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Selvanathan T, Miller SP. Brain health in preterm infants: importance of early-life pain and analgesia exposure. Pediatr Res 2024:10.1038/s41390-024-03245-w. [PMID: 38806664 DOI: 10.1038/s41390-024-03245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/23/2024] [Indexed: 05/30/2024]
Abstract
"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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2
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Mohamed SHM, Reissland N, Anand KJS. An Evidence-Based Discussion of Fetal Pain and Stress. Neonatology 2024:1-7. [PMID: 38781940 DOI: 10.1159/000538848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/10/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The concept of fetal pain results from procedures conducted without anesthesia in preterm newborns and fetuses, which indicate that it is possible to examine fetal pain based on stress hormone, metabolic, and behavioral changes. Anatomical and physiological data suggest that fetuses become capable of processing nociceptive stimuli around midgestation, although the associated changes in fetal brain development remain unclear. What constitutes fetal pain remains controversial in the light of the definition of pain adopted by the International Association for the Study of Pain (IASP), which posits pain as an "unpleasant sensory and emotional experience." SUMMARY Here, we examine the notion that human fetuses cannot "experience" pain and potential implications of this claim. We highlight the key scientific evidence related to fetal pain, including clinical studies on pain in fetuses and preterm newborns. We argue that consistent patterns of stress hormones, metabolic changes, body movements, hemodynamic changes, and pain-related facial expressions in fetuses exposed to invasive procedures overcome the need for subjective proof of pain as articulated in the IASP definition. No study to date has conclusively proven the absence of fetal pain beyond the age of viability. KEY MESSAGES Based on the current evidence, we propose that all fetuses receive anesthesia regardless of the invasive procedures being performed to guarantee the least possible pain and physiological, behavioral, or hormonal responses without exposing the mother or her baby to unnecessary complications.
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Affiliation(s)
- Samirah H M Mohamed
- Obstetric Clinic at the Clinics Hospital of the Medical School, The University of São Paulo, São Paulo, Brazil
- Research Department of the Hospital e Maternidade Vitória, São Paulo, Brazil
- Medical Tutor at the University Center of the Faculty of the Americas, São Paulo, Brazil
| | | | - Kanwaljeet J S Anand
- Departments of Pediatrics, Perioperative, and Pain Medicine, Stanford Child Wellness Lab, Maternal & Child Health Research Institute, Stanford University School of Medicine, Stanford, California, USA
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3
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Henkel ED, Haller CN, Diaz LZ, Ricles V, Wong Grossman AV, Nemergut ME, Krakowski AC. Optimizing pediatric periprocedural pain management part I-Evolving ethics and topical anesthetics. Pediatr Dermatol 2024. [PMID: 38743586 DOI: 10.1111/pde.15635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/13/2024] [Indexed: 05/16/2024]
Abstract
Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger health care community. We highlight the evolution of ethics and expectations around optimizing periprocedural pain management as a fundamental human right. We investigate the state-of-the-art of topical anesthetics, reviewing their mechanisms of action and providing comparisons of their relative safety and efficacy data to help guide clinical selection. In total, this two-part review offers a combination of conventional approaches and innovative techniques that should be used multimodally-in series and in parallel-to help optimize pain management and provide alternatives to sedation medication and general anesthesia.
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Affiliation(s)
- Emily D Henkel
- Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Courtney N Haller
- Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Lucia Z Diaz
- Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
- Dell Children's Medical Center, Austin, Texas, USA
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Victoria Ricles
- Drexel School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Dermatology, St. Luke's University Health Network, Easton, Pennsylvania, USA
| | | | | | - Andrew C Krakowski
- Department of Dermatology, St. Luke's University Health Network, Easton, Pennsylvania, USA
- St. Luke's Children's Hospital, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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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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Zandvoort CS, van der Vaart M, Robinson S, Usman F, Schmidt Mellado G, Evans Fry R, Worley A, Adams E, Slater R, Baxter L, de Vos M, Hartley C. Sensory event-related potential morphology predicts age in premature infants. Clin Neurophysiol 2024; 157:61-72. [PMID: 38064929 DOI: 10.1016/j.clinph.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/18/2023] [Accepted: 11/04/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE We investigated whether sensory-evoked cortical potentials could be used to estimate the age of an infant. Such a model could be used to identify infants who deviate from normal neurodevelopment. METHODS Infants aged between 28- and 40-weeks post-menstrual age (PMA) (166 recording sessions in 96 infants) received trains of visual and tactile stimuli. Neurodynamic response functions for each stimulus were derived using principal component analysis and a machine learning model trained and validated to predict infant age. RESULTS PMA could be predicted accurately from the magnitude of the evoked responses (training set mean absolute error and 95% confidence intervals: 1.41 [1.14; 1.74] weeks,p = 0.0001; test set mean absolute error: 1.55 [1.21; 1.95] weeks,p = 0.0002). Moreover, we show that their predicted age (their brain age) is correlated with a measure known to relate to maturity of the nervous system and is linked to long-term neurodevelopment. CONCLUSIONS Sensory-evoked potentials are predictive of age in premature infants and brain age deviations are related to biologically and clinically meaningful individual differences in nervous system maturation. SIGNIFICANCE This model could be used to detect abnormal development of infants' response to sensory stimuli in their environment and may be predictive of neurodevelopmental outcome.
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Affiliation(s)
- Coen S Zandvoort
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Shellie Robinson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Fatima Usman
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Alan Worley
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maarten de Vos
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium; Department of Development and Regeneration, University Hospitals Leuven, Child Neurology, KU Leuven, Leuven, Belgium
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.
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Bayne T, Frohlich J, Cusack R, Moser J, Naci L. Consciousness in the cradle: on the emergence of infant experience. Trends Cogn Sci 2023; 27:1135-1149. [PMID: 37838614 PMCID: PMC10660191 DOI: 10.1016/j.tics.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/16/2023]
Abstract
Although each of us was once a baby, infant consciousness remains mysterious and there is no received view about when, and in what form, consciousness first emerges. Some theorists defend a 'late-onset' view, suggesting that consciousness requires cognitive capacities which are unlikely to be in place before the child's first birthday at the very earliest. Other theorists defend an 'early-onset' account, suggesting that consciousness is likely to be in place at birth (or shortly after) and may even arise during the third trimester. Progress in this field has been difficult, not just because of the challenges associated with procuring the relevant behavioral and neural data, but also because of uncertainty about how best to study consciousness in the absence of the capacity for verbal report or intentional behavior. This review examines both the empirical and methodological progress in this field, arguing that recent research points in favor of early-onset accounts of the emergence of consciousness.
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Affiliation(s)
- Tim Bayne
- Monash University, Melbourne, VIC, Australia; Brain, Mind, and Consciousness Program, Canadian Institute for Advanced Research, Toronto, Canada.
| | - Joel Frohlich
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen, Germany; Institute for Advanced Consciousness Studies, Santa Monica, CA, USA
| | - Rhodri Cusack
- Thomas Mitchell Professor of Cognitive Neuroscience, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Julia Moser
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN, USA
| | - Lorina Naci
- Trinity College Institute of Neuroscience and Global Brain Health Institute, Trinity College, Dublin, Ireland
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Worley A, Pillay K, Cobo MM, Mellado GS, van der Vaart M, Bhatt A, Hartley C. The PiNe box: Development and validation of an electronic device to time-lock multimodal responses to sensory stimuli in hospitalised infants. PLoS One 2023; 18:e0288488. [PMID: 37440586 DOI: 10.1371/journal.pone.0288488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Recording multimodal responses to sensory stimuli in infants provides an integrative approach to investigate the developing nervous system. Accurate time-locking across modalities is essential to ensure that responses are interpreted correctly, and could also improve clinical care, for example, by facilitating automatic and objective multimodal pain assessment. Here we develop and assess a system to time-lock stimuli (including clinically-required heel lances and experimental visual, auditory and tactile stimuli) to electrophysiological research recordings and data recorded directly from a hospitalised infant's vital signs monitor. The electronic device presented here (that we have called 'the PiNe box') integrates a previously developed system to time-lock stimuli to electrophysiological recordings and can simultaneously time-lock the stimuli to recordings from hospital vital signs monitors with an average precision of 105 ms (standard deviation: 19 ms), which is sufficient for the analysis of changes in vital signs. Our method permits reliable and precise synchronisation of data recordings from equipment with legacy ports such as TTL (transistor-transistor logic) and RS-232, and patient-connected networkable devices, is easy to implement, flexible and inexpensive. Unlike current all-in-one systems, it enables existing hospital equipment to be easily used and could be used for patients of any age. We demonstrate the utility of the system in infants using visual and noxious (clinically-required heel lance) stimuli as representative examples.
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Affiliation(s)
- Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Kirubin Pillay
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | | | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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Rupawala M, Bucsea O, Laudiano-Dray MP, Whitehead K, Meek J, Fitzgerald M, Olhede S, Jones L, Fabrizi L. A developmental shift in habituation to pain in human neonates. Curr Biol 2023; 33:1397-1406.e5. [PMID: 36931271 DOI: 10.1016/j.cub.2023.02.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 11/22/2022] [Accepted: 02/23/2023] [Indexed: 03/18/2023]
Abstract
Habituation to recurrent non-threatening or unavoidable noxious stimuli is an important aspect of adaptation to pain. Neonates, especially if preterm, are exposed to repeated noxious procedures during their clinical care. They can mount strong behavioral, autonomic, spinal, and cortical responses to a single noxious stimulus; however, it is not known whether the developing nervous system can adapt to the recurrence of these inputs. Here, we used electroencephalography to investigate changes in cortical microstates (representing the complex sequential processing of noxious inputs) following two consecutive clinically required heel lances in term and preterm infants. We show that stimulus repetition dampens the engagement of initial microstates and associated behavioral and autonomic responses in term infants, while preterm infants do not show signs of habituation. Nevertheless, both groups engage different longer-latency cortical microstates to each lance, which is likely to reflect changes in higher-level stimulus processing with repeated stimulation. These data suggest that while both age groups are capable of encoding contextual differences in pain, the preterm brain does not regulate the initial cortical, behavioral, and autonomic responses to repeated noxious stimuli. Habituation mechanisms to pain are already in place at term age but mature over the equivalent of the last trimester of gestation and are not fully functional in preterm neonates.
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Affiliation(s)
- Mohammed Rupawala
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Oana Bucsea
- Faculty of Health, Department of Psychology, York University, Toronto, ON M3J 1P3, Canada
| | | | - Kimberley Whitehead
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London WC1E 6DB, UK
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Sofia Olhede
- Department of Statistical Science, University College London, London WC1E 6BT, UK; Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne 1015, Switzerland
| | - Laura Jones
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK.
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Thill B. The fetal pain paradox. FRONTIERS IN PAIN RESEARCH 2023; 4:1128530. [PMID: 37025166 PMCID: PMC10072285 DOI: 10.3389/fpain.2023.1128530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
Controversy exists as to when conscious pain perception in the fetus may begin. According to the hypothesis of cortical necessity, thalamocortical connections, which do not form until after 24-28 weeks gestation, are necessary for conscious pain perception. However, anesthesiologists and neonatologists treat age-matched neonates as both conscious and pain-capable due to observable and measurable behavioral, hormonal, and physiologic indicators of pain. In preterm infants, these multimodal indicators of pain are uncontroversial, and their presence, despite occurring prior to functional thalamocortical connections, has guided the use of analgesics in neonatology and fetal surgery for decades. However, some medical groups state that below 24 weeks gestation, there is no pain capacity. Thus, a paradox exists in the disparate acknowledgment of pain capability in overlapping patient populations. Brain networks vary by age. During the first and second trimesters, the cortical subplate, a unique structure that is present only during fetal and early neonatal development, forms the first cortical network. In the third trimester, the cortical plate assumes this function. According to the subplate modulation hypothesis, a network of connections to the subplate and subcortical structures is sufficient to facilitate conscious pain perception in the fetus and the preterm neonate prior to 24 weeks gestation. Therefore, similar to other fetal and neonatal systems that have a transitional phase (i.e., circulatory system), there is now strong evidence for transitional developmental phases of fetal and neonatal pain circuitry.
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