials, n = 123; I2 = 84%, very low-quality evidence). LIMITATIONS Our results may not be applicable to older infants. CONCLUSIONS EMLA reveals minimal benefits in terms of reduction of pain due to venipuncture procedure in comparison with placebo and no benefit in comparison with sucrose and/or breastfeeding. Moreover, it produced an elevation in methemoglobin levels and skin blanching.
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Affiliation(s)
- Shaneela Shahid
- Departments of Health Research Methods, Evidence, and Impact and .,Pediatrics, McMaster University, Hamilton, Canada
| | - Ivan D Florez
- Departments of Health Research Methods, Evidence, and Impact and.,Department of Pediatrics, Universidad de Antioquia, Medellín, Colombia; and
| | - Lawrence Mbuagbaw
- Departments of Health Research Methods, Evidence, and Impact and.,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, Canada
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9
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Randomized Clinical Trial of Lidocaine Analgesia for Transurethral Bladder Catheterization Delivered via Blunt Tipped Applicator in Young Children. Pediatr Emerg Care 2018; 34:273-279. [PMID: 29232351 DOI: 10.1097/pec.0000000000001358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Transurethral bladder catheterization (TUBC) is a painful, frequently performed procedure for collecting sterile urine. We sought to determine if administration of intraurethral lidocaine before TUBC using a blunt tipped syringe decreases procedural pain in young children in the pediatric emergency department. METHODS Randomized clinical trial of children 0 to 36 months old requiring TUBC for collection of urine in a pediatric emergency department was performed. Patients received intraurethral 2% lidocaine jelly or usual care (no analgesia). Randomization was stratified by sex. Intraurethral lidocaine jelly was administered via Uro-Jet, 5 minutes before TUBC. Baseline child state, lidocaine application, TUBC, and child state 1 minute post-TUBC were videotaped. Neither providers nor parents were blinded to study arm. Videos were scored by a trained, independent, blinded reviewer using the Faces, Legs, Arms, Cry, and Consolability (FLACC) and Modified Behavioral Pain Score scales. Pain scores were compared using the Wilcoxon rank sum test. Our primary outcome was difference in FLACC scores between groups. RESULTS Eighty children were enrolled in the study, and 73 had analyzable data. No differences were detected in pain by mean FLACC score between intervention (8; 95% confidence interval, 7-9) and control (9; 95% confidence interval, 8-10) groups. There were no differences between groups in mean FLACC score when stratified by age or sex or in mean Modified Behavioral Pain Score. CONCLUSIONS Intraurethral lidocaine for TUBC for urine collection using a blunt tipped applicator did not improve procedural pain scores. Pain scores were high across groups. Further study should be performed to improve analgesia for this highly painful procedure.
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10
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Cremillieux C, Makhlouf A, Pichot V, Trombert B, Patural H. Objective assessment of induced acute pain in neonatology with the Newborn Infant Parasympathetic Evaluation index. Eur J Pain 2018; 22:1071-1079. [DOI: 10.1002/ejp.1191] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2018] [Indexed: 11/05/2022]
Affiliation(s)
- C. Cremillieux
- Department of Pediatric Medicine; Neonatal Intensive Care Unit; University Hospital of Saint-Etienne; France
| | - A. Makhlouf
- Department of Pediatric Medicine; Neonatal Intensive Care Unit; University Hospital of Saint-Etienne; France
| | - V. Pichot
- EA SNA-EPIS Research Laboratory; Jean Monnet University of Saint-Etienne; France
| | - B. Trombert
- Public Health and Medical Information Unit; University Hospital of Saint-Etienne; France
| | - H. Patural
- Department of Pediatric Medicine; Neonatal Intensive Care Unit; University Hospital of Saint-Etienne; France
- EA SNA-EPIS Research Laboratory; Jean Monnet University of Saint-Etienne; France
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11
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Lago P, Garetti E, Bellieni CV, Merazzi D, Savant Levet P, Ancora G, Pirelli A. Systematic review of nonpharmacological analgesic interventions for common needle-related procedure in newborn infants and development of evidence-based clinical guidelines. Acta Paediatr 2017; 106:864-870. [PMID: 28295585 DOI: 10.1111/apa.13827] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 12/24/2016] [Accepted: 03/07/2017] [Indexed: 11/28/2022]
Abstract
The aim of this literature review was to develop clinical guidelines for the prevention and control of needle-related pain in newborn infants. The guidelines were developed by the Italian Society of Neonatology, using the Grading of Recommendations, Assessment, Development and Evaluation approach, based on the assessment of 232 papers published between 1986 and 2015. The quality of the evidence was high or moderate for some behavioural and nonpharmacological interventions. CONCLUSION There was sufficient evidence to strongly support the use of nonpharmacological interventions for common needle-related procedures in newborn infants. Combined interventions seemed to be more effective in relieving procedural pain.
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Affiliation(s)
- Paola Lago
- Neonatal Intensive Care Unit; Women's and Children's Health Department; Azienda Ospedaliera-University of Padova; Padova Italy
| | - Elisabetta Garetti
- NICU; Women's and Children's Health Department; Azienda Ospedaliera-University of Modena; Modena Italy
| | | | - Daniele Merazzi
- NICU; Mother's and Infant's Department; Valduce Hospital; Como Italy
| | | | - Gina Ancora
- Women's and Children's Health Department; Infermi Hospital; Azienda Ospedaliera of Rimini; Rimini Italy
| | - Anna Pirelli
- NICU; MBBM Foundation; San Gerardo Hospital; Monza Italy
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12
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Abstract
BACKGROUND Hospitalised newborn neonates frequently undergo painful invasive procedures that involve penetration of the skin and other tissues by a needle. One intervention that can be used prior to a needle insertion procedure is application of a topical local anaesthetic. OBJECTIVES To evaluate the efficacy and safety of topical anaesthetics such as amethocaine and EMLA in newborn term or preterm infants requiring an invasive procedure involving puncture of skin and other tissues with a needle. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase and CINAHL up to 15 May 2016; previous reviews including cross-references, abstracts, and conference proceedings. We contacted expert informants. We contacted authors directly to obtain additional data. We imposed no language restrictions. SELECTION CRITERIA Randomised, quasi-randomised controlled trials, and cluster and cross-over randomised trials that compared the topical anaesthetics amethocaine and eutectic mixture of local anaesthetics (EMLA) in terms of anaesthetic efficacy and safety in newborn term or preterm infants requiring an invasive procedure involving puncture of skin and other tissues with a needle DATA COLLECTION AND ANALYSIS: From the reports of the clinical trials we extracted data regarding clinical outcomes including pain, number of infants with methaemoglobin level 5% and above, number of needle prick attempts prior to successful needle-related procedure, crying, time taken to complete the procedure, episodes of apnoea, episodes of bradycardia, episodes of oxygen desaturation, neurodevelopmental disability and other adverse events. MAIN RESULTS Eight small randomised controlled trials met the inclusion criteria (n = 506). These studies compared either EMLA and placebo or amethocaine and placebo. No studies compared EMLA and amethocaine. We were unable to meta-analyse the outcome of pain due to differing outcome measures and methods of reporting. For EMLA, two individual studies reported a statistically significant reduction in pain compared to placebo during lumbar puncture and venepuncture. Three studies found no statistical difference between the groups during heel lancing. For amethocaine, three studies reported a statistically significant reduction in pain compared to placebo during venepuncture and one study reported a statistically significant reduction in pain compared to placebo during cannulation. One study reported no statistical difference between the two groups during intramuscular injection.One study reported no statistical difference between EMLA and the placebo group for successful venepuncture at first attempt. One study similarly reported no statistically significant difference between Amethocaine and the placebo group for successful cannulation at first attempt.Risk for local redness, swelling or blanching was significantly higher with EMLA (typical risk ratio (RR) 1.65, 95% confidence interval (CI) 1.24 to 2.19; typical risk difference (RD) 0.17, 95% CI 0.09 to 0.26; n = 272; number needed to treat for an additional harmful outcome (NNTH) 6, 95% CI 4 to 11; I2 = 92% indicating considerable heterogeneity) although not for amethocaine (typical RR 2.11, 95% CI 0.72 to 6.16; typical RD 0.05, 95% CI -0.02 to 0.11, n = 221). These local skin reactions for EMLA and amethocaine were reported as short-lasting. Two studies reported no methaemoglobinaemia with single application of EMLA. The quality of the evidence on outcomes assessed according to GRADE was low to moderate. AUTHORS' CONCLUSIONS Overall, all the trials were small, and the effects of uncertain clinical significance. The evidence regarding the effectiveness or safety of the interventions studied is inadequate to support clinical recommendations. There has been no evaluation regarding any long-term effects of topical anaesthetics in newborn infants.High quality studies evaluating the efficacy and safety of topical anaesthetics such as amethocaine and EMLA for needle-related pain in newborn term or preterm infants are required. These studies should aim to determine efficacy of these topical anaesthetics and on homogenous groups of infants for gestational age. While there was no methaemoglobinaemia in the studies that reported methaemoglobin, the efficacy and safety of EMLA, especially in very preterm infants, and for repeated application, need to be further evaluated in future studies.
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Affiliation(s)
| | - Christine Taylor
- University of Western SydneyParramatta Campus, Bldg EI G15Locked Bag 1797PenrithAustralia2751
| | - Kaye Spence
- The Children's Hospital at WestmeadGrace Centre for Newborn CareLocked Bag 4001WestmeadAustralia2145
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Development of Cardiovascular Indices of Acute Pain Responding in Infants: A Systematic Review. Pain Res Manag 2016; 2016:8458696. [PMID: 27445630 PMCID: PMC4904608 DOI: 10.1155/2016/8458696] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/20/2015] [Indexed: 11/21/2022]
Abstract
Background. Cardiovascular indices of pain are pervasive in the hospital setting. However, no prospective research has examined the development of cardiac responses to acutely painful procedures in the first year of life. Objectives. Our main goal was to synthesize existing evidence regarding the development of cardiovascular responses to acutely painful medical procedures over the first year of life in preterm and term born infants. Methods. A systematic search retrieved 6994 articles to review against inclusion criteria. A total of 41 studies were included in the review. Results. In response to acutely painful procedures, most infants had an increase in mean heart rate (HR) that varied in magnitude both across and within gestational and postnatal ages. Research in the area of HR variability has been inconsistent, limiting conclusions. Conclusions. Longitudinal research is needed to further understand the inherent variability of cardiovascular pain responses across and within gestational and postnatal ages and the causes for the variability.
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Messerer B, Krauss-Stoisser B, Urlesberger B. [Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz 2015; 28:31-42. [PMID: 24550025 DOI: 10.1007/s00482-014-1391-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.
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Affiliation(s)
- B Messerer
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 29, 8036, Graz, Österreich,
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15
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Abstract
Pain assessment and measurement are the cornerstones of pain management. Pain assessment connotes a comprehensive multidimensional description. Conversely, pain measurement provides a numeric quantitative description of each factor illustrating pain qualities. Pain scales provide a composite score used to guide practice and research. The type of infant pain instrument chosen is a significant factor in guiding pain management practice. The purpose of this review was to summarize current infant pain measures by introducing a conceptual framework for pain measurement. Although more than 40 infant pain instruments exist, many were devised solely for research purposes; several of the newly developed instruments largely overlap with existing instruments. Integration of pain management into daily practice remains problematic. Understanding how each instrument measures infant pain allows clinicians to make better decisions about what instrument to use with which infant and in what circumstances. In addition, novel new measurement techniques need further testing.
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16
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Hui-Chen F, Hsiu-Lin C, Shun-Line C, Tai-Ling T, Li-Jung W, Hsing-I T, San-Nan Y. The effect of EMLA cream on minimizing pain during venipuncture in premature infants. J Trop Pediatr 2013; 59:72-3. [PMID: 22961215 DOI: 10.1093/tropej/fms040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Painful procedures for premature infants in neonatal intensive care units remain inevitable. The goal of this study is to evaluate the effect of an eutectic mixture of local anesthetic (EMLA) cream for minimizing pain in premature infants during venipuncture in neonatal intensive care units. METHODS This study enrolled 32 premature infants. A repeated-measures design was used. The scores of the 'Neonatal Pain, Agitation and Sedation Scale' (N-PASS) of each enrolled preterm infant were measured before, during and 10 min after venipuncture without and with EMLA cream use. Paired t-tests were used to compare the difference of N-PASS scores without and with EMLA cream use. RESULTS Paired t-tests revealed a significant decrease in N-PASS scores during venipuncture in infants with EMLA cream. There was no significant change of N-PASS scores before, during and 10 min after venipuncture with EMLA cream by analysis of repeated analysis of variance. CONCLUSION EMLA cream for minimizing pain during venipuncture could be recommended for premature infants.
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Affiliation(s)
- Fan Hui-Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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17
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Harrison TM, Brown RL. Autonomic nervous system function in infants with transposition of the great arteries. Biol Res Nurs 2012; 14:257-68. [PMID: 21613339 PMCID: PMC3296865 DOI: 10.1177/1099800411407687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The ability to maintain and respond to challenges to homeostasis is primarily a function of the autonomic nervous system (ANS). In infants with complex congenital heart defects this ability may be impaired. This study described change in ANS function before and after surgical correction in infants with transposition of the great arteries (TGA) and in healthy infants. A total of 15 newborn infants with TGA were matched with 16 healthy infants on age, gender, and feeding type. The ANS function was measured using heart rate variability (HRV). Data were collected preoperatively in the 1st week of life and postoperatively before, during, and after feeding at 2 weeks and 2 months of age. Infants with TGA demonstrated significantly lower high-frequency and low-frequency HRV preoperatively (p < .001) when compared with healthy infants. At 2 weeks, infants with TGA were less likely than healthy infants to demonstrate adaptive changes in high-frequency HRV during feeding (Wald Z = 2.002, p = .045), and at 2 months, 40% of TGA infants exhibited delayed postfeeding recovery. Further research is needed to more thoroughly describe mechanisms of a physiologically adaptive response to feeding and to develop nursing interventions supportive of these high-risk infants.
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Affiliation(s)
- Tondi M Harrison
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH 43205, USA.
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18
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A comparison of pain measures in newborn infants after cardiac surgery. Pain 2011; 152:1758-1765. [DOI: 10.1016/j.pain.2011.03.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 02/26/2011] [Accepted: 03/15/2011] [Indexed: 11/23/2022]
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Biran V, Gourrier E, Cimerman P, Walter-Nicolet E, Mitanchez D, Carbajal R. Analgesic effects of EMLA cream and oral sucrose during venipuncture in preterm infants. Pediatrics 2011; 128:e63-70. [PMID: 21669894 DOI: 10.1542/peds.2010-1287] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal of this study was to compare the analgesic effect of sucrose with that of the combination of sucrose and the local anesthetic cream EMLA during venipuncture in preterm neonates. METHODS This randomized, double-blind prospective study included infants younger than 37 weeks' gestational age during 1 routine venipuncture for blood sampling. Each child randomly received either sucrose plus application of a placebo cream (S group) or sucrose plus EMLA cream (S+E group) before venipuncture. Venipuncture-induced pain was assessed through videotapes of the procedures by using the Douleur Aiguë Nouveau-né (DAN) behavioral scale. Pain was assessed at 2 phases: during venipuncture (from needle introduction to its removal) and during the recovery period (30 seconds after needle removal). Pain scores over time and between treatments were compared by using repeated-measures analysis of variance. RESULTS The study included 76 children (37 in the S group, 39 in the S+E group). Mean (SD) DAN pain scores for the S group and the S+E group were 7.7 (2.1) and 6.4 (2.5), respectively, during venipuncture and 7.1 (2.8) and 5.7 (3.3) during the postinjection period. A significant time and treatment effect in favor of the S+E group was observed. CONCLUSION The combination of sucrose and EMLA cream revealed a higher analgesic effect than sucrose alone during venipuncture in these preterm infants.
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Affiliation(s)
- Valérie Biran
- Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Cong X, Cusson RM, Hussain N, Zhang D, Kelly SP. Kangaroo care and behavioral and physiologic pain responses in very-low-birth-weight twins: a case study. Pain Manag Nurs 2011; 13:127-38. [PMID: 22929600 DOI: 10.1016/j.pmn.2010.10.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 10/25/2010] [Accepted: 10/25/2010] [Indexed: 10/18/2022]
Abstract
The purpose of this case study was to describe pain responses in three study conditions: longer (30 minutes) kangaroo care (KC) before and throughout heel stick (KC30), shorter (15 minutes) KC before and throughout heel stick (KC15), and incubator care throughout heel stick (IC) in 28-week gestational age twins. Pain responses were measured by crying time, Preterm Infant Pain Profile (PIPP), and heart rate variability indexes, including low-frequency power (LF, representing sympathetic activity), high-frequency power (HF, parasympathetic activity), and LF/HF ratio (sympathetic-parasympathetic balance). Both twins cried more and had higher PIPP pain scores and tachycardia during heel stick in the IC condition. Infant B had an incident of apnea and tachycardia by the end of the heel stick and a bradycardia episode during recovery in the IC condition. The twins had lower LF/HF ratios (better autonomic nervous system balance) during recovery in both longer and shorter KC conditions compared with the IC condition. Infant B had difficulty returning to LF/HF ratio baseline level after the painful procedure in the IC condition. These data suggest that both longer and shorter KC before and throughout painful procedures can be helpful in reducing behavioral and physiologic pain responses in preterm infants.
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Affiliation(s)
- Xiaomei Cong
- University of Connecticut School of Nursing, Storrs, Connecticut 06269-2026, USA.
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21
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Celebioglu A, Akpinar RB, Tezel A. The pain response of infants in Turkey to vaccination in different injection sites. Appl Nurs Res 2009; 23:101-5. [PMID: 20420997 DOI: 10.1016/j.apnr.2008.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 01/18/2008] [Accepted: 03/22/2008] [Indexed: 11/17/2022]
Abstract
This study was carried out with the aim of comparing pain responses of children who receive intramuscular (IM) vaccination in deltoid muscle versus the pain responses of those who receive IM vaccination in the vastus lateralis. A total of 185 infants were randomly assigned to one of the two study groups. The deltoid group and the vastus lateralis group were vaccinated respectively in the deltoid muscle and the vastus lateralis. Our results indicated that pain response of infants was similar in each group. However, crying duration of the children who received the vastus lateralis vaccination was shorter than that of the deltoid group after the procedure.
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Affiliation(s)
- Ayda Celebioglu
- Department of Pediatric Nursing, Ataturk University, Erzurum, Turkey, 25240
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22
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Choi EK, Jung JM, Sin JB. Pain reducing effect of vapocoolant spray during injection and heelstick procedure in neonates. KOREAN JOURNAL OF PEDIATRICS 2008. [DOI: 10.3345/kjp.2008.51.5.481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Eun Kyong Choi
- Department of Pediatrics, College of Medicine, Inje University, Busan, Korea
| | - Ji Mi Jung
- Department of Pediatrics, College of Medicine, Inje University, Busan, Korea
| | - Jong Beom Sin
- Department of Pediatrics, College of Medicine, Inje University, Busan, Korea
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23
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Abstract
During the past two decades there has been a substantial increase in the number and types of topical anesthetics available. Options for the prevention of neonatal pain associated with skin-breaking procedures were previously limited to injections of lidocaine hydrochloride. Topical anesthetics are now available as creams, gels, and a heat-activated patch system. Although lidocaine injection continues to be widely used for pain associated with circumcision, lumbar puncture, or placement of central venous lines, practical information regarding the use of newer agents in the neonate is needed. This review seeks to expand the options for topical anesthesia in neonates.
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Affiliation(s)
- Victoria Tutag Lehr
- Department of Pharmacy Practice, The Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Division of Clinical Pharmacology & Toxicology, Children's Hospital of Michigan, Detroit, MI, USA
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24
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Yeo LF, Eichenfield LF, Chan YC. Skin surgery in children: local anaesthesia and sedation techniques. Expert Opin Pharmacother 2007; 8:317-27. [PMID: 17266467 DOI: 10.1517/14656566.8.3.317] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the past, procedural pain control in young children was undertreated as it was incorrectly alleged that their neuronal pain pathways were undeveloped. However, it is now recognised that even neonates are able to experience pain. Moreover, intensely painful physical experiences in childhood can have persisting physiological and psychological consequences. Therefore, the management of acute pain is essential. In this paper, the authors provide an in-depth discussion regarding the anaesthetic options for paediatric patients undergoing dermatological surgery.
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25
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Cohen LL, Bernard RS, McClellan CB, Piazza-Waggoner C, Taylor BK, MacLaren JE. Topical Anesthesia Versus Distraction for Infants' Immunization Distress: Evaluation With 6-Month Follow-Up. CHILDRENS HEALTH CARE 2006. [DOI: 10.1207/s15326888chc3502_1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Anand KJS, Johnston CC, Oberlander TF, Taddio A, Lehr VT, Walco GA. Analgesia and local anesthesia during invasive procedures in the neonate. Clin Ther 2006; 27:844-76. [PMID: 16117989 DOI: 10.1016/j.clinthera.2005.06.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area. OBJECTIVE The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates. METHODS Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded. RESULTS The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.
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Affiliation(s)
- K J S Anand
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.
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28
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Park SK, Kim EY. Pain reduction at venipuncture in newborn infants : oral glucose solution, EMLA cream® and pacifiers. KOREAN JOURNAL OF PEDIATRICS 2006. [DOI: 10.3345/kjp.2006.49.4.388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Sang Kee Park
- Department of Pediatrics, College of Medicine, Chosun University, Gwangju, Korea
| | - Eun Young Kim
- Department of Pediatrics, College of Medicine, Chosun University, Gwangju, Korea
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29
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Abstract
Neonates in the neonatal intensive care unit experience painful procedures. Over the last 10 years, investigators have examined several pharmacologic and nonpharmacolgic treatment strategies to decrease or eliminate the pain associated with mechanical ventilation, endotrachial intubation, insertion of percutaneous or central venous lines, heel stick, and venipuncture. These procedures and others are addressed as well as the reported severity of pain associated with these procedures. Progress has been made in the past decade to establish evidence-based treatments that will help the clinician more effectively relieve neonatal stress and pain when performing many routine procedures.
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Affiliation(s)
- Karen C D'Apolito
- Neonatal Nurse Practitioner Program, Vanderbilt University School of Nursing, Nashville, Tenn, USA.
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30
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Abstract
UNLABELLED Pain in the neonate is a complex subject. The assessment of pain should be simple and clinically usable. So far, the scales that have been used to assess pain are too time consuming and complex. The analysis of cry in a simple manner, as described in this issue of Acta Paediatrica by Bellieni et al., could be used in a simple and effective way at the bedside. CONCLUSION Since sick and premature newborns are not studied, the scale needs further confirmation.
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Affiliation(s)
- Jens Schollin
- Department of Paediatrics, Orebro University Hospital, Orebro, Sweden.
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31
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Abstract
Pain is subjective. The pain response is individual and is learned through social learning and experience. Early pain experiences may play a particularly important role in shaping an individual's pain responses. Painful medical procedures such as immunizations, venipunctures and dental care, and minor emergency department procedures such as laceration repair, compose a significant portion of the average child's experience with painful events. Inadequate relief of pain and distress during childhood painful medical procedures may have long-term negative effects on future pain tolerance and pain responses. This article reviews the evidence for long-term negative effects of inadequately treated procedural pain, the determinants of an individual's pain response, tools to assess pain in children, and interventions to reduce procedural pain and distress. Future research directions and a model for conceptualizing and studying pediatric procedural pain are proposed.
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Affiliation(s)
- Kelly D Young
- David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA.
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32
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Abstract
Based on the content of the article, you will be able to: Identify the two drugs in EMLA and the youngest pediatric age for its approved use. List the procedures for which EMLA has been used to control pain in infants. Describe the efficacy of EMLA vs. other agents in treating pain. Discuss the potential adverse effects of EMLA in infants. See page 48 for instructions.
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MESH Headings
- Administration, Cutaneous
- Age Factors
- Anesthetics, Combined/adverse effects
- Anesthetics, Combined/therapeutic use
- Anesthetics, Local/adverse effects
- Anesthetics, Local/therapeutic use
- Blood Specimen Collection/adverse effects
- Circumcision, Male/adverse effects
- Humans
- Infant
- Infant, Newborn
- Injections, Intramuscular/adverse effects
- Intensive Care, Neonatal
- Lidocaine/adverse effects
- Lidocaine/therapeutic use
- Lidocaine, Prilocaine Drug Combination
- Neonatal Nursing
- Ointments
- Pain/diagnosis
- Pain/drug therapy
- Pain/etiology
- Pain Measurement
- Patient Selection
- Phlebotomy/adverse effects
- Prilocaine/adverse effects
- Prilocaine/therapeutic use
- Research Design
- Safety
- Spinal Puncture/adverse effects
- Treatment Outcome
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Lillieborg S, Otterbom I, Ahlen K. Topical anaesthesia in neonates, infants and children. Br J Anaesth 2004; 92:450; author reply 450-1. [PMID: 14970141 DOI: 10.1093/bja/aeh522] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Studies of paediatric procedural distress have flourished over the past two decades, with psychological intervention strategies showing consistently high efficacy in reducing pain and fear. This review concentrates briefly on the acquisition and treatment of fear, arguing that what is witnessed clinically is not needle fear or phobia, but anticipatory or procedural distress. The main focus is on how such procedures could be amended to incorporate psychological techniques routinely, outlining specific guidelines for clinical practice.
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Affiliation(s)
- A J A Duff
- Department of Clinical Psychology, Ashley Wing Extension, St James's University Hospital, Leeds LS9 7TF, UK.
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35
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Comparison of Heart Rate Response to an Epinephrine Test Dose and Painful Stimulus in Children During Sevoflurane Anesthesia. Reg Anesth Pain Med 2003. [DOI: 10.1097/00115550-200309000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lindh V, Wiklund U, Blomquist HK, Håkansson S. EMLA cream and oral glucose for immunization pain in 3-month-old infants. Pain 2003; 104:381-8. [PMID: 12855349 DOI: 10.1016/s0304-3959(03)00046-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED The objective of this study is to determine whether use of lidocaine-prilocaine 5% cream (EMLA) and oral glucose decreases pain associated with diphteria-pertussis-tetanus (DPT) immunization in 3-month-old infants. DESIGN randomized, double-blind, controlled trial in outpatient paediatric practice in northern Sweden. EMLA or placebo was applied to the infant's lateral region of the right thigh and covered with an occlusive dressing 1h before the immunization. In addition, 1 ml of glucose (300 mg/ml) or placebo (water) was instilled on the baby's tongue within 2 min before the DPT-injection. Forty-five infants received EMLA and glucose and 45 infants placebo cream and water. ECG was recorded and stored in a computer and the procedure was videotaped. The parents and the nurse assessed the infants' pain on a visual analogue scale (VAS) after the immunization. Heart rate and heart rate variability pre- and post-injection were calculated. From the videotapes, the modified behavioural pain scale (MBPS) was used to assess pain scores during baseline and after immunization. The latency of the first cry and total crying time were measured. The parents and the nurse scored the infants' pain on the VAS significantly lower in the treatment group than in the placebo group. The infants' responses to the immunization measured as the difference in MBPS scores pre- and post-injection were significantly lower in the EMLA-glucose group compared with the placebo group. More infants cried after the immunization in the placebo group compared with the EMLA-glucose group and the latency of the first cry after the injection was shorter in the placebo group. A biphasic transient heart rate response with a marked deceleration followed by a subsequent acceleration was seen more frequently in the placebo group compared to the EMLA-glucose group. EMLA and glucose alleviate immunization pain in 3-month-old infants.
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Affiliation(s)
- Viveca Lindh
- Department of Clinical Sciences, Pediatrics, University Hospital, Umeå University, S-901 85 Umeå, Sweden.
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Weinberger B, Hanna N, Gropper CA, Heck DE, Laskin DL, Laskin JD. Transdermal Xenobiotics in Newborn Skin. ACTA ACUST UNITED AC 2003; 22:51-67. [PMID: 37007905 PMCID: PMC10061589 DOI: 10.1081/cus-120019330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Newborn infants are regularly exposed to a wide variety of topical agents, including treatments for rashes, antimicrobial agents, solvents, and skin barriers or moisturizers. Premature and hospitalized infants are also exposed to topical iodine for antisepsis and to topical analgesic agents. The fact that most of these agents have not been specifically evaluated for use in infants has recently been recognized as a major public health concern. The epidermis of preterm infants is not fully developed, constituting an incomplete barrier to systemic absorption of topical agents. Thus, substances applied to the skin can have adverse systemic effects. Povidone-iodine and steroid creams have been associated with thyroid and hypothalamic-pituitary axis suppression, respectively, in premature infants. Application of topical EMLA (Eutectic Mixture of Local Anesthetics) for analgesia has been implicated in methemoglobinemia in premature infants. Exposure to natural latex in gloves and medical equipment may sensitize infants, leading to the development of airway hyperreactivity and other allergic manifestations. Therefore, it is advisable to limit skin exposure of premature infants to xenobiotics. Further work is required to define safe doses of common agents. In addition, transdermal administration of systemic medications, including methylxanthines, may be practical in premature infants.
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Affiliation(s)
- Barry Weinberger
- Division of Neonatology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Correspondence: Barry Weinberger, M.D., Associate Professor of Pediatrics, Division of Neonatology, St. Peter’s University Hospital, 254 Easton Avenue, New Brunswick, NJ 08903, USA; Fax: 732-249-6306;
| | - Nazeeh Hanna
- Division of Neonatology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Charles A. Gropper
- Department of Dermatology, Mount Sinai School of Medicine, New York, New York, USA
| | - Diane E. Heck
- Department of Pharmacology and Toxicology, Rutgers University, Piscataway, New Jersey, USA
| | - Debra L. Laskin
- Department of Pharmacology and Toxicology, Rutgers University, Piscataway, New Jersey, USA
| | - Jeffrey D. Laskin
- Department of Environmental and Community Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Gradin M, Eriksson M, Holmqvist G, Holstein A, Schollin J. Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream. Pediatrics 2002; 110:1053-7. [PMID: 12456899 DOI: 10.1542/peds.110.6.1053] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE A number of studies have shown that orally administered sweet-tasting solutions reduce signs of pain during painful procedures. The local anesthetic cream EMLA has recently been shown to be safe for use in neonates. This study compared the pain-reducing effect of orally administered glucose with that of EMLA cream during venipuncture in newborns. METHODS Randomized, controlled, double-blind study including 201 newborns undergoing venipuncture for clinical purposes. Ninety-nine of the newborns received EMLA on the skin and orally administered placebo (sterile water), and 102 received glucose 30% orally and placebo (Unguentum Merck) on the skin. Symptoms associated with pain at venipuncture were measured with the Premature Infant Pain Profile (PIPP) scale (also validated for full-term infants). Heart rate and crying time were recorded. RESULTS There were no differences in background variables between the 2 groups. The results shows that the PIPP scores were significantly lower in the glucose group (mean: 4.6) compared with the EMLA group (mean: 5.7). The duration of crying in the first 3 minutes was significantly lower in the glucose group (median: 1 second) than in the EMLA group (median: 18 seconds). There were significantly fewer patients in the glucose group who were scored having pain (defined as PIPP score above 6); 19.3% compared with 41.7% in the EMLA group. The changes in heart rate were similar in both groups. CONCLUSIONS We found that glucose is effective in reducing symptoms associated with pain from venipuncture in newborns and seems to be better than the local anesthetic cream EMLA.
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Affiliation(s)
- Maria Gradin
- Department of Pediatrics, Orebro University Hospital, Orebro, Sweden.
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Pons G, Tréluyer JM, Dimet J, Merlé Y. Potential benefit of Bayesian forecasting for therapeutic drug monitoring in neonates. Ther Drug Monit 2002; 24:9-14. [PMID: 11805715 DOI: 10.1097/00007691-200202000-00002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Therapeutic drug monitoring in neonate has been hampered by invasiveness of blood samplings raising ethical problems. A methodologic approach has been developped in adults and in children that is still unsufficiently developped in neonates, the Bayesian forecasting of drug plasma concentration. This method is particularly attractive in neonates using a few blood samples from an individual patient and more informations from a prior patient sample representative of the population the individual patient belongs to. The present article aims at reviewing the different procedures and methods to minimize invasiveness during therapeutic drug monitoring in neonate and at reviewing the methods for improving the quality of different dose adjustments using a Bayesian approach.
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Affiliation(s)
- Gérard Pons
- Perinatal and Pediatric Pharmacology, Saint-Vincent de Paul Hospital, René Descartes University, Paris, France.
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Abstract
The provision of sedation and analgesia is an integral aspect of the care of PICU patients. A careful systems approach to the provision of sedation and analgesia can minimize complications and maximize benefit to patients. Vigilance in monitoring and adherence to published guidelines are important for safety. Physicians must define the goals in clearly devising a plan and tailor the prescription to those goals rather than use a regimented protocol for all patients.
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Affiliation(s)
- D M Polaner
- Department of Anesthesia, University of Colorado School of Medicine, Children's Hospital, Denver, Colorado, USA.
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