Pain and stress in infancy and childhood--where to now?

[Medical and psychological aspects of the treatment of connatal dacryostenosis : Parental evaluation of their own and their child's stress]

BACKGROUND

Lacrimal probing and syringing for connatal dacryostenosis can be performed under local (LA) and general anesthesia (GA). In cases of invasive medical procedures, pain and anxiety can be distressing for children and their parents.

MATERIALS AND METHODS

Using questionnaires (n = 65), parents were asked to evaluate their own stress and that of their child during lacrimal probing and syringing. Analyzing different subgroups, the impact of the kind of anesthesia (LA vs. GA), trust in medical treatment, therapeutic success, prior experiences with GA, parental educational level, age of parents and children, number of children, and time between the intervention and the interview on the stress was examined. Stress level was evaluated on a scale from 1 (no stress) to 10 (maximal stress).

RESULTS

Mean children's age was 8.5 ± 7.42 months. Mean age of the parents was 30.8 ± 6.17 years. Treating children under LA, parents reported moderate to severe stress levels for themselves (mean, M = 7.15) and for their children (M = 7.82). Children's stress levels were significantly higher when the treatment was performed under LA (n = 47; M = 7.34) in comparison to GA (n = 18; M = 6.06; p < 0.05). Parents having two or more children reported significantly lower stress levels than those with only one child. Furthermore, prior experiences with GA led to significantly higher parental stress levels when their children were treated under GA. Other factors did not show any impact on parent's and children's stress levels.

CONCLUSIONS

Parents might have been influenced by hearing the children's reaction (e. g., crying) during the intervention under LA. Nevertheless, parents had a higher acceptance of this type of intervention (LA) in comparison to GA. This effect was even stronger among parents with prior experience of GA.

Optimum Concentration of Caudal Ropivacaine & Clonidine - A Satisfactory Analgesic Solution for Paediatric Infraumbilical Surgery Pain

INTRODUCTION

Ropivacaine is amide local anaesthetic pure S(-)enantiomer of bupivacaine. Its duration of analgesia is similar to that of Bupivacaine (in equivalent doses) but the motor block is slower in onset, less intense, shorter in duration for a given level of sensory block with lesser cardiac side effects but addition of an adjuvant like clonidine which is an imidazoline derivative has been studied for its sedative, anxiolytic and analgesic properties.

AIM

This study was aimed to show the optimum concentrations of Ropivacaine and Clonidine to maximize analgesia without side effects by evaluating its safety and efficacy.

MATERIALS AND METHODS

Sixty children aged 2-10 years of ASA grade 1, scheduled to undergo infraumbilical surgeries were randomly allocated to Group A & Group B of 30 each. Group A received 0.2% Ropivacaine with normal saline and Group B received 0.2% Ropivacaine and preservative free Clonidine 1μg/kg, the total volume of solution being 1ml/kg haemodynamic changes were monitored intraoperatively and haemodynamic parameters along with motor blockade, pain score and sedation score were assessed postoperatively.

STATISTICAL ANALYSIS

Done with unpaired student t and Mann-Whitney test.

RESULTS

The groups were comparable regarding demographic characterstics. The mean duration of analgesia was prolonged in group B (12+2.22 hours) than in group A (6.53+1.16 hours) with p-value <0.001 leading to less rescue analgesia in former group. None of the children in the groups had a pain score of ≥ 4 at the end of 2 hours. A 6.6% and 60% of group A children had score of ≥ 4 at the end of 4(th) & 6(th) hour respectively. None in Group B had a score of ≥ 4. At the end of 8(th) hour, only 6.6% of the children in Group B had a pain score of ≥ 4 whereas it was 33.33% in Group A which is statistically significant. No bradycardia or hypotension and no significant sedation.

CONCLUSION

Combination of Ropivacaine and Clonidine in the concentration used (0.2% ropivacaine and 1μg/kg of clonidine) can be optimal for postoperative analgesia in paediatric population.

Analgesia and anesthesia for neonates: Study design and ethical issues

OBJECTIVE

The purpose of this article is to summarize the clinical, methodologic, and ethical considerations for researchers interested in designing future trials in neonatal analgesia and anesthesia, hopefully stimulating additional research in this field.

METHODS

The MEDLINE, PubMed, EMBASE, and Cochrane register databases were searched using subject headings related to infant, newborn, neonate, analgesia, anesthesia, ethics, and study design. Cross-references and personal files were searched manually. Studies reporting original data or review articles related to these topics were assessed and critically evaluated by experts for each topical area. Data on population demographics, study characteristics, and cognitive and behavioral outcomes were abstracted and synthesized in a systematic manner and refined by group members. Data synthesis and results were reviewed by a panel of independent experts and presented to a wider audience including clinicians, scientists, regulatory personnel, and industry representatives at the Newborn Drug Development Initiative workshop. Recommendations were revised after extensive discussions at the workshop and between committee members.

RESULTS

Designing clinical trials to investigate novel or currently available approaches for analgesia and anesthesia in neonates requires consideration of salient study designs and ethical issues. Conditions requiring treatment include pain/stress resulting from invasive procedures, surgical operations, inflammatory conditions, and routine neonatal intensive care. Study design considerations must define the inclusion and exclusion criteria, a rationale for stratification, the confounding effects of comorbid conditions, and other clinical factors. Significant ethical issues include the constraints of studying neonates, obtaining informed consent, making risk-benefit assessments, defining compensation or rewards for participation, safety considerations, the use of placebo controls, and the variability among institutional review boards in interpreting federal guidelines on human research. For optimal study design, investigators must formulate well-defined study questions, choose appropriate trial designs, estimate drug efficacy, calculate sample size, determine the duration of the studies, identify pharmacokinetic and pharmacodynamic parameters, and avoid drug-drug interactions. Specific outcome measures may include scoring on pain assessment scales, various biomarkers and their patterns of response, process outcomes (eg, length of stay, time to extubation), intermediate or long-term outcomes, and safety parameters.

CONCLUSIONS

Much more research is needed in this field to formulate a scientifically sound, evidence-based, and clinically useful framework for management of anesthesia and analgesia in neonates. Newer study designs and additional ethical dilemmas may be defined with accumulating data in this field.

Pain and stress in the human fetus

It is not known if the fetus can actually feel pain, but noxious stimulation during fetal life does cause detectable stress responses. These responses cause both short and long-term changes in the central nervous system, which can affect subsequent pain behaviour. Reducing the stress response is known to be beneficial in children and adults and recent evidence suggests this is also true for the fetus. However, the optimal amount of suppression required and the best method of achieving this (opioid or regional anaesthesia techniques) remain unknown. Prevention and treatment of pain is a basic human right, regardless of age, and if the technique of fetal surgery is to progress then a greater understanding of nociception and the stress response is required.

Efficacy of continuous versus intermittent morphine administration after major surgery in 0-3-year-old infants; a double-blind randomized controlled trial

A randomized double-blind clinical trial compared the efficacy of 10 microg/kg/h morphine continuous intravenous infusion (CM) with that of 30 microg/kg morphine (IM) every 3h after major abdominal or thoracic surgery, in 181 infants aged 0-3 years. Efficacy was assessed by the caregiving nurses with the COMFORT 'behavior' and a visual analogue scale (VAS) for pain, every 3h in the first 24h after surgery. Random regression modeling was used to simultaneously estimate the effect of randomized group assignment, actual morphine dose (protocol dosage plus extra morphine when required), age category, surgical stress, and the time-varying covariate mechanical ventilation on COMFORT 'behavior' and the observational VAS rated pain, respectively. Overall, no statistical differences were found between CM and IM morphine administration in reducing postoperative pain. A significant interaction effect of condition with age category showed that the CM assignment was favorable for the oldest age category (1-3 years old). The greatest differences in pain response and actual morphine dose were between neonates and infants aged 1-6 months, with lower pain response in neonates who were on average satisfied with the protocol dosage of 10 microg/kg/h. Surgical stress and mechanical ventilation were not related to postoperative pain or morphine doses, leaving the inter-individual differences in pain response and morphine requirement largely unexplained.

Remifentanil and the tunnelling phase of paediatric ventriculoperitoneal shunt insertion. A double-blind, randomised, prospective study

Sixty-two children were randomly allocated to receive, during inhalational anaesthesia with isoflurane and nitrous oxide, either 1.0 microg x kg(-1) remifentanil (n = 33) or saline (n = 29) just before the tunnelling phase of ventriculoperitoneal shunt insertion, in a double-blind study. The remifentanil group showed little stress response to tunnelling as indicated by median (interquartile range [range]) change in heart rate -5.2 (-11.4 to 9.8 [-19.4 to 30.4])%, mean arterial pressure -5.0 (-20.8 to 15.5 [-40.9 to 42.9])% or plasma norepinephrine -13.5 (-38.1 to -2.5 [-77.7 to 81.5])% compared with the saline group, in which the changes were 20.1 (11.5-36.1 [2.1-83.1])%, 42.7 (27.1-56.8 [3.2-73.5])% and 13.3 (0.8-70.0 [-45.2 to 337.5])%, respectively (p < 0.001 for all comparisons). These changes were consistent across most different age categories. The cardiovascular response in the saline group lasted for 8 (4-15 [0-39]) min. Tracheal extubation occurred after 3 (2-4 [1-8]) min in the remifentanil group and 3 (2-6 [0-15]) min in the saline group (p = 0.29), with transfer to the recovery area and discharge to the ward, respectively, 4 (4-5 [1-10]) min and 9 (7-13 [2-32]) min in the remifentanil group and 7 (4-8 [2-18]) min and 14 (10-19 [7-44]) min in the saline group (p = 0.06 and 0.01, respectively). Postoperatively there was some evidence of respiratory depression and increased oxygen requirements in all age categories, but this was similar in both groups. Overall, the maximum increase from baseline in transcutaneous carbon dioxide tension was 41.2 (11.3-66.7 [-2.0 to 141.7])% in the remifentanil group compared with 30.7 (20.5-55.1 [1.7-159])% in the saline group (p = 0.8), and the time taken for transcutaneous carbon dioxide tension to decrease to < 6.0 kPa was 4 (0-13 [0-60]) min compared with 7 (0-13 [0-60]) min, respectively (p = 0.75). There was no difference between the two groups in postoperative analgesic requirements or in blood loss and there were no significant side-effects. We conclude that remifentanil is an appropriate and safe analgesic to provide balanced anaesthesia to cover the tunnelling phase of paediatric ventriculoperitoneal shunt insertion.

Behavior, pain perception, and the extremely low-birth weight survivor

This article explores the literature concerning responses to pain of both premature and term-born newborn infants, the evidence for short-term and long-term effects of pain, and behavioral sequelae in individuals who have experienced repeated early pain in neonatal life as they mature. There is no doubt that pain causes stress in babies and this in turn may adversely affect long-term neurodevelopmental outcome. Although there are methods for assessing dimensions of acute reactivity to pain in an experimental setting, there are no very good measures available at the present time that can be used clinically. In the clinical setting repeated or chronic pain is more likely the norm rather than infrequent discrete noxious stimuli of the sort that can be readily studied. The wind-up phenomenon suggests that, exposed to a cascade of procedures as happens with clustering of care in the clinical setting in an attempt to provide periods of rest for stressed babies, an infant may in fact perceive procedures that are not normally viewed as noxious, as pain. Pain exposure during lifesaving intensive medical care of ELBW neonates may also affect subsequent reactivity to pain in the neonatal period, but behavioral differences are probably not likely to be clinically significant in the long term. Prolonged and repeated untreated pain in the newborn period, however, may produce a relatively permanent shift in basal autonomic arousal related to prior NICU pain experience, which may have long-term sequelae. In the long run, the most significant clinical effects of early pain exposure may be on neurodevelopment, contributing to later attention, learning, and behavior problems in these vulnerable children. Although there is considerable evidence to support a variety of adverse effects of early pain, there is less information about the long-term effects of opiates and benzodiazepines on the developing central nervous system. Current evidence reviewed suggests that judicious use of morphine for adjustment to mechanical ventilation may ameliorate the altered autonomic response. It may be very important, however, to distinguish stress from pain. Animal evidence suggests that the neonatal brain is affected differently when exposed to morphine administered in the absence of pain than in the presence of pain. Pain control may be important for many reasons but overuse of morphine or benzodiazepines may have undesirable long-term effects. This is a rapidly evolving area of knowledge of clear relevance to clinical management likely to affect long-term outcomes of high-risk children.

Are twitches, startles, and body movements pain indicators in extremely low birth weight infants?

OBJECTIVE

The goal of this study was to examine whether body activity such as postural, trunk, and limb movements may be potential pain cues in preterm infants.

DESIGN

Convenience sample.

SETTING

Level III neonatal intensive care unit (NICU).

PATIENTS

Extremely low birth weight (< or = 1,000 g) preterm infants (n = 64) undergoing routine NICU medical care.

OUTCOME MEASURES

Procedures likely to differ in evoking distress (i.e., endotracheal suctioning, chest physical therapy, diaper change, or nasogastric feed) were observed. Behaviors were recorded at bedside using the Neonatal Individualized Developmental Care and Assessment Program system.

RESULTS

Changes in heart rate and sleep/waking state were related to the procedures, supporting the assumption of differing relative disruption to the infant. Arching, squirming, startles, and twitching were not observed significantly more during procedures than at baseline. After controlling for background variables, finger splay and leg extension were significantly related to ongoing procedures. Facial brow raising was a function of the number of invasive procedures in the past 24 hours; thus, it may be a useful cue of sensitization.

CONCLUSIONS

Some extensor movements seemed to be distress signals, whereas tremors, startles, and twitches were not related to discomfort during the observation period. These behaviors may differ qualitatively during longer lasting tissue invasive events. The results of this study indicate the need for more in-depth study of patterns of motor activity in preterm infants over longer observation periods to evaluate potential signs of stress and pain in babies undergoing NICU medical care.

Validation of the premature infant pain profile in the clinical setting

OBJECTIVE

The Premature Infant Pain Profile (PIPP) is a 7-indicator composite measure developed to assess acute pain in preterm and term neonates. It has been validated in studies using synchronized videotaping of infants undergoing procedures. The purpose of this study was to establish (a) construct validity of the PIPP and (b) inter- and intrarater reliability of the PIPP prospectively in the clinical environment.

DESIGN

A randomized, crossover design was used.

SETTING

The study was conducted in a Level III outborn neonatal intensive care unit.

PARTICIPANTS

A convenience sample of 43 neonates, stratified by gestational age, was studied.

INTERVENTIONS

Each infant experienced three separate, randomly ordered events: baseline, a painful event, and a nonpain event. Infants were videotaped and scored at the bedside using the PIPP by the nurse caring for the infant and the clinical nurse specialist who bad expertise in infant pain. The videotapes were later reviewed by two additional experts; one in real time and one using a second-to-second stop frame technique.

RESULTS

Repeated-measures analysis of the main effects and interactions yielded a statistically significant main effect for event (pain, nonpain, baseline), thus differentiating pain from nonpain and baseline events (F = 48, p = 0.0001) and establishing construct validity. Interrater reliability analysis of individual event scores of the PIPP yielded reliability coefficients of 0.93-0.96. Intrarater reliability coefficients analysis for individual events were equally high at 0.94-0.98.

CONCLUSIONS

This study demonstrates that the PIPP is a pain measure with good construct validity and excellent inter- and intrarater reliability for the assessment of procedural pain of preterm and term infants in clinical settings.

Postoperative recovery evaluated with a new, tactile scale (TaS) in children undergoing ophthalmic surgery

Following pediatric eye surgery, visual scales for assessment of recovery are inadequate due to impairment of vision. A tactile scale (TaS) was therefore developed and tested in a pilot-trial. Fifty children, 23 girls and 27 boys undergoing different types of ophthalmic surgery used TaS to rate postoperative pain and nausea. TaS was easy to explain to children and easy to use. Ratings ranging from light discomfort to severe pain were made by 49 children, whereas one child reported no pain at any time following surgery. Analgesics were administered to 38% of the patients and the administration of analgesics was significantly (P=0.01, simple regression) related to the ratings of pain by TaS. The mean ratings of pain by TaS were significantly (P<0.05, General Linear Model followed by Dunnett's t-test) lower up to 3 h after the administration of analgesics compared to ratings before analgesics were given, indicating that ratings by TaS were related to the children's actual level of pain. Nausea and/or vomiting was common and was reported or recorded in 28 children (56%). After further validation, TaS may be a useful tool for assessment of postoperative pain and efficacy of given treatments in children and adults, not only after eye procedures, but also following other types of surgery.

Pain in neonate

Anatomical, functional and neurochemical maturation of pain pathways is well developed in fetus and neonates. Various physiological and behavioural responses to painful stimuli in neonates substantiate their ability to feel pain. Biological effects of pain are systematically studied in human fetus and neonates. Pain expressions in the newborn not only reflect tissue damage but are a function of ongoing behavioural state. The ultimate aim should be to keep neonates free from pain and other stressful stimuli as far as possible, by advocating minimal handling protocol, giving comforts after painful procedures, local anesthesia while carrying out painful procedures like cutdown and insertion of chest tubes, and if a baby is ventilated fentanyl and/or midazalam infusion must be carried out during initial periods of ventilation.