Painful procedures can affect post-natal growth and neurodevelopment in preterm infants

Effects of acoustic stimulation on painful procedures in preterm and full-term infants: A systematic review and network meta-analysis

AIM

This study aims to compare and rank the effects of acoustic stimulation on painful procedures in both preterm and full-term infants.

METHODS

Six databases including Medline, Web of Science, the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Embase, and SinoMed, were searched from inception to July, 2023. A Bayesian network meta-analysis with random effects models was performed using R software and Stata 15.0. The quality of included studies was assessed using the Cochrane Collaboration's tool. The study protocol was registered at PROSPERO (Registration number: CRD42023451102).

RESULTS

A total of 28 studies involving 2624 preterm and full-term infants were included and 8 acoustic stimulation interventions were identified. Regarding pain levels during procedures, maternal voice, maternal voice plus, music therapy and maternal voice plus, music therapy plus, other pharmaceutical interventions, vocal music therapy, white noise, and white noise plus were significantly more effective than control group [standardized mean differences (SMD) ranged from -2.6 to -0.87]. White noise plus was the most effective intervention for reducing pain levels during procedures (90.6 %). Regarding pain levels after procedures (no specific time mentioned), maternal voice, maternal voice plus, music therapy and maternal voice plus, music therapy plus, other pharmaceutical interventions, other non-pharmaceutical interventions, routine care, vocal music therapy, and white noise plus were significantly more effective than control group (SMD ranged from -4.7 to -1.6). Music therapy and maternal voice plus was the most effective intervention for reducing pain levels after procedures, without specific time mentioned (95.29 %). Regarding pain levels 1 min after procedures, only music therapy plus and other pharmaceutical interventions were effective (SMD ranged from -4.5 to -4.9) and music therapy plus was the most effective intervention (93.41 %). No interventions had significant effects on pain levels 3, 5, and 10 min after procedures. Regarding heart rate, only white noise plus could provide a lower increase during procedures. For oxygen saturation, only vocal music therapy could provide a lower decrease after painful procedures (no specific time mentioned). No interventions had significant effects on stabilizing respiratory rate.

CONCLUSION

This review suggests that multiple acoustic stimulation interventions are effective for pain relief in both preterm and full-term infants undergoing painful procedures. More high quality studies with larger sample size are required to generate evidence regarding the short- and long-term effectiveness and safety of acoustic stimulation interventions on painful procedures.

Comparative effectiveness of multi-sensory interventions for reducing pain among premature infants: A systematic review and network meta-analysis

BACKGROUND

A series of multi-sensory interventions are proved to be effective in reducing pain among premature infants. Nevertheless, there lacks a comparison of these interventions to find the most suitable and optimal one for clinical decision-making.

OBJECTIVE

This systematic review and network meta-analysis aims to compare the effectiveness of various multi-sensory interventions, and to identify the optimal intervention for alleviating pain in premature infants.

METHODS

A comprehensive literature search was performed on August 19, 2024 to identify pertinent clinical trials. The Cochrane Risk of Bias (version 2) was used to assess the quality and potential bias of each included study. Network meta-analysis was used to assess the effectiveness of various interventions and to identify the optimal ones.

RESULTS

A total of 18 clinical trials involving 1408 premature infants were included. Three multi-sensory interventions were shown to be superior to routine practice in reducing pain among premature infants, including tactile-kinesthetic intervention, tactile-auditory intervention and tactile-visual-gustatory-olfactory intervention (all, P < 0.05). Among these interventions, tactile-kinesthetic intervention ranks the best for its effectiveness in alleviating procedural pain among premature infants. Subgroup network meta-analysis demonstrated that the tactile-visual-gustatory-auditory-olfactory intervention ranked the best for its effectiveness in reducing pain from invasive procedures, with the tactile-auditory intervention best for non-invasive procedures.

CONCLUSIONS

Our study suggests that cautious assessment and identification should be prioritized to select appropriate multi-sensory interventions based on pain procedures, thus to effectively reduce pain in premature infants. Subsequent studies are needed to refine and optimize these strategies for broader application.

PROSPERO REGISTRY

CRD42024510352.

Evaluation of the Relationship between Pain Exposure and Somatosensory Evoked Potentials in Preterm Infants: A Prospective Cohort Study

BACKGROUND AND AIM

First, to compare somatosensory evoked potentials (SEPs) in preterm newborns without major brain injury studied at term equivalent age (TEA) with a term historical control group. Second, to investigate the impact of pain exposure during the first 28 days after birth on SEPs. Third, to evaluate the association between SEPs and Bayley-III at 2 years corrected age (CA).

METHODS

Infants born at <32 weeks' gestational age (GA) were studied with continuous-SEPs. First, SEP differences between preterm and term infants were analyzed. Second, regression analyses were conducted to explore the association between SEPs and painful procedures, and then between SEPs and neurodevelopment.

RESULTS

86 preterm infants were prospectively enrolled. Preterm infants exhibited prolonged N1 latencies, central conduction times (CCTs), lower N1-P1 amplitudes, and more recurrently abnormal SEPs compared to term infants. Higher pain exposure predicted longer N1 latency and slower CCT (all p < 0.005), adjusting for clinical risk factors. Younger GA and postmenstrual age (PMA) at SEP recording were associated with longer N1 latency and lower N1-P1 amplitude (all p < 0.005). A normal SEP at TEA positively predicted cognitive outcome at 2 years CA (p < 0.005).

CONCLUSION

Pain exposure and prematurity were risk factors for altered SEP parameters at TEA. SEPs predicted cognitive outcome.

Effects of white noise on preterm infants in the neonatal intensive care unit: A meta-analysis of randomised controlled trials

AIM

To critically assess the effects of white noise on the pain level, weight gain and vital signs (heart rate, respiratory rate and oxygen saturation) of preterm infants in neonatal intensive care units (NICUs).

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

Ten databases (PubMed, Cochrane Library, Embase, Web of Science, CINAHL, PsycINFO, SinoMed, China National Knowledge Infrastructure, VIP and Wanfang Data) were systematically reviewed from inception to July 2022. Two reviewers evaluated the risk of bias separately using the Cochrane Collaboration criteria and extracted data using a predesigned information form.

RESULTS

The meta-analysis included eight eligible RCTs. According to statistical analysis, white noise significantly affected the pain level, weight gain, heart rate, respiratory rate and oxygen saturation in preterm infants. Regardless of the outcome measurement timing, gestational age and birth weight of preterm infants, subgroup analysis demonstrated that white noise reduced the pain level, heart rate and respiratory rate and promoted weight gain in preterm infants in NICUs.

CONCLUSION

White noise is a practical and potentially useful therapy for premature neonates in NICUs. No Patient or Public Contribution.

Predictors of Stress Exposure in Hospitalized Preterm Infants

BACKGROUND

Stress exposure in the neonatal intensive care unit (NICU) is associated with poor outcomes in preterm infants. However, factors predicting subsequent NICU stress exposure have not been identified.

PURPOSE

To characterize NICU stressors experienced by preterm infants during the first 2 weeks of life and identify demographic, perinatal, and institutional variables associated with stress exposure.

METHODS

A secondary analysis of data from a nonexperimental, prospective study was conducted using data from 60 very preterm infants born 28 to 31 weeks gestational age. Stress exposures during the first 2 weeks of life, operationalized as number of invasive procedures, were characterized by type and quantity for each infant using data extracted from electronic health records. Associations between number of invasive procedures and demographic, perinatal, or institutional variables were analyzed using linear regressions with robust standard errors.

RESULTS

Preterm infants experienced, on average, 98 (SD = 41.8) invasive procedures. Of these invasive procedures, nasal and/or oral suctioning episodes (58.1%), followed by skin-breaking procedures (32.6%), were most frequent. Differences in the number of invasive procedures were found for maternal race; infants born to Black mothers experienced fewer total invasive procedures than infants born to White mothers. The number of invasive procedures also varied across NICUs.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Preterm infant stress exposure differed by maternal race and NICU, consistent with research findings of differential treatment of diverse infants. Further research is needed to understand the reasons for these differences and to identify best practices to standardize neonatal care.

Morphine exposure and neurodevelopmental outcome in infants born extremely preterm

AIM

To investigate the association between morphine exposure in the neonatal period and neurodevelopment at 2 and 5 years of age while controlling for potential confounders.

METHOD

We performed a retrospective, single-centre cohort study on 106 infants (60 males, 46 females; mean gestational age 26 weeks [SD 1]) born extremely preterm (gestational age < 28 weeks). Morphine administration was expressed as cumulative dose (mg/kg) until term-equivalent age. Neurodevelopmental outcome was assessed at 2 years with the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version and at 5 years with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition, Dutch version. Multiple linear regression analysis was used to assess the association between morphine exposure and outcome.

RESULTS

Sixty-four out of 106 (60.4%) infants included in the study received morphine. Morphine exposure was not associated with poorer motor, cognitive, and language subscores of the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version at 2 years. Morphine exposure was associated with lower Full-Scale IQ scores (p = 0.008, B = -9.3, 95% confidence interval [CI] = -15.6 to -3.1) and Performance IQ scores (p = 0.005, B = -17.5, 95% CI = -27.9 to -7) at 5 years of age.

INTERPRETATION

Morphine exposure in infants born preterm is associated with poorer Full-Scale IQ and Performance IQ at 5 years. Individualized morphine administration is advised in infants born extremely preterm.

The relationship between NICU stress and neurodevelopmental outcomes of preterm infants: A multi-center prospective cohort study in China

PURPOSE

To examine the relationship between NICU stress exposure and the neurodevelopmental outcomes of preterm infants.

DESIGN AND METHODS

A multicenter, prospective cohort study was conducted between May 2021 and June 2022. Preterm infant participants (28-34 weeks gestational age) were recruited at birth from three NICUs of three tertiary hospitals by convenience sampling. The NICU stress includes acute NICU stress and chronic NICU stress which were measured over the total NICU hospitalization for each infant using the Neonatal Infant Stressor Scale (NISS). Neurodevelopmental outcomes of preterm infants were assessed at 3 months corrected age (CA) using the Ages and Stages Questionnaire, Third Edition (ASQ-3).

RESULTS

Of one hundred and thirty preterm infant participants, 108 preterm infants were included into analysis. Results showed that acute NICU stress exposure significantly predicted the neurodevelopmental abnormalities in communication function (RR: 1.001, 95%CI: 1.000-1.001, p = .011), while chronic NICU stress exposure was significantly associated with the problem-solving function (RR: 1.003, 95%CI: 1.001-1.005, p = .002) at 3 months CA. No significant associations were found between NICU stress exposure and other dimensions of neurodevelopmental outcomes, including gross motor, fine motor, and personal-social functions.

CONCLUSION

NICU stress exposure demonstrated a significant predicting relationship with abnormalities in communication and problem-solving functions of preterm infants at 3 months CA.

PRACTICE IMPLICATIONS

During the NICU hospitalization, neonatal health caregivers should systematically monitor the NICU stress exposure to prevent neurodevelopmental problems in preterm infants.

Touch Experiences of Preterm Infants During Essential Nursing Care

Purpose: To characterize and quantify touch experienced by preterm infants in the NICU during essential nursing care, identify instances of skin-to-skin touch between infants and caregivers, and identify clinical/demographic variables associated with touch experiences. Design: Cross-sectional study. Sample: Preterm infants (N = 20) born 27-32 weeks post-menstrual age. Main Outcome Variable: Categories of touch during observations. Results: Touch experienced by infants during day and night shifts was primarily direct touch that was further categorized as general handling. During day shifts, 30 percent of direct touch was provided for comfort, but only 9.7 percent of touch was provided exclusively for comfort (i.e., without more intrusive touch). During night shifts, 10.6 percent of direct touch was provided for comfort, and 3 percent was categorized as exclusive comforting touch. Caregivers wore gloves for >89 percent of infant touch. Only the level of respiratory support was associated with touch categories during both shifts.

An integrative review of clinician-administered comforting touch interventions and acute stress responses of preterm infants

PROBLEM

Preterm infants experience numerous stressors in the neonatal intensive care unit. Non-pharmacological interventions, including maternal comforting touch, reduce stress responses of preterm infants; however, the effects of clinician-administered comforting touch are unclear. The purpose of this integrative review was to synthesize findings from clinical trials to determine the effect of clinician-administered comforting touch on preterm infants' acute stress responses.

ELIGIBILITY CRITERIA

Eligible clinical trials were published in English between 2001 and October 2021 and reported effects of clinician-administered comforting touch on acute stress responses in preterm infants.

SAMPLE

Thirty clinical trials were included.

RESULTS

Researchers tested the effect of comforting static touch, massage, massage with kinesthetic stimulation, sensorial saturation, and Yakson. There was significant heterogeneity in study design, comparison condition, and context of intervention delivery. Results varied; some studies demonstrated efficacy of comforting touch in reducing acute stress responses and others showed no effect. Generally, comforting touch provided during stressful procedures was associated with lower stress responses compared to standard care and was an effective adjunct to other stress management strategies. However, comforting touch alone was insufficient for managing pain, especially during skin-breaking procedures.

CONCLUSIONS

While comforting touch may be a useful part of stress management plans for preterm infants, additional research is needed to determine when comforting touch is appropriate and effective.

IMPLICATIONS

Comforting touch is beneficial to preterm infants and should be provided for stress management. For highly intrusive or painful procedures, comforting touch can be provided as part of a comprehensive stress management plan.

Development of neonatal high-risk preterm infants in comparison to full-term counterparts

Studies on preterm infants usually exclude high-risk neonatal infants with neurological problems. However, it is important to study high-risk preterm infants to better understand later developmental problems. Therefore, this cross-sectional study aimed to compare the cognitive, motor, language, and social-emotional development of high-risk preterm (PT) infants with infants born full-term (FT) with no biological vulnerabilities during early development (up to the first 15 months of age). The sample comprised 133 infants (54 born PT and 79 born FT) assessed in independent subsamples at 6-8 and 12-15 months of age, considering the corrected age for prematurity in the PT infants. Infant development (cognitive, motor, language, and social-emotional) was evaluated using the Bayley-III Scales. Medical charts were reviewed to obtain the clinical history. A multivariate analysis of variance and analysis of variance tests were performed to examine the differences between groups related to infant developmental indicators, controlling for age and socioeconomic variables. Although the PT infants performed significantly more poorly than their FT counterparts, the scores of the PT group were still within the normal range on all Bayley-III domains (cognitive, language, motor, and social-emotional) than their FT counterparts. The findings of the present study provide a better understanding of the developmental prognosis of high-risk PT infants and extend support for preventive intervention programs to improve early childhood development.

Development and Implementation of a Neonatal Pain Management Guideline for Minor Surgeries

BACKGROUND

Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use.

PURPOSE

To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time.

METHODS

An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months.

RESULTS

The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time.

IMPLICATIONS FOR PRACTICE

A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse.

IMPLICATIONS FOR RESEARCH

Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.

Opioid analgesia and temperature regulation are associated with EEG background activity and MRI outcomes in neonates with mild-to-moderate hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia

BACKGROUND

Therapeutic hypothermia (TH) without sedation may lead to discomfort, which may be associated with adverse consequences in neonates with hypoxic-ischemic encephalopathy (HIE). The aim of this study was to assess the association between level of exposure to opioids and temperature, with electroencephalography (EEG) background activity post-TH and magnetic resonance imaging (MRI) brain injury in neonates with HIE.

METHODS

Thirty-one neonates with mild-to-moderate HIE who underwent TH were identified. MRIs were reviewed for presence of brain injury. Quantitative EEG background features including EEG discontinuity index and spectral power densities were calculated during rewarming and post-rewarming periods. Dose of opioids administered during TH and temperatures were collected from the medical charts. Multivariable linear and logistic regression analyses were conducted to assess the associations between cumulative dose of opioids and temperature with EEG background and MRI while adjusting for markers of HIE severity.

RESULTS

Higher opioid doses (β = -0.21, p = 0.02) and reduced skin temperature (β = 0.14, p < 0.01) were associated with lower EEG discontinuity index recorded post-TH. Higher opioid doses (β = 0.75, p = 0.01) and reduced skin temperature (β = -0.39, p = 0.02) were also associated with higher EEG Delta power post-TH. MRI brain injury was observed in 14 patients (45%). In adjusted regression analyses, higher opioid doses (OR = 0.00; 95%CI: 0-0.19; p = 0.01), reduced skin temperature (OR = 41.19; 95%CI: 2.27-747.86; p = 0.01) and reduced cooling device output temperature (OR = 1.91; 95%CI: 1.05-3.48; p = 0.04) showed an association with lower odds of brain injury.

CONCLUSIONS

Higher level of exposure to opioids and reduced skin temperature during TH in mild-to-moderate HIE were associated with improved EEG background activity post-TH. Moreover, higher exposure to opioids, reduced skin temperature and reduced device output temperature were associated with lower odds of brain injury on MRI.

A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit

BACKGROUND

Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications.

PURPOSE

The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU).

METHODS

A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period.

RESULTS

Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period.

IMPLICATIONS FOR PRACTICE

The development of a dedicated, local team played a key role in improving vascular access in the NICU.

IMPLICATIONS FOR RESEARCH

Proximity of specialized teams provides a solution to address gaps in care in the NICU.

Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN)

CONTEXT

Laryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates.

METHODS

A group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology.

RESULTS

Among the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1-), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1-). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided.

CONCLUSION

This statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices.

Less invasive surfactant administration is associated with a higher need for nonpharmacological pain-relieving interventions compared to the intubation-surfactant extubation technique in preterm infants

Aim

LISA is a promising method in improving preterm outcome. The aim of this study was to assess whether the INSURE (intubation-surfactant extubation) technique or LISA (less invasive surfactant administration) procedure for surfactant administration is associated with more pain-relieving interventions after the intervention in preterm infants.

Methods

Preterm infants born at <32 weeks gestational age admitted to the Neonatal Intensive Care Unit of Innsbruck University hospital between Jan 2012 and June 2017 subjected to INSURE or LISA were included in the study, which was performed as a retrospective analysis of routinely collected data. Pain assessments were made bedside using the Bernese Pain Scale for Neonates.

Results

During the study period 15 preterm infants (median gestational age 30.7 weeks; range: 25.9-32.0 weeks) were subjected to INSURE technique and 59 (median gestational age 29.4 weeks; range: 25.1-31.4 weeks) to LISA. Infants subjected to LISA showed a higher need for nonpharmacological pain-relieving interventions in the first three days of life.

Conclusion

LISA procedure compared to INSURE technique was associated with a higher need for pain-relieving interventions in the first three days of life. Prospective randomized controlled trials are needed to optimize this less invasive method for surfactant application with special focus on pain in neonates.

Measures of Stress Exposure for Hospitalized Preterm Infants

BACKGROUND

Extended hospitalization in neonatal intensive care units subjects preterm infants to multiple stress exposures that affect long-term cognitive functioning, motor development, and stress reactivity. Measurement of stress exposure is challenging with multiple measures of stress exposure in use, including counts of skin-breaking or invasive procedures or counts of noxious sensory exposures.

OBJECTIVES

The purpose of this analysis was to compare measures of stress exposure commonly used by researchers and to determine the predictive validity of these measures for early neurobehavior. We accomplished this objective through the following specific aims: (a) describe the stress exposures of preterm infants in the first 2 weeks of life, (b) determine the correlations among measures of stress exposure, and (c) compare the predictive validity of measures of stress exposure for early neurobehavior.

METHODS

Very preterm infants born between 28 and 31 weeks postmenstrual age were enrolled from four neonatal intensive care units in a large Midwest city. We measured stress exposure over the first 14 days of life for each infant as a count of skin-breaking procedures, a count of invasive procedures, and cumulative scores derived from the Neonatal Infant Stressor Scale. Neurobehavior was assessed at 35 weeks postmenstrual age using the motor development and vigor and alertness/orientation subscales from the Neurobehavioral Assessment of the Preterm Infant. We used Spearman's rho to determine correlations among the measures of stress exposure and multiple linear regression to determine the predictive validity of each stress exposure measure for neurobehavioral outcomes.

RESULTS

Seventy-one preterm infants were included in the analysis. We found marked variance across individuals in all measures of stress exposure. There were moderate-high correlations among the measures of stress exposure. No measure of stress exposure was associated with early neurobehavior.

DISCUSSION

The stress experiences of hospitalized preterm infants vary. This variance is reflected in all measures of stress exposure. Because measures of stress exposure are highly correlated, the most objective measure requiring the least interpretation should be used. However, the currently available measures of stress exposure used in this analysis may not reflect the infant's physiological stress responses and fail to associate with early neurobehavior.

Reference Charts for Neonatal Cranial Volume Based on 3D Laser Scanning to Monitor Head Growth

Background: Postnatal brain growth is an important predictor of neurodevelopmental outcome in preterm infants. A new reliable proxy for brain volume is cranial volume, which can be measured routinely by 3-D laser scanning. The aim of this study was to develop reference charts for normal cranial volume in newborn infants at different gestational ages starting from late preterm for both sexes. Methods: Cross-sectional cohort study in a German university hospital, including singleton, clinically stable, neonates born after 34 weeks of gestation. Cranial volume was measured in the first week of life by a validated 3-D laser scanner. Cranial volume data was modeled to calculate percentile values by gestational age and birth weight and to develop cranial volume reference charts for girls and boys separately. Results: Of the 1,703 included infants, 846 (50%) were female. Birth weights ranged from 1,370 to 4,830 grams (median 3,370). Median cranial volume ranged from 320 [interquartile range (IQR) 294-347] ml at 34 weeks to 469 [IQR 442-496] ml at 42 weeks and was higher in boys than in girls. Conclusions: This study presents the first reference charts of cranial volume which can be used in clinical practice to monitor brain growth between 34 and 42 weeks gestation in infants.

Experience with Real-Time Continuous Glucose Monitoring in Newborns with Congenital Hyperinsulinemic Hypoglycemia

BACKGROUND

Effective treatment and close monitoring of hypoglycemia in children with congenital hyperinsulinemic hypoglycemia (CHH) is vital to prevent brain damage. The current use of capillary sampling schedules does not provide a comprehensive assessment of glycemic status and fails to detect asymptomatic hypoglycemia episodes.

AIM

To investigate the efficacy and accuracy of a real-time continuous glucose monitoring system (RT-CGMS) in neonates with CHH.

METHODS

A sensor connected to RT-CGMS was inserted into the newborn patients and maintained for at least 6 days during their stay in the hospital. We compared the readings of CGMS with capillary blood glucose values using Bland-Altman analysis.

RESULTS

A total of 110 blood glucose values were compared to readings from the CGMS. All results were calculated and plotted for CGMS values at 0-4, 5-9, 10-14, 15-19, 20-24, and 25-29 min after capillary blood glucose sampling. CGMS readings were highly correlated with blood glucose values, especially during normoglycemia. In case of hypoglycemia, the mean difference between the CGMS and capillary glucose values was higher. Although the false positive rate for hypoglycemia was relatively high in CGMS, RT-CGMS may show some episodes of hypoglycemia earlier than blood measurement.

CONCLUSION

RT-CGMS is accurate during normoglycemia, and it can reduce the number of capillary blood samples in children with CHH.

Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors

BACKGROUND

Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered.

OBJECTIVES

We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN.

METHODS

We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14 days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models.

RESULTS

Premature birth (b = -0.721), caffeine (b = -0.302), and the behavioural states quiet and awake (b = -0.283), active and asleep (b = -0.158), and quiet and asleep (b = -0.498) were associated with changes in behavioural pain scores. Premature birth (b = -0.232), mechanical ventilation (b = -0.196), and duration of the heel stick procedure (b = 0.0004) were associated with changes in physiological pain scores. Premature birth (b = -0.907), Caffeine (b = -0.402), the behavioural states quiet and awake (b = -0.274), and quiet and asleep (b = -0.459), and duration of the heel stick procedure (b = 0.001) were associated with changes in the modified BPSN total scores.

CONCLUSIONS

Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs.

SIGNIFICANCE

We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Impact of a dedicated nursing team on central line-related complications in neonatal intensive care unit

Aim: To evaluate the impact of a dedicated nursing team on central line insertion success and catheter-related complications.Methods: Five nurses were trained in central line insertion and maintenance practices and replaced a team primarily comprised of neonatal-perinatal medicine fellows. A prospective observational cohort study with pre/post-intervention analysis was designed to compare certain aspects of central line insertion and related complications between the two models.Results: Six hundred and twenty peripherally inserted central catheters were attempted preintervention (period 1) in 325 infants, and 630 were attempted in 406 infants postintervention (period 2). Successful central line placement on the first attempt increased significantly from 56.6% in period 1-71.4% in period 2 (p < .001), and needle sticks per attempt decreased (3.5 versus 3; p = .03). All central line-related complications decreased from 12.8 per 1000 line days in period 1 to 5.5 in period 2 (rate ratio = 0.40; 95% confidence interval: 0.29, 0.65). The most significant reduction was noted in phlebitis (4.9-0.5 per 1000 line days; rate ratio = 0.10; 95% confidence interval: 0.03, 0.30)Conclusion: Implementation of a dedicated nursing-based central line team, skilled in insertion and certain aspects of catheter maintenance, significantly improved insertion rates and reduced line-related complications.