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Kinoshita M, Olsson E, Borys F, Bruschettini M. Opioids for procedural pain in neonates. Cochrane Database Syst Rev 2023; 6:CD015056. [PMID: 37350685 PMCID: PMC10292809 DOI: 10.1002/14651858.cd015056.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
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.
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Affiliation(s)
- Mari Kinoshita
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Franciszek Borys
- II Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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Abstract
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.
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Affiliation(s)
- Mari Kinoshita
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Franciszek Borys
- II Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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Sharma N, Arahna VP, Saxena S, Ateef M, Samuel AJ. Scoping out the scope of scoping reviews in neonatal and pediatric pain management: A scoping review methodological framework. J Pediatr Surg 2022; 57:1599-1608. [PMID: 34876296 DOI: 10.1016/j.jpedsurg.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE This methodological framework was purposed to discuss the considerations for conducting scoping review for neonatal and pediatric pain management (NPPM) from the perspectives of Arksey and O' Malley and Joanna Briggs Institute (JBI) framework. Till now, there is no scoping review or standard methods are available for identifying, prioritizing, or reporting research gaps in the area of NPPM. METHODS AND RESULTS Scoping reviews were utilized to map the literature comprehensively across a range of study designs in a particular area. This methodological framework describes the methods used to identify, prioritize, and display research gaps in the area of NPPM. Different methods to determine research gaps have been described in this framework. This scoping review methodological framework also discussed methods for conducting scoping review in two levels with methodological considerations given by Arksey and O'Malley, and JBI Institute. Search terms and search terminologies are described to conduct scoping review effectively for NPPM. Through, this standard scoping review methodological considerations, the general understanding and current advances in NPPM can be widened. CONCLUSION This methodological framework describes the methods for conducting scoping review effectively in the area of NPPM. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Neha Sharma
- Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana 133207, India.
| | - Vencita Priyanka Arahna
- Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana 133207, India.
| | - Shikha Saxena
- School Based Rehabilitation Services, Physiotherapy Division, Communicare Therapy Inc., Ottawa , Canada.
| | - Mahamed Ateef
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al Majmaah 11952, Saudi Arabia.
| | - Asir John Samuel
- Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana 133207, India.
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Sawleshwarkar K, Singh M, Bajaj R, Loya S, Chikhlondhe R, Bhave S. Implementing use of sucrose analgesia (non-pharmacological management of neonatal pain) in a standalone private facility level 3 neonatal care unit using point of care quality improvement methodology. BMJ Open Qual 2022; 11:e001830. [PMID: 35705258 PMCID: PMC9204459 DOI: 10.1136/bmjoq-2022-001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/31/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Neonatal pain not only has negative impact on the acute physiological parameters of the neonate but also has got the potential to cause long-term neurodevelopmental disabilities. However, neonatal pain especially related to procedures is not well recognised and often poorly managed in neonatal intensive care unit (NICU). LOCAL PROBLEM Oral sucrose solution became available commercially in late 2017 and this provided us the opportunity to alleviate some of the procedural pain in neonates admitted in our NICU. METHODS Point of care quality improvement method (POCQI) was leveraged to identify root causes, change ideas and solutions were tested using PDSA cycles. Four procedures were selected by team for sucrose analgesia namely intravenous cannula insertion, tracheal suctioning, removal of tapes and phlebotomy. Change ideas tested included training of staff and doctors, providing dosage chart in NICU, method of administration of sucrose, affixing sucrose vial to baby bed, using prefilled sucrose syringe and bedside availability of sucrose and checklist for documentation. The study was conducted over a period of 8 weeks from 15 June 2017 on all eligible babies getting admitted. AIM STATEMENT We aim to increase compliance to administration of sucrose analgesia to all eligible newborns (undergoing 4 selected procedures intravenous cannula insertion, tracheal suctioning, removal of tapes and phlebotomy) in NICU prior to painful procedure from current 0% to >80% by 8 weeks. RESULTS This quality improvement study implementing the use of evidence-based sucrose analgesia using PDSA cycles found that percentage of babies getting sucrose analgesia has increased from baseline 0% to 96.27% in the study period and is sustained at >80% for 4 years. CONCLUSIONS POCQI methodology can be used effectively to implement a new simple strategy of administering oral sucrose solution to address procedural pain in care pathway of neonates admitted in NICU. Sustaining the gains achieved by POCQI needs active leadership involvement and addressing adaptive or behavioural challenges with solutions like team huddles.
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Affiliation(s)
- Kedar Sawleshwarkar
- Nationwide Quality of Care Network, New Delhi, India
- NICU, Deogiri Childrens Hospital, Aurangabad, Maharashtra, India
| | - Mahtab Singh
- Nationwide Quality of Care Network, New Delhi, India
| | - Ramesh Bajaj
- NICU, Deogiri Childrens Hospital, Aurangabad, Maharashtra, India
| | - Sanjog Loya
- NICU, Deogiri Childrens Hospital, Aurangabad, Maharashtra, India
| | | | - Sunita Bhave
- NICU, Deogiri Childrens Hospital, Aurangabad, Maharashtra, India
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Neonatal Nurse and Midwife Competence Regarding Pain Management in Neonates: A Systematic Review. Adv Neonatal Care 2022; 22:E34-E42. [PMID: 34224481 DOI: 10.1097/anc.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neonates in need of intensive care are often subjected to numerous painful procedures. Despite the growing scientific research, hospitalized neonates continue to experience unrelieved pain. Enhancing the competence of neonatal intensive care nurses is an integral component of effective pain management. PURPOSE The purpose of this article is to identify and synthesize the existing evidence on nurses' and midwives' competence regarding neonatal pain management internationally. METHODS/SEARCH STRATEGY The review was guided by Whittemore and Knafl's 5-stage framework, with 8 databases searched in June 2020 including PubMed, CINAHL Complete (via EBSCOhost), MEDLINE (via EBSCOhost), PsycINFO (via Ovid), EMBASE, Scopus, Cochrane Library, and Google Scholar. Reference lists of selected articles were also hand-searched. Studies were reviewed independently for methodology and inclusion and exclusion criteria. The initial search yielded 3037 articles; 19 met the inclusion criteria and were included for analysis: qualitative (n = 5) and quantitative (n = 14). FINDINGS/RESULTS Nurses' and midwives' competence regarding neonatal pain management in the neonatal intensive care unit is discussed in relation to knowledge, attitudes, behaviors, and perceptions of competence by most studies. The barriers to effective neonatal pain management were found to relate to nurses' and midwives' factors, underutilized pain assessment tools, and organizational factors. Potential facilitators to effective neonatal pain management included clear evidence-based guidelines/protocols, adequate training, and the use of appropriate and accurate pain assessment tools. Parent involvement and a team approach to neonatal pain management were also identified. IMPLICATIONS FOR PRACTICE AND RESEARCH These findings suggest that further research is necessary to address the barriers and promote facilitators to improve neonatal pain management.
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Affiliation(s)
- Mari Kinoshita
- Department of Pediatrics; Clinical Sciences Lund, Lund University; Lund Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | | | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
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Guo W, Liu X, Zhou X, Wu T, Sun J. Efficacy and safety of combined nonpharmacological interventions for repeated procedural pain in preterm neonates: A systematic review of randomized controlled trials. Int J Nurs Stud 2020; 102:103471. [DOI: 10.1016/j.ijnurstu.2019.103471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
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Squillaro A, Mahdi EM, Tran N, Lakshmanan A, Kim E, Kelley-Quon LI. Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach. Clin Ther 2019; 41:1701-1713. [PMID: 31431300 PMCID: PMC6790974 DOI: 10.1016/j.clinthera.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain. FINDINGS After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking. IMPLICATIONS The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.
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Affiliation(s)
- Anthony Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Nhu Tran
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Calmer: a robot for managing acute pain effectively in preterm infants in the neonatal intensive care unit. Pain Rep 2019; 4:e727. [PMID: 31041426 PMCID: PMC6455690 DOI: 10.1097/pr9.0000000000000727] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/19/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction: For preterm infants in the neonatal intensive care unit, early exposure to repeated procedural pain is associated with negative effects on the brain. Skin-to-skin contact with parents has pain-mitigating properties, but parents may not always be available during procedures. Calmer, a robotic device that simulates key pain-reducing components of skin-to-skin contact, including heart beat sounds, breathing motion, and touch, was developed to augment clinical pain management. Objective: Our objective was to evaluate the initial efficacy of Calmer for mitigating pain in preterm infants. We hypothesized that, compared to babies who received a human touch–based treatment, facilitated tucking, infants on Calmer would have lower behavioural and physiological pain indices during a single blood test required for clinical care. Methods: Forty-nine preterm infants, born between 27 and 36 weeks of gestational age, were randomized either to facilitated tucking or Calmer treatment. Differences between groups in changes across 4 procedure phases (baseline 1, baseline 2, poke, and recovery) were evaluated using (1) the Behavioral Indicators of Infant Pain scored by blind coders from bedside videotape and (2) heart rate and heart rate variability continuously recorded from a single-lead surface ECG (lead II) (Biopac, Canada) sampled at 1000 Hz using a specially adapted portable computer system and processed using Mindware. Results: No significant differences were found between groups on any outcome measures. Conclusion: Calmer provided similar treatment efficacy to a human touch–based treatment. More research is needed to determine effects of Calmer for stress reduction in preterm infants in the neonatal intensive care unit over longer periods.
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Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve! Arch Pediatr 2018; 25:476-479. [DOI: 10.1016/j.arcped.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 08/01/2018] [Accepted: 09/23/2018] [Indexed: 11/27/2022]
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Repeated exposure to sucrose for procedural pain in mouse pups leads to long-term widespread brain alterations. Pain 2018; 158:1586-1598. [PMID: 28715355 DOI: 10.1097/j.pain.0000000000000961] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oral sucrose is administered routinely to reduce pain of minor procedures in premature infants and is recommended as standard care in international guidelines. No human or animal studies on effects of early repeated sucrose exposure on long-term brain development have been done in the context of pain. We evaluated the effects of repeated neonatal sucrose treatment before an intervention on long-term brain structure in mouse pups. Neonatal C57Bl/6J mice (n = 109) were randomly assigned to one of 2 treatments (vehicle vs sucrose) and one of 3 interventions (handling, touch, or needle-prick). Mice received 10 interventions daily from postnatal day 1 to 6 (P1-6). A dose of vehicle or 24% sucrose was given orally 2 minutes before each intervention. At P85-95, brains were scanned using a multichannel 7.0 T MRI. Volumes of 159 independent brain regions were obtained. Early repetitive sucrose exposure in mice (after correcting for whole brain volume and multiple comparisons) lead to smaller white matter volumes in the corpus callosum, stria terminalis, and fimbria (P < 0.0001). Cortical and subcortical gray matter was also affected by sucrose with smaller volumes of hippocampus and cerebellum (P < 0.0001). These significant changes in adult brain were found irrespective of the type of intervention in the neonatal period. This study provides the first evidence of long-term adverse effects of repetitive sucrose exposure and raises concerns for the use of this standard pain management practice during a period of rapid brain development in very preterm infants.
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Boyle EM, Bradshaw J, Blake KI. Persistent pain in neonates: challenges in assessment without the aid of a clinical tool. Acta Paediatr 2018; 107:63-67. [PMID: 28925559 DOI: 10.1111/apa.14081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/06/2017] [Accepted: 09/15/2017] [Indexed: 02/06/2023]
Abstract
AIM Evaluation of comfort and pain in neonates is important for management. Specific signs of persistent pain in neonates remain undefined; few validated clinical tools assess persistent pain. We sought to determine (i) difficulty perceived by staff and parents in assessing comfort/persistent pain in babies, (ii) strategies employed when no clinical tool is used and (iii) variation between clinicians' assessments. METHODS Parent and staff questionnaires addressed difficulty in assessing pain/comfort in neonates and strategies used in making assessments. RESULTS A total of 47 of 50 (94%) parents and 83 of 91 (91%) staff participated; 50% of staff reported it was moderately/very difficult to assess persistent pain, and 13% very easy; 75% of parents found it moderately/very easy and 23% difficult to assess their baby's comfort; 15% of parents thought staff found pain assessment difficult. Staff described 94 different factors indicative of comfort and 139 factors of persistent pain. Terminology differed widely and was often nonspecific; 67% of staff described forming a 'general impression'. CONCLUSION Pain assessment is challenging for staff. Most parents feel confident in assessing their babies' comfort, but may overestimate the ease with which staff can do so. Indicators of persistent pain/comfort are poorly defined; staff use differing, subjective assessments, which may complicate communication between carers.
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Affiliation(s)
- Elaine M. Boyle
- Department of Health Sciences; University of Leicester; Leicester UK
| | - Joanna Bradshaw
- Neonatal Unit; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - Kathryn I. Blake
- Neonatal Unit; University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
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13
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Alizadeh A, Naseri M, Ravanshad Y, Sorouri S, Banihassan M, Azarfar A. Use of sedative drugs at reducing the side effects of voiding cystourethrography in children. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:42. [PMID: 28465701 PMCID: PMC5393102 DOI: 10.4103/1735-1995.202139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/11/2016] [Accepted: 12/02/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Imaging of the kidneys and urinary tract has a significant and critical role for diagnosis of genitourinary system diseases. Although technological progress goes toward less invasive approaches, some of the current methods are still invasive and annoying. Voiding cystourethrography (VCUG) is the best and most accurate method for diagnosis and grading of vesicoureteral reflux. VCUG is a distressful procedure that gives serious anxiety and pain in a large proportion of children and fear for parents; therefore, using effective sedative drugs with the least side effects is necessary and should be considered. MATERIALS AND METHODS In this review article, importance and efficacy of different drugs before catheterization VCUG be compared in the base of literature survey on EMBASE, PubMed, and Cochrane source. RESULTS We found that the treatment should be based on nonpharmacological and pharmacological methods; nonpharmacological treatment includes the psychological preparation before procedures as a safety precaution with little or no risk modality, as well as reassuring support. The presence of parents during painful procedures cannot alleviate children distress. Pharmacological methods include oral midazolam (0.5 mg/kg) and intranasal use (0.2 mg/kg) that had been used 10 min before the procedure can effect on anterograde amnesia and sedation without considerable effect on accuracy and grade of reflux. Nitric oxide has a shorter recovery time versus midazolam but has a potential risk for deep sedation and may interfere with the child's voiding phase. CONCLUSION In summary, oral midazolam of 0.5-0.6 mg/kg or 0.2 mg/kg intranasal is acceptable drug that can be used before VCUG.
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Affiliation(s)
- Anahita Alizadeh
- Department of Clinical Toxicology, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Naseri
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yalda Ravanshad
- Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shahabaddin Sorouri
- Department of Internal Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Malihe Banihassan
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Anoush Azarfar
- Department of Pediatric Nephrology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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14
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016; 1:7. [PMID: 28066825 PMCID: PMC5218543 DOI: 10.12688/wellcomeopenres.10005.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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15
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016. [PMID: 28066825 DOI: 10.12688/wellcomeopenres.10005.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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16
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Tekin M, Yıldırım Ş, Aylanç H, Kaymaz N, Battal F, Topaloğlu N, Başer E, Binnetoğlu FK. Does intrauterine tobacco exposure increase the pain perception of newborns? J Pain Res 2016; 9:319-23. [PMID: 27330324 PMCID: PMC4898259 DOI: 10.2147/jpr.s108500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to assess whether there was a difference in the pain-perception levels of newborns born to mothers who smoked during pregnancy and newborns born to mothers who were not exposed to active or passive smoking during pregnancy. Materials and methods A total of 60 newborns born by normal spontaneous vaginal birth between June 2013 and June 2014 were included in the study: 30 born to mothers who smoked during pregnancy, and 30 born to mothers not exposed to smoking. Mothers or newborns who had taken analgesics or sedative medications in the previous 24 hours, newborns not born at term, and sick newborns were not included in the study. During the routine hepatitis B-vaccination injection given at postnatal 48 hours, the newborns’ behavior was monitored and recorded by video camera. The data obtained from the recordings were evaluated according to the Neonatal Pain, Agitation, and Sedation Scale and analyzed with SPSS 20. Results The median pain score of the group exposed to tobacco smoke in utero was 8.5, while the median pain score of the unexposed group was 6 (P<0.001). Conclusion Exposure to tobacco smoke in utero may increase the pain-perception levels of newborns.
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Affiliation(s)
- Mustafa Tekin
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Şule Yıldırım
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Hakan Aylanç
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Nazan Kaymaz
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Fatih Battal
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Naci Topaloğlu
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Esra Başer
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Fatih Köksal Binnetoğlu
- Department of Pediatrics, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
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17
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Hogan ME, Shah VS, Smith RW, Yiu A, Taddio A. Glucose for the management of procedural pain in neonates. Hippokratia 2015. [DOI: 10.1002/14651858.cd009721.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mary-Ellen Hogan
- University of Toronto; Graduate Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy; 144 College Street Toronto ON Canada M5S 3M2
| | - Vibhuti S Shah
- University of Toronto; Department of Paediatrics and Institute of Health Policy, Management and Evaluation; 600 University Avenue Toronto ON Canada M5G 1X5
| | - Ryan W Smith
- University of Toronto; Graduate Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy; 144 College Street Toronto ON Canada M5S 3M2
| | - Ashley Yiu
- University of Toronto; Leslie Dan Faculty of Pharmacy; 144 College Street Toronto ON Canada M5S 3M2
| | - Anna Taddio
- Hospital for Sick Children Research Institute; Graduate Department of Pharmaceutical Sciences; 555 University Avenue Toronto ON Canada M5G 1X8
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18
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Hss AS, Linus-Lojikip S, Ismail Z, Ishahar NH, Yusof SS. Neonatal preintubation sedation: a national survey in Malaysia. BMC Res Notes 2015; 8:660. [PMID: 26553069 PMCID: PMC4638092 DOI: 10.1186/s13104-015-1653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/29/2015] [Indexed: 12/02/2022] Open
Abstract
Background There is a shift of practice towards administering sedation in neonates around the world. At the present moment, there is no available data or literature on the practice of sedation before intubation of neonates in Malaysia thus, evaluation of these practice was not possible. This study was conducted to evaluate neonatal preintubation sedation practice and the availability of neonatal preintubation sedation policy in government, university and private Malaysian Neonatal Intensive Care Units (NICUs) in 2007. Methods All 43 NICUs in Malaysia were identified and approached to participate in the study. Phone interviews with doctors’ in-charge of NICUs were conducted in 29 governments, 3 universities and in 7 private NICUs. Results Only 7 NICUs had written policy on neonatal preintubation sedation
use. Seventy-seven percent and 97.4 % of NICUs used sedation during emergency intubation and during planned intubation respectively. Sixty seven percent used either morphine or midazolam with no preference of either drug. Conclusion This study showed a significant proportion of NICUs used sedation during emergency or planned intubation. However, the majority does not write policy on neonatal preintubation sedation use (82.1 %). The types and drug administration methods are not standardized in all of the NICUs. This will require a standard national written policy to be developed.
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Affiliation(s)
- Amar-Singh Hss
- Pediatric Department and Clinical Research Centre Perak, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990, Ipoh, Perak, Malaysia.
| | - Sharon Linus-Lojikip
- Clinical Research Centre Perak, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990, Ipoh, Perak, Malaysia.
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19
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Sedation and analgesia practices among Spanish neonatal intensive care units. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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20
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Cruz M, Fernandes A, Oliveira C. Epidemiology of painful procedures performed in neonates: A systematic review of observational studies. Eur J Pain 2015. [DOI: 10.1002/ejp.757] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- M.D. Cruz
- Nursing School of the University of Évora; Portugal
- Health Sciences Research Unit; Nursing hosted by the Nursing School of Coimbra; Portugal
| | - A.M. Fernandes
- Nursing School of Coimbra; Portugal
- Health Sciences Research Unit; Nursing hosted by the Nursing School of Coimbra; Portugal
| | - C.R. Oliveira
- Faculty of Medicine of the University of Coimbra; Portugal
- CNC-Center for Neuroscience and Cell Biology; University of Coimbra; Portugal
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21
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Avila-Alvarez A, Carbajal R, Courtois E, Pertega-Diaz S, Muñiz-Garcia J, Anand KJS. [Sedation and analgesia practices among Spanish neonatal intensive care units]. An Pediatr (Barc) 2015; 83:75-84. [PMID: 25979386 DOI: 10.1016/j.anpedi.2015.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/25/2015] [Accepted: 03/27/2015] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. METHOD A multicenter, observational, longitudinal and prospective study. RESULTS Thirty neonatal units participated and included 468 neonates. Of these, 198 (42,3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam. The variables associated with receiving sedation and/or analgesia were, to have required invasive ventilation (P<.001; OR=23.79), a CRIB score >3 (P=.023; OR=2.26), the existence of pain evaluation guides in the unit (P<.001; OR=3.82), and a pain leader (P=.034; OR=2.35). CONCLUSIONS Almost half of the neonates admitted to intensive care units receive sedatives or analgesics. There is significant variation between Spanish neonatal units as regards sedation and analgesia prescribing. Our results provide evidence on the "state of the art", and could serve as the basis of preparing clinical practice guidelines at a national level.
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Affiliation(s)
- A Avila-Alvarez
- Unidad de Neonatología, Servicio de Pediatría, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade de A Coruña (UDC), A Coruña, España.
| | - R Carbajal
- Service d'Urgences Pédiatriques, Hôpital d'enfants Armand Trousseau, Inserm UMR 1153, Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Université Pierre et Marie Curie, París, Francia
| | - E Courtois
- Service d'Urgences Pédiatriques, Hôpital d'enfants Armand Trousseau, Inserm UMR 1153, Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Université Pierre et Marie Curie, París, Francia
| | - S Pertega-Diaz
- Grupo de Investigación de Epidemiología Clínica y Bioestadística, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade de A Coruña (UDC), A Coruña, España
| | - J Muñiz-Garcia
- Instituto Universitario de Ciencias de la Salud, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade de A Coruña (UDC), A Coruña, España
| | - K J S Anand
- University of Tennessee Health Science Center, Menphis, Estados Unidos
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22
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Khoza SLT, Tjale AA. Knowledge, attitudes and practices of neonatal staff concerning neonatal pain management. Curationis 2014; 37:E1-9. [PMID: 26864181 DOI: 10.4102/curationis.v37i2.1246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 07/25/2014] [Accepted: 09/30/2014] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Neonatal pain management has received increasing attention over the past four decades. Research into the effects of neonatal pain emphasises the professional, ethical and moral obligations of staff to manage pain for positive patient outcomes. However, evaluation studies continuously report evidence of inadequate neonate pain management and a gap between theory and practice. OBJECTIVE This study reviewed current practice in neonatal pain management to describe the knowledge, attitudes and practices of nurses and doctors regarding pain management for neonates in two academic hospitals. METHOD A non-experimental, prospective quantitative survey, the modified Infant Pain Questionnaire, was used to collect data from 150 nurses and doctors working in the neonatal wards of two academic hospitals in central Gauteng. RESULTS The response rate was 35.33% (n=53), most respondents being professional nurses (88.68%; n=47) working in neonatal intensive care units (80.77%; n=42); 24 (45.28%) had less than 5 years' and 29 respondents 6 or more years' working experience in neonatal care. A review of pain management in the study setting indicated a preference for pharmacological interventions to relieve moderate to severe pain. An association (p<0.05) was found between pain ratings on 5 procedures and frequency of administration of pharmacological pain management. Two-thirds of respondents (64%) reported that there were no pain management guidelines in the neonatal wards in which they worked. CONCLUSION The interventions to manage moderate neonatal pain are in line with international guidelines. However, neonatal pain management may not occur systematically based on prior assessment of neonatal pain, choice of most appropriate intervention and evaluation. This study recommends implementation of a guideline to standardise practice and ensure consistent and adequate pain management in neonates.
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Affiliation(s)
- Sizakele L T Khoza
- Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand.
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23
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A comparative study of two remifentanil doses for procedural pain in ventilated preterm infants: a randomized, controlled study*. Pediatr Crit Care Med 2014; 15:451-5. [PMID: 24717908 DOI: 10.1097/pcc.0000000000000123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Remifentanil is an ultrashort-acting synthetic opioid, and the metabolism of which is not influenced by hepatic or renal function. This study aims to compare the efficacy of two remifentanil doses during procedures in ventilated preterm infants. DESIGN Prospective, randomized, double-blind, noninferiority trial. SETTING Neonatal ICU. PATIENTS Preterm infants who were supported by a mechanical ventilator with tracheal tube and requiring central venous access. INTERVENTIONS Two remifentanil dosages were administered in mechanically ventilated preterm infants during peripherally inserted central catheter insertion. Fourteen preterm infants were randomly assigned to low-dose (0.1 μg/kg/min) or high-dose (0.25 μg/kg/min) remifentanil infusion. The Premature Infant Pain Profile was used to score pain during the procedure, and changes in the Premature Infant Pain Profile score between needle puncture and baseline were analyzed to investigate the noninferiority of low-dose to high-dose remifentanil. Occurrence of cardiorespiratory complications was also recorded. MEASUREMENTS AND MAIN RESULTS The median gestational age (minimum, maximum) was 26 weeks (24, 31), and the median birth weight was 825 g (610, 1,280). Changes in Premature Infant Pain Profile in the high-dose and low-dose groups were 1.43 ± 3.10 and -0.60 ± 5.32, respectively. The difference in changes in the Premature Infant Pain Profile score between the high-dose and low-dose groups was -2.03 ± 4.13. The corresponding lower limit of one-tailed 97.5% CI was -7.24, below the noninferiority margin. Apneic events and bradycardia did not occur in the low-dose group; however, there were three episodes of apnea (42.9%) and one of bradycardia (14.3%) in the high-dose group (p = 0.683 and 0.366, respectively). CONCLUSION For mechanically ventilated preterm infants, the use of remifentanil at 0.25 μg/kg/min as an analgesic for short procedures represents a therapeutic option. Our pilot study suggests the need for larger randomized trials.
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24
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Walter-Nicolet E, Zanichelli C, Coquery S, Cimerman P. [Implementation of a specific premedication protocol for tracheal intubation in the delivery room. Practice in two level-III hospitals]. Arch Pediatr 2014; 21:961-7. [PMID: 24726672 DOI: 10.1016/j.arcped.2014.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 11/18/2013] [Accepted: 02/15/2014] [Indexed: 11/19/2022]
Abstract
UNLABELLED Tracheal intubation in neonates is a painful procedure performed daily in the delivery room despite the widespread development of noninvasive ventilation. Specific analgesia is not commonly performed. The objective of this observational study was to compare practices between two level-III centers: one with a specific protocol for premedication before tracheal intubation of newborns in the delivery room, the other without. RESULTS One hundred and fifteen neonates were intubated in the delivery room and included over a 4-month period: 25% of them received specific premedication before intubation, exclusively in the center with the protocol. None of the extreme premature neonates (age≤28 gestational weeks) received analgosedation before the procedure. Nalbuphine, midazolam, and sufentanil were mainly used, via the intravenous or intrarectal route. Infants receiving a premedication were significantly heavier and had a greater gestational age than the others (1500 g [range, 1180-2260 g] vs. 1170 [range, 860-1680 g] P=0.003, and 31 GW [range, 29-34 GW] vs. 29 [range, 27-32 GW] P=0.014, respectively). Most pediatricians (85-100%) favored a specific protocol for sedation before tracheal intubation. Implementation of a specific protocol allows specific analgesia to be implemented for newborns undergoing tracheal intubation. Further studies should be conducted to determine the best strategies for pain management during tracheal intubation of neonates, especially in the delivery room.
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Affiliation(s)
- E Walter-Nicolet
- Service de néonatologie, hôpital Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France; Service de néonatologie, hôpital Trousseau, AP-HP, 26, avenue Arnold-Netter, 75012 Paris, France.
| | - C Zanichelli
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Coquery
- Service de néonatologie, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
| | - P Cimerman
- Centre national de ressources contre la douleur, hôpital Trousseau, AP-HP, 26, avenue Arnold-Netter, 75012 Paris, France
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Ozawa M, Yokoo K. Pain management of neonatal intensive care units in Japan. Acta Paediatr 2013; 102:366-72. [PMID: 23311590 DOI: 10.1111/apa.12160] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 12/19/2012] [Accepted: 01/09/2013] [Indexed: 11/27/2022]
Abstract
AIM To describe current neonatal pain management and individual and organizational factors that can improve neonatal pain practice from the viewpoints of both head nurses and head neonatologists in Japan. METHODS An anonymous questionnaire was sent to general perinatal maternal and child medical centres that had level 3 units across Japan. RESULTS A total of 61 of 89 head nurses and 54 of 89 head neonatologists replied. The responses of head nurses and head neonatologists were almost the same. More than 60% of units (head nurses, 65%; head neonatologists, 61%) did not use pain scales, and about 63% units (both head nurses and head neonatologists) had no rules for health care professionals on the best methods for implementing pain relief for painful diagnostic and therapeutic procedures. Only 17% of head nurses and 24% of head neonatologists considered that nurses and physicians in their units collaborated in pain management, and <20% of units (both head nurses and head neonatologists) had written guidelines for their unit on neonatal pain management. CONCLUSION This study suggested that Japanese neonatal intensive care units need national guidelines for pain management, and these might improve collaboration between nurses and physicians in minimizing neonatal pain.
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Affiliation(s)
- Mio Ozawa
- Midwifery and Maternal-Newborn Nursing; Graduate School of Biomedical & Health Sciences; Hiroshima University; Hiroshima Japan
| | - Kyoko Yokoo
- Midwifery and Maternal-Newborn Nursing; Graduate School of Biomedical & Health Sciences; Hiroshima University; Hiroshima Japan
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Enquête nationale sur la prise en charge de la douleur liée à l’intubation trachéale du nouveau-né dans les maternités de niveau III. Arch Pediatr 2013; 20:123-9. [DOI: 10.1016/j.arcped.2012.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 05/15/2012] [Accepted: 11/05/2012] [Indexed: 11/18/2022]
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Bellieni CV, Aloisi AM, Ceccarelli D, Valenti M, Arrighi D, Muraca MC, Temperini L, Pallari B, Lanini A, Buonocore G. Intramuscular injections in newborns: analgesic treatment and sex-linked response. J Matern Fetal Neonatal Med 2012; 26:419-22. [DOI: 10.3109/14767058.2012.733777] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Boettcher M, Göttler S, Stoffel L, Schwab K, Berger S, Mérat M. Schmerzmanagement bei Kindern in der Schweiz. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2680-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hogan ME, Shah VS, Smith RW, Yiu A, Taddio A. Glucose for the management of procedural pain in neonates. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Liaw JJ, Yang L, Chou HL, Yin T, Chao SC, Lee TY. Psychometric analysis of a Taiwan-version pain assessment scale for preterm infants. J Clin Nurs 2011; 21:89-100. [DOI: 10.1111/j.1365-2702.2011.03770.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Maia ACA, Coutinho SB. Fatores que influenciam a prática do profissional de saúde no manejo da dor do recém-nascido. REVISTA PAULISTA DE PEDIATRIA 2011. [DOI: 10.1590/s0103-05822011000200020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVO: Apresentar revisão sobre as principais variáveis que podem influenciar as ações e as atitudes dos profissionais de saúde no manejo adequado da dor no período neonatal. FONTES DOS DADOS: Pesquisa bibliográfica, nas bases de dados Medline, SciELO e Lilacs, entre 1995 e 2009, restrita aos artigos escritos em inglês e português. Foram utilizados os seguintes descritores: "dor", "Terapia Intensiva Neonatal" e "profissional de Saúde". Avaliaram-se 88 artigos, sem seleção pelo desenho, sendo incluídos os 55 mais relevantes e recentes. SÍNTESE DOS DADOS: Os estudos confirmaram que o manejo da dor no neonato pelos profissionais de saúde é inadequado. Essa prática pode estar relacionada aos seguintes fatores: conhecimento insuficiente quanto à fisiopatologia da dor; não utilização de métodos de avaliação; falta de normatização sistemática ou protocolos; e falha na comunicação e incorporação da teoria na prática diária por parte da equipe multiprofissional. São acrescidos ainda os fatores subjetivos, pessoais e profissionais, que podem interferir na avaliação e no tratamento da dor no recém-nascido. CONCLUSÕES: Os obstáculos para um manejo adequado da dor são multifatoriais e o conhecimento das atitudes e crenças das equipes de saúde que trabalham com neonatos é muito importante. Há necessidade de investimentos na capacitação, formação e sensibilização dos profissionais acerca do controle e do tratamento da dor, com o intuito de proporcionar um cuidado mais humanizado ao neonato.
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Walter-Nicolet E, Annequin D, Biran V, Mitanchez D, Tourniaire B. Pain management in newborns: from prevention to treatment. Paediatr Drugs 2010; 12:353-65. [PMID: 21028915 DOI: 10.2165/11318900-000000000-00000] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
All neonates in the Neonatal Intensive Care Unit (NICU) or during the first days of life undergo painful and stressful procedures. Epidemiologic studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Prevention is the first step of pain management, and practical guidelines should be used in the NICU. Assessment must be done with adequate tools that take into account the infant's pathology and gestational age. Distinguishing between acute and prolonged pain is important for both assessment and treatment. The most common drugs that have been studied for the treatment of pain and stress are opioids, hypnosedatives, and NMDA receptor antagonists. Morphine and fentanyl are most frequently used for acute or prolonged pain in the NICU. They have potent analgesic effects and few immediate or long-term adverse effects. Midazolam is a commonly used hypnosedative, but its adverse effects limit its use. Drugs such as propofol and ketamine have been used for acute painful procedures; however, further research is needed to assess their long-term effects. Use of non-pharmacologic pain management techniques has increased in recent years. These methods are easy, inexpensive, and effective in helping newborns recover from painful procedures. Sweet solutions and non-nutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and facilitated tucking are the most commonly employed and evaluated non-pharmacologic methods. Hospitals should promote and improve parent involvement in pain management. In-service education and well organized hospital teams are crucial for successful implementation of pain protocols in newborns.
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Affiliation(s)
- Elizabeth Walter-Nicolet
- Unité Fonctionnelle de lutte contre la douleur, Hôpital d'enfants Armand Trousseau, Assistance Publique Hôpitaux de Paris, Paris, France
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Canadian Neonatologist Practices Regarding Opioid Use in Ventilated and Spontaneously Breathing Infants Undergoing Medical Procedures. Clin J Pain 2010; 26:422-8. [DOI: 10.1097/ajp.0b013e3181d36da7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The debate about the management of pain in the neonate has continued to evolve over the past 30 years. This controversy can be understood as evolving through now three eras of thought about the effect of pain and its management in newborns and infants. The first generation was characterized by a widespread belief that newborns lacked the complete development of the neuroanatomical and neuroendocrine components necessary to perceive pain. During this period, newborns often received inadequate anesthesia and analgesia for painful procedures, if not no treatment at all. The second generation was heralded by research that demonstrated that newborns did demonstrate similar or even exaggerated physiological and hormonal responses to pain compared with those observed in older children and adults and that exposure to prolonged or severe pain may increase neonatal morbidity. Controversy in this generation focused around the dosage of analgesia to newborns as well as the risks and benefits of pain management techniques. We are now in a third generation of thought about pain in the neonate, defined by intense debate over the significance of a growing number of studies in immature animal models that demonstrate degenerative effects of several anesthetics on neuronal structure. The challenge of this era is to integrate the advances in diagnosis and treatment achieved in previous generations with ongoing adaptation of clinical practice as dictated by research advances in the field. In this review, we examine the evolution of medical thought and ethical concerns regarding pain treatment in the neonate.
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Affiliation(s)
- Thomas Mancuso
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Newnham CA, Inder TE, Milgrom J. Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale. Early Hum Dev 2009; 85:549-55. [PMID: 19520525 DOI: 10.1016/j.earlhumdev.2009.05.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stress experiences, while pervasive, are less likely than painful experiences to be managed in still-hospitalised preterm infants. AIM We aimed to quantify the severity of common stressors for preterm infants with a view to providing a tool to manage presumed accumulated infant stress. METHODS AND SUBJECTS Seventeen doctors and 130 nurses who work in Neonatal Intensive and Special Care Nurseries rated the perceived stress severity of 44 acute events and 24 chronic living conditions for preterm infants at three ages (<28 weeks, 28-32 weeks, >32 weeks post-conceptional age) and for themselves. Acute items (such as heel lance) were organised into nursing, peripheral venous access, peripheral arterial access, central vascular access, ventilation, nutrition, medical procedures, surgery, radiology and miscellaneous categories. Chronic living conditions included items such as receiving intranasal oxygen and having a systemic infection. RESULTS Doctors and nurses perceived nearly all items to be stressful to infants to some degree and to be equally stressful across ages. The degree of stress experienced by clinicians themselves was generally low and moderately correlated with presumed infant stress for the same items. Presumed infant stress was inversely related to clinician age. CONCLUSION Based on these results we developed the Neonatal Infant Stressor Scale to help track, measure and manage presumed accumulated stress in preterm neonates.
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Affiliation(s)
- C A Newnham
- Parent-Infant Research Institute, Clinical and Health Psychology, Austin Health, Melbourne, Australia.
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Abstract
BACKGROUND Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews. OBJECTIVE To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants. METHODS A structured review was conducted on published systematic reviews and meta-analyses of pharmacological and nonpharmacological interventions of acute procedural pain in hospitalized infants. Searches were completed in the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL and PsycINFO. Two reviewers independently selected articles for review and rated the methodological quality of the included reviews using a validated seven-point quality assessment measure. Any discrepancies were resolved by a third reviewer. RESULTS Of 1469 potential systematic reviews on interventions for painful procedures in hospitalized infants, 11 high-quality reviews were included in the analysis. Pharmacological interventions supported by research evidence included premedication for intubation, dorsal penile nerve block and EMLA (AstraZeneca Canada, Inc) for circumcision, and sucrose for single painful procedures. Non-nutritive sucking, swaddling, holding, touching, positioning, facilitative tucking, breast feeding and supplemental breast milk were nonpharmacological interventions supported for procedural pain. CONCLUSION There is a growing number of high-quality reviews supporting procedural pain management in infants. Ongoing research of single, repeated and combined pharmacological and nonpharmacological interventions is required to provide the highest quality evidence to clinicians for decision-making on optimal pain management.
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