1
|
Li D, Du H, Qu ST, Wu JL, Li YC, Xu QY, Chen X, Dai XX, Xu JT, Wang Q, Xu GY. Thalamic Nucleus Reuniens Glutamatergic Neurons Mediate Colorectal Visceral Pain in Mice via 5-HT 2B Receptors. Neurosci Bull 2024; 40:1421-1433. [PMID: 38739251 PMCID: PMC11422542 DOI: 10.1007/s12264-024-01207-0] [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: 10/27/2023] [Accepted: 12/26/2023] [Indexed: 05/14/2024] Open
Abstract
Irritable bowel syndrome (IBS) is a common functional bowel disorder characterized by abdominal pain and visceral hypersensitivity. Reducing visceral hypersensitivity is the key to effectively relieving abdominal pain in IBS. Increasing evidence has confirmed that the thalamic nucleus reuniens (Re) and 5-hydroxytryptamine (5-HT) neurotransmitter system play an important role in the development of colorectal visceral pain, whereas the exact mechanisms remain largely unclear. In this study, we found that high expression of the 5-HT2B receptors in the Re glutamatergic neurons promoted colorectal visceral pain. Specifically, we found that neonatal maternal deprivation (NMD) mice exhibited visceral hyperalgesia and enhanced spontaneous synaptic transmission in the Re brain region. Colorectal distension (CRD) stimulation induced a large amount of c-Fos expression in the Re brain region of NMD mice, predominantly in glutamatergic neurons. Furthermore, optogenetic manipulation of glutamatergic neuronal activity in the Re altered colorectal visceral pain responses in CON and NMD mice. In addition, we demonstrated that 5-HT2B receptor expression on the Re glutamatergic neurons was upregulated and ultimately promoted colorectal visceral pain in NMD mice. These findings suggest a critical role of the 5HT2B receptors on the Re glutamatergic neurons in the regulation of colorectal visceral pain.
Collapse
Affiliation(s)
- Di Li
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China
| | - Han Du
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China
| | - Shu-Ting Qu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, 215123, China
| | - Jing-Lai Wu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China
| | - Yong-Chang Li
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China
| | - Qi-Ya Xu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China
| | - Xia Chen
- Department of Anesthesiology, Children's Hospital of Soochow University, Suzhou, 215123, China
| | - Xiao-Xuan Dai
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China
| | - Ji-Tian Xu
- Department of Physiology and Neurobiology, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China
| | - Qian Wang
- Department of Anesthesiology, Children's Hospital of Soochow University, Suzhou, 215123, China.
| | - Guang-Yin Xu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, 215123, China.
| |
Collapse
|
2
|
Subedi R, Bhatta M, Chaudhary R, Karn BK, Yadav U, Yadav SP. Effectiveness of facilitated tucking on reducing pain during heel stick in neonates: a randomized controlled experimental study. Ann Med Surg (Lond) 2024; 86:5211-5217. [PMID: 39238983 PMCID: PMC11374241 DOI: 10.1097/ms9.0000000000002321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/18/2024] [Indexed: 09/07/2024] Open
Abstract
Background Pain in neonates is associated with adverse neurodevelopmental outcomes in the later days of life. Facilitated tucking is a nonpharmacological method of pain relief. The study aims to compare the effect of facilitated tucking in pain reduction in neonates. Materials and methods This was a randomized controlled experimental study conducted in the neonatal ward of a tertiary care center. There were 25 neonates randomized each in the experimental and control groups (total of 50), based on computer-generated random tables. The experimental group was placed in a facilitated tucking position during heel stick, while the control group was kept in the usual position, as done routinely. A self-structured questionnaire and Neonatal Infant Pain Scale were used. The main outcome measures were the mean Neonatal Infant Pain Scale score, and change in preprocedure and postprocedure heart rate and oxygen saturation in the two groups. Ethical clearance and informed written consent were sought. Results Neonates in the experimental group had significantly lesser pain (less Neonatal Infant Pain Scale score) than the neonates in the control group (P<0.001). There was also a significant increment in the mean heart rate and a decrease in the oxygen saturation after the procedure in the control group, indicating significantly more pain perception (P<0.001) in the control group. Conclusions Facilitated tucking was found to be effective in reducing the pain during heel stick procedures in neonates.
Collapse
Affiliation(s)
| | - Mukesh Bhatta
- Department of Paediatrics and Adolescent Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Province 1, Nepal
| | | | | | | | - Shankar P Yadav
- Department of Paediatrics and Adolescent Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Province 1, Nepal
| |
Collapse
|
3
|
Mueller ME, Graz MB, Truttmann AC, Schneider J, Duerden EG. Neonatal amygdala volumes, procedural pain and the association with social-emotional development in children born very preterm. Brain Struct Funct 2024:10.1007/s00429-024-02845-w. [PMID: 39103553 DOI: 10.1007/s00429-024-02845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/19/2024] [Indexed: 08/07/2024]
Abstract
Very preterm birth (< 32 weeks' gestational age) is associated with later social and emotional impairments, which may result from enhanced vulnerability of the limbic system during this period of heightened vulnerability. Evidence suggests that early procedural pain may be a key moderator of early brain networks. In a prospective cohort study, neonates born very preterm (< 30 weeks' gestation) underwent MRI scanning at term-equivalent age (TEA) and clinical data were collected (mechanical ventilation, analgesics, sedatives). Procedural pain was operationalized as the number of skin breaking procedures. Amygdala volumes were automatically extracted. The Strengths and Difficulties questionnaire was used to assess social-emotional outcomes at 5 years of age (mean age 67.5 months). General linear models were employed to examine the association between neonatal amygdala volumes and social-emotional outcomes and the timing and amount of procedural pain exposure (early within the first weeks of life to TEA) as a moderator, adjusting for biological sex, gestational age, 5-year assessment age, days of mechanical ventilation and total cerebral volumes. A total of 42 preterm infants participated. Right amygdala volumes at TEA were associated with prosocial behaviour at age 5 (B = -0.010, p = 0.005). Procedural pain was found to moderate the relationship between right amygdala volumes in the neonatal period and conduct problems at 5 years, such that early skin breaking procedures experienced within the first few weeks of life strengthened the association between right amygdala volumes and conduct problems (B = 0.005, p = 0.047). Late skin breaking procedures, experienced near TEA, also strengthened the association between right amygdala volumes and conduct problems (B = 0.004, p = 0.048).
Collapse
Affiliation(s)
- Megan E Mueller
- Applied Psychology, Faculty of Education, Western University, 1137 Western Rd, London, ON, N6G 1G7, Canada
| | - Myriam Bickle Graz
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Anita C Truttmann
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Juliane Schneider
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Emma G Duerden
- Applied Psychology, Faculty of Education, Western University, 1137 Western Rd, London, ON, N6G 1G7, Canada.
- Departments of Pediatrics & Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Canada.
- Children's Health Research Institute, London, Canada.
| |
Collapse
|
4
|
Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res 2024; 95:1224-1236. [PMID: 38114609 PMCID: PMC11035150 DOI: 10.1038/s41390-023-02895-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.
Collapse
Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.
- Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Manon Bender
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California, San Francisco, California, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yvonne Wu
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mike Cotton
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
| | - Sidhartha Tan
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pia Wintermark
- Division of Neonatology, Montreal Children's Hospital, Montreal, Quebec, Canada
- McGill University Health Centre - Research Institute, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
5
|
Ling R, Wang Y, Zheng W, Min C, Chen M, Xia D, Li X. Effects of different types of neonatal pain on somatosensory and cognitive development in male juvenile rats. Brain Behav 2023; 13:e3309. [PMID: 37968885 PMCID: PMC10726798 DOI: 10.1002/brb3.3309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Premature infants are inevitably exposed to painful events, including repetitive procedures, inflammation, or mixed stimulation that may induce long-term behavioral outcomes. Here, we set up three neonatal painful models to investigate their long-term effect on somatosensation and cognition. METHODS Three types of neonatal pain models in rat were set up. Rat pups were randomly assigned to four groups. The needling pain (NP) group received repetitive needle pricks on the paws from the day of birth (PD0) to postnatal day 7 (PD7) to mimic the diagnostic and therapeutic procedures. The inflammatory pain (IP) group received the injection of carrageenan into the left hindpaw at PD3 to induce IP in peripheral tissues. The mixed pain group received a combination of the NP and IP (NIP). The control (CON) group was untreated. We performed behavioral and biochemical testing of juvenile rats (PD21-PD26). RESULTS The NIP group showed a longer hypersensitivity than the NP group, when given a secondary inflammatory stimulation. NP led to insensitivity to anxiety-causing stimuli and impairment of fear memory both aggravated by NIP. NP reduced the expression of synapse-related molecules (GluN1/PSD95/GFAP) in the medial prefrontal cortex, and NIP exacerbated this decrease. The corticosterone secretion in the NIP group increased after the behavioral task, compared with those in other three groups. CONCLUSION A combination of NP with inflammation occurring in the neonatal period might aggravate the adverse effects of each on somatosensory and cognitive development of rats, the mechanism of which might be associated with the increase of corticosterone secretion and the dysregulation of synaptic molecules.
Collapse
Affiliation(s)
- Ru Ling
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| | - Yueshu Wang
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| | - Wen Zheng
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| | - Cuiting Min
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| | - Mengying Chen
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| | - Dongqing Xia
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| | - Xiaonan Li
- Department of Child Health CareChildren's Hospital of Nanjing Medical UniversityNanjingJiangsuP. R. China
| |
Collapse
|
6
|
Archer VA, Samiee-Zafarghandy S, Farrokyhar F, Briatico D, Braga LH, Walton JM. Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP). PLoS One 2023; 18:e0294519. [PMID: 37983228 PMCID: PMC10659208 DOI: 10.1371/journal.pone.0294519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05678244, Registered December 6, 2022.
Collapse
Affiliation(s)
- Victoria Anne Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | | | - Daniel Briatico
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luis H. Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - J. Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
7
|
Kavurt S, Arslan Z, Unal S, Bas AY, Demirel N. The effect of oscillometric blood pressure measurement on pain response in preterm infants. J Paediatr Child Health 2023; 59:1251-1255. [PMID: 37694507 DOI: 10.1111/jpc.16490] [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: 02/16/2023] [Revised: 08/01/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIM Preterm neonates are exposed to many painful procedures in neonatal intensive care units. This study aims to evaluate the effect of oscillometric blood pressure (BP) measurement on pain response in preterm infants. METHODS This prospective study was performed over 4 months in a level III neonatal intensive care unit. Premature neonates whose gestational age was <34 weeks and postmenstrual age <36 weeks were included if they had no systemic diseases. BP measurement was performed on the right arm. The Premature Infant Pain Profile-Revised (PIPP-R) scores were evaluated three times before, during, and 10 min after BP measurement. RESULTS During the 5-month period, 100 preterm neonates (53 male infants) were included in the study. Median birth weight and gestational age of the infants were 1148 (IQR: 1015-1300) g and 28 (IQR: 27-30) weeks, respectively. PIPP-R scores were found to be ≥7 in 34% of neonates. PIPP-R scores increased during BP measurement and decreased after. CONCLUSION Our results demonstrated that oscillometric BP measurement which is generally accepted as a non-invasive tool for monitoring can produce mild pain in premature neonates of postmenstrual age <36 weeks.
Collapse
Affiliation(s)
- Sumru Kavurt
- Department of Neonatology, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Zehra Arslan
- Department of Neonatology, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Sezin Unal
- Department of Neonatology, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ahmet Yagmur Bas
- Department of Neonatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Nihal Demirel
- Department of Neonatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| |
Collapse
|
8
|
Wingert TEA, Hekmat D, Ayad I. Regional Anesthesia for Neonates. Neoreviews 2023; 24:e626-e641. [PMID: 37777613 DOI: 10.1542/neo.24-10-e626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.
Collapse
Affiliation(s)
- Theodora E A Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Diana Hekmat
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ihab Ayad
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| |
Collapse
|
9
|
Pessano S, Romantsik O, Olsson E, Hedayati E, Bruschettini M. Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants. Cochrane Database Syst Rev 2023; 9:CD015594. [PMID: 37767875 PMCID: PMC10535798 DOI: 10.1002/14651858.cd015594.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Lumbar puncture (LP) is a common invasive procedure, most frequently performed to diagnose infection. Physicians perform LP in newborn infants with the help of an assistant using a strict aseptic technique; it is important to monitor the infant during all the steps of the procedure. Without adequate analgesia, LP can cause considerable pain and discomfort. As newborns have increased sensitivity to pain, it is crucial to adequately manage the procedural pain of LP in this population. OBJECTIVES To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non-pharmacological interventions, or other pharmacological interventions. SEARCH METHODS We searched CENTRAL, PubMed, Embase, and three trial registries in December 2022. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs comparing drugs used for pain management, sedation, or both, during LP. We considered the following drugs suitable for inclusion. • Topical anesthetics (e.g. eutectic mixture of local anesthetics [EMLA], lidocaine) • Opioids (e.g. morphine, fentanyl) • Alpha-2 agonists (e.g. clonidine, dexmedetomidine) • N-Methyl-D-aspartate (NMDA) receptor antagonists (e.g. ketamine) • Other analgesics (e.g. paracetamol) • Sedatives (e.g. benzodiazepines such as midazolam) DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) or standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). Our main outcomes were successful LP on first attempt, total number of LP attempts, episodes of bradycardia, pain assessed with validated scales, episodes of desaturation, number of episodes of apnea, and number of infants with one or more episodes of apnea. We used the GRADE approach to evaluate the certainty of the evidence. MAIN RESULTS We included three studies (two RCTs and one quasi-RCT) that enrolled 206 newborns. One study included only term infants. All studies assessed topical treatment versus placebo or no intervention. The topical anesthetics were lidocaine 4%, lidocaine 1%, and EMLA. We identified no completed studies on opioids, non-steroidal anti-inflammatory drugs, alpha-2 agonists, NMDA receptor antagonists, other analgesics, sedatives, or head-to-head comparisons (drug A versus drug B). Based on very low-certainty evidence from one quasi-RCT of 100 LPs in 76 infants, we are unsure if topical anesthetics (lidocaine), compared to no anesthesia, has an effect on the following outcomes. • Successful LP on first attempt (first-attempts success in 48% of LPs in the lidocaine group and 42% of LPs in the control group) • Number of attempts per LP (mean 1.9 attempts, [standard error of the mean 0.2] in the lidocaine group, and mean 2.1 attempts [standard error of the mean 2.1] in the control group) • Episodes of bradycardia (0% of LPs in the lidocaine group and 4% of LPs in the control group) • Episodes of desaturation (0% of LPs in the lidocaine group and 8% of LPs in the control group) • Occurrence of apnea (RR 3.24, 95% CI 0.14 to 77.79; risk difference [RD] 0.02, 95% CI -0.03 to 0.08). Topical anesthetics compared to placebo may reduce pain assessed with the Neonatal Facial Coding System (NFCS) score (SMD -1.00 standard deviation (SD), 95% CI -1.47 to -0.53; I² = 98%; 2 RCTs, 112 infants; low-certainty evidence). No studies in this comparison reported total number of episodes of apnea. We identified three ongoing studies, which will assess the effects of EMLA, lidocaine, and fentanyl. Three studies are awaiting classification. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effect of topical anesthetics (lidocaine) compared to no anesthesia on successful lumbar puncture on first attempt, the number of attempts per lumbar puncture, episodes of bradycardia, episodes of desaturation, and occurrence of apnea. Compared to placebo, topical anesthetics (lidocaine or EMLA) may reduce pain assessed with the NFCS score. One ongoing study will assess the effects of systemic treatment.
Collapse
Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Olga Romantsik
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ehsan Hedayati
- Nezam Mafi Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - 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
| |
Collapse
|
10
|
Shah PS, Torgalkar R, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev 2023; 8:CD004950. [PMID: 37643989 PMCID: PMC10464660 DOI: 10.1002/14651858.cd004950.pub4] [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: 08/31/2023]
Abstract
BACKGROUND Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in neonates experiencing pain or stress. Non-pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012. OBJECTIVES The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores. DATA COLLECTION AND ANALYSIS We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one-third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin-to-skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin-to-skin contact (low-certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin-to-skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate-certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin-to-skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin-to-skin contact (low-certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate-certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low-certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau-né (DAN) score compared to positioning, holding or placebo (low-certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low-certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate-certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low-certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low-certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low-certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low-certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies. AUTHORS' CONCLUSIONS Moderate-/low-certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non-pharmacological interventions. Low-certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population.
Collapse
Affiliation(s)
- Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto and Mount Sinai Hospital, Toronto, Canada
| | - Ranjit Torgalkar
- Department of Paediatrics, Division of Neonatology, Kentucky Children's Hospital, University of Kentucky, Lexington, USA
| | - Vibhuti S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto and Mount Sinai Hospital, Toronto, Canada
| |
Collapse
|
11
|
Chen X, Zhu H, Mei L, Shu Q, Cheng X, Luo F, Zhao Y, Chen S, Pan Y. Video-Based versus On-Site Neonatal Pain Assessment in Neonatal Intensive Care Units: The Impact of Video-Based Neonatal Pain Assessment in Real-World Scenario on Pain Diagnosis and Its Artificial Intelligence Application. Diagnostics (Basel) 2023; 13:2661. [PMID: 37627921 PMCID: PMC10453072 DOI: 10.3390/diagnostics13162661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/02/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Neonatal pain assessment (NPA) represents a huge global problem of essential importance, as a timely and accurate assessment of neonatal pain is indispensable for implementing pain management. PURPOSE To investigate the consistency of pain scores derived through video-based NPA (VB-NPA) and on-site NPA (OS-NPA), providing the scientific foundation and feasibility of adopting VB-NPA results in a real-world scenario as the gold standard for neonatal pain in clinical studies and labels for artificial intelligence (AI)-based NPA (AI-NPA) applications. SETTING A total of 598 neonates were recruited from a pediatric hospital in China. METHODS This observational study recorded 598 neonates who underwent one of 10 painful procedures, including arterial blood sampling, heel blood sampling, fingertip blood sampling, intravenous injection, subcutaneous injection, peripheral intravenous cannulation, nasopharyngeal suctioning, retention enema, adhesive removal, and wound dressing. Two experienced nurses performed OS-NPA and VB-NPA at a 10-day interval through double-blind scoring using the Neonatal Infant Pain Scale to evaluate the pain level of the neonates. Intra-rater and inter-rater reliability were calculated and analyzed, and a paired samples t-test was used to explore the bias and consistency of the assessors' pain scores derived through OS-NPA and VB-NPA. The impact of different label sources was evaluated using three state-of-the-art AI methods trained with labels given by OS-NPA and VB-NPA, respectively. RESULTS The intra-rater reliability of the same assessor was 0.976-0.983 across different times, as measured by the intraclass correlation coefficient. The inter-rater reliability was 0.983 for single measures and 0.992 for average measures. No significant differences were observed between the OS-NPA scores and the assessment of an independent VB-NPA assessor. The different label sources only caused a limited accuracy loss of 0.022-0.044 for the three AI methods. CONCLUSION VB-NPA in a real-world scenario is an effective way to assess neonatal pain due to its high intra-rater and inter-rater reliability compared to OS-NPA and could be used for the labeling of large-scale NPA video databases for clinical studies and AI training.
Collapse
Affiliation(s)
- Xiaofei Chen
- Gastroenterology Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China;
| | - Huaiyu Zhu
- College of Information Science and Electronic Engineering, Zhejiang University, Hangzhou 310027, China; (H.Z.); (Y.Z.)
| | - Linli Mei
- Administration Department of Nosocomial Infection, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China; (L.M.); (Q.S.)
| | - Qi Shu
- Administration Department of Nosocomial Infection, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China; (L.M.); (Q.S.)
| | - Xiaoying Cheng
- Quality Improvement Office, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China;
| | - Feixiang Luo
- Neonatal Intensive Care Unit, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China;
| | - Yisheng Zhao
- College of Information Science and Electronic Engineering, Zhejiang University, Hangzhou 310027, China; (H.Z.); (Y.Z.)
| | - Shuohui Chen
- Administration Department of Nosocomial Infection, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China; (L.M.); (Q.S.)
| | - Yun Pan
- College of Information Science and Electronic Engineering, Zhejiang University, Hangzhou 310027, China; (H.Z.); (Y.Z.)
| |
Collapse
|
12
|
Brekke SM, Halvorsen ST, Bjørkvoll J, Thorsby PM, Rønnestad A, Zykova SN, Bakke LH, Dahl SR, Haaland K, Eger SHW, Solberg MT, Solevåg AL. The association between infant salivary cortisol and parental presence in the neonatal intensive care unit during and after COVID-19 visitation restrictions: A cross-sectional study. Early Hum Dev 2023; 182:105788. [PMID: 37224589 DOI: 10.1016/j.earlhumdev.2023.105788] [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: 03/16/2023] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Parent-infant interaction in the neonatal intensive care unit (NICU) promotes health and reduces infant stress. During the COVID-19 pandemic, however, NICUs restricted parent-infant interaction to reduce viral transmission. This study examined the potential relationship between pandemic visitation restrictions, parental presence and infant stress as measured by salivary cortisol. METHODS A two-NICU cross-sectional study of infants with gestational age (GA) 23-41 weeks, both during (n = 34) and after (n = 38) visitation restrictions. We analysed parental presence with and without visitation restrictions. The relationship between infant salivary cortisol and self-reported parental NICU presence in hours per day was analysed using Pearson's r. A linear regression analysis included potential confounders, including GA and proxies for infant morbidity. The unstandardised B coefficient described the expected change in log-transformed salivary cortisol per unit change in each predictor variable. RESULTS Included infants had a mean (standard deviation) GA of 31(5) weeks. Both maternal and paternal NICU presence was lower with versus without visitation restrictions (both p ≤0.05). Log-transformed infant salivary cortisol correlated negatively with hours of parental presence (r = -0.40, p = .01). In the linear regression, GA (B = -0.03, p = .02) and central venous lines (B = 0.23, p = .04) contributed to the variance in salivary cortisol in addition to parental presence (B = -0.04 p = .04). CONCLUSION COVID-19-related visitation restrictions reduced NICU parent-infant interaction and may have increased infant stress. Low GA and central venous lines were associated with higher salivary cortisol. The interaction between immaturity, morbidity and parental presence was not within the scope of this study and merits further investigation.
Collapse
Affiliation(s)
- Stine Marie Brekke
- Department of Master and Postgraduate Education, Lovisenberg Diaconal University College, Oslo, Norway; The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
| | - Silje Torp Halvorsen
- Department of Master and Postgraduate Education, Lovisenberg Diaconal University College, Oslo, Norway; The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Julie Bjørkvoll
- Department of Master and Postgraduate Education, Lovisenberg Diaconal University College, Oslo, Norway; The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Per Medbøe Thorsby
- Hormone laboratory, Department of Medical Biochemistry and Biochemical endocrinology and metabolism research group, Oslo University Hospital, Oslo, Norway
| | - Arild Rønnestad
- The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Institute for clinical medicine, Faulty of medicine, University of Oslo, Oslo, Norway
| | - Svetlana N Zykova
- Hormone laboratory, Department of Medical Biochemistry and Biochemical endocrinology and metabolism research group, Oslo University Hospital, Oslo, Norway
| | - Liv Hanne Bakke
- Hormone laboratory, Department of Medical Biochemistry and Biochemical endocrinology and metabolism research group, Oslo University Hospital, Oslo, Norway
| | - Sandra Rinne Dahl
- Hormone laboratory, Department of Medical Biochemistry and Biochemical endocrinology and metabolism research group, Oslo University Hospital, Oslo, Norway
| | - Kirsti Haaland
- The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Siw Helen Westby Eger
- The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Marianne Trygg Solberg
- Department of Master and Postgraduate Education, Lovisenberg Diaconal University College, Oslo, Norway
| | - Anne Lee Solevåg
- Department of Master and Postgraduate Education, Lovisenberg Diaconal University College, Oslo, Norway; The Department of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
13
|
Kinoshita M, Stempel KS, Borges do Nascimento IJ, Bruschettini M. Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates. Cochrane Database Syst Rev 2023; 3:CD014876. [PMID: 36870076 PMCID: PMC9983301 DOI: 10.1002/14651858.cd014876.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
BACKGROUND Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain 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. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period. OBJECTIVES To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all-cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non-pharmacological interventions, different types of opioids, or other drugs. SEARCH METHODS We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi-RCTs. SELECTION CRITERIA: We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non-pharmacological interventions; 3) different types of opioids; or 4) other drugs. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all-cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta-analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level). Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all-cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD -0.03, 95% CI -0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 2: opioids versus non-pharmacological interventions No trials were included in this comparison. Comparison 3: head-to-head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all-cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI -0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage. Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI -0.85 to 1.05; 71 participants, 1 study; I² = not applicable). No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all-cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage. AUTHORS' CONCLUSIONS Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all-cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non-pharmacological interventions.
Collapse
Affiliation(s)
- Mari Kinoshita
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Fetal Medicine Research Center, University of Barcelona, Barcelona, Spain
| | | | - Israel Junior Borges do Nascimento
- School of Medicine and University Hospital, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
14
|
Momany AM, Jasper E, Markon KE, Nikolas MA, Ryckman KK. Latent class analysis to characterize neonatal risk for neurodevelopmental differences. J Child Psychol Psychiatry 2023; 64:100-109. [PMID: 35837724 PMCID: PMC9771897 DOI: 10.1111/jcpp.13671] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neonatal risk factors, such as preterm birth and low birth weight, have been robustly linked to neurodevelopmental deficits, yet it is still unclear why some infants born preterm and/or low birth weight experience neurodevelopmental difficulties while others do not. The current study investigated this heterogeneity in neurodevelopmental abilities by examining additional neonatal morbidities as risk factors, utilizing latent class analysis to classify neonates into groups based on similar neonatal risk factors, and including neonates from the full spectrum of gestational age. METHODS Neonates who received neonatal care at an academic public hospital during an almost 10-year period (n = 19,951) were included in the latent class analysis, and 21 neonatal indicators of health were used. Neonatal class, sex, and the interaction between neonatal class and sex were used to examine differences in neurodevelopment at 18 months of age in a typically developing population. RESULTS The best fitting model included five infant classes: healthy, hypoxic, critically ill, minorly ill, and complicated delivery. Scores on the parent-rated neurodevelopmental measure differed by class such that infants in the critically ill, minorly ill, and complicated delivery classes had lower scores. There was no main effect of sex on the neurodevelopmental measure scores, but the interaction between sex and neonatal class was significant for three out of five neurodevelopmental domains. CONCLUSIONS The current study extends the understanding of risk factors in neurodevelopment by including several neonatal medical conditions that are often overlooked and by using a person-centered, as opposed to variable-centered, approach. Future work should continue to examine risk factors, such as maternal health during pregnancy and medical interventions for newborns, in relation to neonatal risks and neurodevelopment by using a person-centered approach.
Collapse
Affiliation(s)
- Allison M. Momany
- Stead Family Department of Pediatrics, Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Elizabeth Jasper
- Department of Obstetrics and GynecologyVanderbilt University Medical CenterNashvilleTNUSA
- Department of Biomedical Informatics and Vanderbilt Genetics InstituteVanderbilt University Medical CenterNashvilleTNUSA
| | - Kristian E. Markon
- Department of Psychological and Brain SciencesUniversity of IowaIowa CityIAUSA
| | - Molly A. Nikolas
- Department of Psychological and Brain SciencesUniversity of IowaIowa CityIAUSA
| | | |
Collapse
|
15
|
Pessano S, Romantsik O, Hedayati E, Olsson E, Bruschettini M. Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015594. [PMCID: PMC9749080 DOI: 10.1002/14651858.cd015594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non‐pharmacological interventions, or other pharmacological interventions.
Collapse
Affiliation(s)
| | - Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and ChildIRCCS Istituto Giannina GasliniGenoaItaly
| | - Olga Romantsik
- Department of Clinical Sciences Lund, PaediatricsLund University, Skåne University HospitalLundSweden
| | - Ehsan Hedayati
- Nezam Mafi HospitalAhvaz Jundishapur University of Medical SciencesAhvazIran
| | | | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University HospitalLundSweden,Cochrane Sweden, Lund University, Skåne University HospitalLundSweden
| |
Collapse
|
16
|
Karunanayake A, Devanarayana NM, Rajindrajith S. Early life events in functional abdominal pain disorders in children. PLoS One 2022; 17:e0275419. [PMID: 36322579 PMCID: PMC9629606 DOI: 10.1371/journal.pone.0275419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/18/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives Functional abdominal pain disorders (FAPDs) are common gastrointestinal problems in children, and the pathophysiology is thought to be multifactorial. Adverse early life events (ELE) induce alterations in the central nervous system, perhaps predisposing individuals to develop FAPDs. We aimed to study the potential adverse ELE that are associated with FAPDs. Methods We steered a school-based survey involving 1000 children from 4 randomly selected schools. FAPDs were assessed using the translated Rome III questionnaire, and ELE were identified using a pre-tested, parental questionnaire. FAPDs were diagnosed using the Rome III criteria. Results Hundred and eighty-two (182) children had FAPDs (62.1% girls, mean age 8.5, SD 2.1). ELE of them were compared with 571 children without FAPDs (51.1% girls, mean age 8.8, SD 1.9). According to the binary logistic regression analysis, family members with abdominal pain, family member with chronic pain other than abdominal pain, prenatal maternal complications and interventional deliveries, were recognized as potential risk factors for the development of FAPDs. Breast feeding over two years has shown to reduce the prevalence of FAPDs.a. Conclusions Prenatal maternal medical problems are associated a with higher prevalence of FAPDs later in life. Prolonged breastfeeding and normal vaginal delivery could be considered as factors that reduce the vulnerability of developing FAPDs in children. Therefore, minimizing pregnancy-related complications, encouraging vaginal deliveries, and encouraging breastfeeding are potentially valuable measures to prevent FAPDs during childhood.
Collapse
|
17
|
Reddy S, Nesargi SV, Stevens S, Jose J, Babu H. Procedural Analgesia in the Neonatal Intensive Care Unit: A Quality Improvement Initiative. Am J Perinatol 2022; 39:1688-1692. [PMID: 33706395 DOI: 10.1055/s-0041-1726121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Neonates perceive pain which also has adverse long-term consequences. Newborns experience several painful procedures a day. Various methods of analgesia may be used but are underutilized. The SMART aim of this project was to increase the use of procedural analgesia from 11.5 to 75% in 6 months by using quality improvement principles. STUDY DESIGN After a baseline audit, a root cause analysis was done. Based on this, a series of interventions were done as Plan-Do-Study-Act (PDSA) cycles. These included posters on analgesia, display of the pain protocol, orders for analgesia, a written test, small power point presentations on the importance of analgesia, and reminders on the trays used for procedures. At the end of each PDSA cycle, an audit was done to determine the proportion of times analgesia was used. Process indicators were also used when possible. Analysis was done by using the Chi-square test and the paired t-test. RESULTS At baseline 11% of procedures were done after giving analgesia. This significantly improved to 40% at the end of the first PDSA, and 81% after third PDSA. This was sustained at 75% over the next 2 months. CONCLUSION Procedural analgesia can improve and be sustained by using simple interventions. KEY POINTS · Procedural pain in neonates can be decreased by the use of analgesia.. · However, most units do not utilize analgesia appropriately.. · This QI showed that simple interventions can optimize use of procedural analgesia..
Collapse
Affiliation(s)
- Sushma Reddy
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Saudamini V Nesargi
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Sofia Stevens
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Jiya Jose
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Hindumati Babu
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, Karnataka, India
| |
Collapse
|
18
|
Amin K, Patel K. Role of Psychologists in Pediatric Congenital Heart Disease. Pediatr Clin North Am 2022; 69:865-878. [PMID: 36207098 DOI: 10.1016/j.pcl.2022.05.002] [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] [Indexed: 12/31/2022]
Abstract
Congenital heart disease (CHD) is stressful to both pediatric patients and their caregivers. Maternal anxiety during pregnancy is associated with adverse perinatal outcomes. After birth, a prolonged hospital stay can be taxing on the infant and caregiver leading to long-term adverse effects. During adolescence, CHD continues to serve as a stressor for the child not only due to medical care but also due to social limitations and bullying. Many patients also struggle during the transition from adolescence to adult care. Psychologists may aid both the parents and child at all stages from pregnancy to the child's transition to adulthood.
Collapse
Affiliation(s)
- Kanhai Amin
- Yale University, 261 Park St, New Haven, CT 06511, USA
| | - Keshav Patel
- Department of Internal Medicine, University of Illinois at Chicago College of Medicine, University of Illinois at Chicago, 840 South Wood Street, Room 440, MC 718, Chicago, IL 60612-7323, USA.
| |
Collapse
|
19
|
Tauzin M, Gouyon B, Hirt D, Carbajal R, Gouyon JB, Brunet AC, Ortala M, Goro S, Jung C, Durrmeyer X. Frequencies, Modalities, Doses and Duration of Computerized Prescriptions for Sedative, Analgesic, Anesthetic and Paralytic Drugs in Neonates Requiring Intensive Care: A Prospective Pharmacoepidemiologic Cohort Study in 30 French NICUs From 2014 to 2020. Front Pharmacol 2022; 13:939869. [PMID: 35924063 PMCID: PMC9341520 DOI: 10.3389/fphar.2022.939869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: No consensus exists about the doses of analgesics, sedatives, anesthetics, and paralytics used in critically ill neonates. Large-scale, detailed pharmacoepidemiologic studies of prescription practices are a prerequisite to future research. This study aimed to describe the detailed prescriptions of these drug classes in neonates hospitalized in neonatal intensive care units (NICU) from computerized prescription records and to compare prescriptions by gestational age. Materials and Methods: We included all neonates requiring intensive care in 30 French level III units from 2014 through 2020 with a computerized prescription for an analgesic, sedative, anesthetic, or paralytic agent. We described frequencies of prescription, methods of administration, concomitant drug prescriptions, and dosing regimen, and compared them across gestational ages. Results: Among 65,555 neonates, 29,340 (44.8%) were prescribed at least one analgesic (acetaminophen in 37.2% and opioids in 17.8%), sedative (9.8%), anesthetic (8.5%), and/or paralytic agent (1%). Among preterm infants born before 28 weeks, 3,771/4,283 (88.0%) were prescribed at least one of these agents: 69.7% opioids, 41.2% sedatives, 32.5% anesthetics, and 5.8% paralytics. The most frequently prescribed agents were sufentanil (in 10.3% of neonates) and morphine (in 8.0% of neonates) for opioids, midazolam (9.3%) for sedatives, ketamine (5.7%) and propofol (3.3%) for anesthetics. In most neonates, opioids and sedatives were prescribed as continuous infusion, whereas anesthetics were prescribed as single doses. Opioids, sedatives and paralytics were mostly prescribed in association with another agent. Doses varied significantly by gestational age but within a limited range. Gestational age was inversely related to the frequency, cumulative dose and duration of prescriptions. For example, morphine prescriptions showed median (IQR) cumulative doses of 2601 (848-6750) vs. 934 (434-2679) µg/kg and median (IQR) durations of 7 (3-15) vs. 3 (2-5) days in infants born <28 vs. ≥ 37 weeks of gestation, respectively (p-value<0.001). Conclusion: The prescriptions of analgesic, sedative, anesthetic, or paralytic agent were frequent and often combined in the NICU. Lower gestational age was associated with higher frequencies, longer durations and higher cumulative doses of these prescriptions. Dose-finding studies to determine individualized dosing regimens and studies on long-term neurodevelopmental outcome according to received cumulative doses are required.
Collapse
Affiliation(s)
- Manon Tauzin
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
| | - Béatrice Gouyon
- Centre d’Etudes Périnatales de L’Océan Indien (CEPOI, EA7388), Université de La Réunion, Saint Pierre, France
| | - Déborah Hirt
- Pharmacology Department, Hôpital Cochin APHP, Paris, France
| | - Ricardo Carbajal
- Pediatric Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Armand Trousseau- Sorbonne Université, Paris, France
- Institut National de La Santé et de La Recherche Médicale UMR1153, Paris, France
| | - Jean-Bernard Gouyon
- Centre d’Etudes Périnatales de L’Océan Indien (CEPOI, EA7388), Université de La Réunion, Saint Pierre, France
| | | | | | - Seydou Goro
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Camille Jung
- Clinical Research Center, CHI Créteil, Créteil, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
- Faculté de Médecine de Créteil, IMRB, GRC CARMAS, Université Paris Est Créteil, Créteil, France
| |
Collapse
|
20
|
Steinbauer P, Monje FJ, Kothgassner O, Goreis A, Eva C, Wildner B, Schned H, Deindl P, Seki D, Berger A, Olischar M, Giordano V. The consequences of neonatal pain, stress and opiate administration in animal models: An extensive meta-analysis concerning neuronal cell death, motor and behavioral outcomes. Neurosci Biobehav Rev 2022; 137:104661. [PMID: 35427643 DOI: 10.1016/j.neubiorev.2022.104661] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 01/21/2023]
Abstract
This systematic review and meta-analysis aimed to investigate the association of neonatal exposure to pain, stress, opiate administration alone, as well as opiate administration prior to a painful procedure on neuronal cell death, motor, and behavioral outcomes in rodents. In total, 36 studies investigating the effect of pain (n = 18), stress (n = 15), opiate administration (n = 13), as well as opiate administration prior to a painful event (n = 7) in rodents were included in our meta-analysis. The results showed a large effect of pain (g = 1.37, 95% CI 1.00-1.74, p < .001) on neuronal cell death. Moreover, higher number of neonatal pain events were significantly associated with increased neuronal cell death, increased anxiety (b = -1.18, SE = 0.43, p = .006), and depressant-like behavior (b = 1.74, SE = 0.51, p = .027) in rodents. Both opiates and pain had no impact on motor function (g = 0.26, 95% CI 0.18-0.70, p = .248).
Collapse
Affiliation(s)
- Philipp Steinbauer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Francisco J Monje
- Department of Neurophysiology and Neuropharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Oswald Kothgassner
- Department of Child and Adolescent Psychiatry, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andreas Goreis
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria; Outpatient Unit for Research, Teaching and Practice, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Chwala Eva
- Information Retrieval Office, University Library of the Medical University of Vienna, Vienna, Austria
| | - Brigitte Wildner
- Information Retrieval Office, University Library of the Medical University of Vienna, Vienna, Austria
| | - Hannah Schned
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Philipp Deindl
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children's Hospital, University Medical Center Hamburg, Eppendorf, Germany
| | - David Seki
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria; Department of Microbiology and Ecosystem Science Division of Microbial Ecology, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Monika Olischar
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
21
|
Ojha S, Abramson J, Dorling J. Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice? BMJ Paediatr Open 2022; 6:e001460. [PMID: 36053596 PMCID: PMC9092181 DOI: 10.1136/bmjpo-2022-001460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/22/2022] [Indexed: 01/09/2023] Open
Abstract
Mechanical ventilation is an uncomfortable and potentially painful intervention. Opioids, such as morphine and fentanyl, are used for analgesia and sedation but there is uncertainty whether they reduce pain in mechanically ventilated infants. Moreover, there may be short-term and long-term adverse consequences such as respiratory depression leading to prolonged mechanical ventilation and detrimental long-term neurodevelopmental effects. Despite this, opioids are widely used, possibly due to a lack of alternatives.Dexmedetomidine, a highly selective alpha-2-adrenergic agonist with analgesic and sedative effects, currently approved for adults, has come into use in newborn infants. It provides analgesia and simulates natural sleep with maintenance of spontaneous breathing and upper airway tone. Although data on pharmacokinetics-pharmacodynamics in preterm infants are scant, observational studies report that using dexmedetomidine in conjunction with opioids/benzodiazepines or on its own can reduce the cumulative exposure to opioids/benzodiazepines. As it does not cause respiratory depression, dexmedetomidine could enable quicker weaning and extubation. Dexmedetomidine has also been suggested as an adjunct to therapeutic hypothermia in hypoxic ischaemic encephalopathy and others have used it during painful procedures and surgery. Dexmedetomidine infusion can cause bradycardia and hypotension although most report clinically insignificant effects.The increasing number of publications of observational studies and clinical use demonstrates that dexmedetomidine is being used in newborn infants but data on safety and efficacy are scant and not of high quality. Importantly, there are no data on long-term neurodevelopmental impact on preterm or term-born infants. The acceptance of dexmedetomidine in routine clinical practice must be preceded by clinical evidence. We need adequately powered and well-designed randomised controlled trials investigating whether dexmedetomidine alone or with opioids/benzodiazepines in infants on mechanical ventilation reduces the need for opioids/benzodiazepine and improves neurodevelopment at 24 months and later as compared with the use of opioids/benzodiazepines alone.
Collapse
Affiliation(s)
- Shalini Ojha
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Janine Abramson
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
22
|
Contactless radar-based breathing monitoring of premature infants in the neonatal intensive care unit. Sci Rep 2022; 12:5150. [PMID: 35338172 PMCID: PMC8956695 DOI: 10.1038/s41598-022-08836-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/03/2022] [Indexed: 01/18/2023] Open
Abstract
Vital sign monitoring systems are essential in the care of hospitalized neonates. Due to the immaturity of their organs and immune system, premature infants require continuous monitoring of their vital parameters and sensors need to be directly attached to their fragile skin. Besides mobility restrictions and stress, these sensors often cause skin irritation and may lead to pressure necrosis. In this work, we show that a contactless radar-based approach is viable for breathing monitoring in the Neonatal intensive care unit (NICU). For the first time, different scenarios common to the NICU daily routine are investigated, and the challenges of monitoring in a real clinical setup are addressed through different contributions in the signal processing framework. Rather than just discarding measurements under strong interference, we present a novel random body movement mitigation technique based on the time-frequency decomposition of the recovered signal. In addition, we propose a simple and accurate frequency estimator which explores the harmonic structure of the breathing signal. As a result, the proposed radar-based solution is able to provide reliable breathing frequency estimation, which is close to the reference cabled device values most of the time. Our findings shed light on the strengths and limitations of this technology and lay the foundation for future studies toward a completely contactless solution for vital signs monitoring.
Collapse
|
23
|
Dutriez-Casteloot I, Emmanuelli V, Wiart JF, Tavernier A, Besengez C, Storme L, Houfflin-Debarge V. Long-Lasting Analgesia With Transdermal Fentanyl: A New Approach in Rat Neonatal Research. Front Pharmacol 2022; 13:798011. [PMID: 35370716 PMCID: PMC8968727 DOI: 10.3389/fphar.2022.798011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background: With advances in neonatal care, management of prolonged pain in newborns is a daily concern. In addition to ethical considerations, pain in early life would have long-term effects and consequences. However, its treatment remains inadequate. It was therefore important to develop an experimental model of long-lasting analgesia for neonatal research. Materials and Methods: Experiments were performed in six groups of rats with transdermal fentanyl 0, 3, 12, 50, 100, or 200 μg/kg/h from second postnatal day (P2) until weaning. Assessment of analgesia was carried out at P21, with behavioral scores (ranging from 0 to 3) using a 4% formalin test. Plasma levels of fentanyl were determined by UPLC/TQD at P22. Growth rate was investigated. Results: Fentanyl 100 and 200 μg/kg/h reduced scores of formalin-evoked behavioral pain. They increased time spent in pain score 0 (8 min 55 s and 6 min 34 s versus 23 s in controls) as in low pain scores 1 and 2, and decreased time in the most severe pain score 3 (19 min 56 s and 17 min 39 s versus 44 min 15 s). Fentanylemia increased in a dose-dependent manner from 50 μg/kg/h (2.36 ± 0.64 ng/ml) to 200 μg/kg/h (8.66 ± 1.80 ng/ml). Concerning growth, no difference was observed except weaker growth from P17 to P22 with 200 μg/kg/h. Clinically, we noticed no visible side effect from 3 to 100 μg/kg/h. Concomitantly, 200 μg/kg/h was responsible for ophthalmological side effects with appearance of corneal bilateral clouding in 90% pups. No difference was observed between male and female rats. Conclusion: Altogether, results indicate that transdermal fentanyl 100 μg/kg/h is an efficient therapeutic for long-lasting analgesia in lactating pups. This new model provides a useful tool for protection and welfare, and future opportunity for studying long-term health consequences of sustainable neonatal analgesia.
Collapse
Affiliation(s)
- Isabelle Dutriez-Casteloot
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
- Department of Biology, Faculty of Sciences and Technology, University of Lille, Lille, France
| | - Virginie Emmanuelli
- Department of Obstetrics, Jeanne de Flandre Hospital, University Hospital Center of Lille, Lille, France
| | - Jean-François Wiart
- Department of Toxicology, University Hospital Center of Lille, Lille, France
| | - Annabelle Tavernier
- Department of Biology, Faculty of Sciences and Technology, University of Lille, Lille, France
| | - Capucine Besengez
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
| | - Laurent Storme
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
| | - Véronique Houfflin-Debarge
- ULR2694 METRICS-Perinatal Environment and Health, University of Lille, Lille, France
- Department of Obstetrics, Jeanne de Flandre Hospital, University Hospital Center of Lille, Lille, France
| |
Collapse
|
24
|
van Dokkum NH, de Kroon MLA, Dijk PH, Kraft KE, Reijneveld SA, Bos AF. Course of Stress during the Neonatal Intensive Care Unit Stay in Preterm Infants. Neonatology 2022; 119:84-92. [PMID: 34883490 DOI: 10.1159/000520513] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/25/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Understanding the course of stress during the neonatal intensive care unit stay may provide targets for interventions. Our aim was to describe the course of stress in preterm infants during the first 28 days of life, the influence of gestational age, and associations with clinical characteristics. METHODS In a single centre prospective cohort study, we included infants with a gestational age <30 weeks and/or birth weight <1,000 g. We measured stress over the first 28 days using the Neonatal Infant Stressor Scale (NISS). We plotted daily NISS total and subcategory scores by gestational age. The subcategories were (1) nursing, (2) skin-breaking, (3) monitoring and imaging, and (4) medical morbidity-related scores. We assessed associations of cumulative NISS scores over the first 7, 14, and 28 days with clinical characteristics using regression analyses. RESULTS We included 45 infants, with a median gestational age of 27 weeks. The mean daily NISS score was 66.5 (SD 8.7), with highest scores in the first 7 days of life. Scores decreased the slowest for the lowest gestational ages, in particular for nursing scores, rather than skin-breaking, monitoring and imaging, and medical morbidity-related scores. Adjusted for gestational age, infants with lower Apgar scores, sepsis, intraventricular haemorrhages, and on mechanical ventilation had significantly higher cumulative NISS scores at 7, 14, and 28 days. CONCLUSION NISS scores varied greatly within infants and over time, with the highest mean scores in the first week after birth. The course of declining NISS scores in the first 28 days depended on gestational age at birth.
Collapse
Affiliation(s)
- Nienke H van Dokkum
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marlou L A de Kroon
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter H Dijk
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karianne E Kraft
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sijmen A Reijneveld
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arend F Bos
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
25
|
Adcock SJJ. Early Life Painful Procedures: Long-Term Consequences and Implications for Farm Animal Welfare. FRONTIERS IN ANIMAL SCIENCE 2021. [DOI: 10.3389/fanim.2021.759522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Farm animals routinely undergo painful husbandry procedures early in life, including disbudding and castration in calves and goat kids, tail docking and castration in piglets and lambs, and beak trimming in chicks. In rodents, inflammatory events soon after birth, when physiological systems are developing and sensitive to perturbation, can profoundly alter phenotypic outcomes later in life. This review summarizes the current state of research on long-term phenotypic consequences of neonatal painful procedures in rodents and farm animals, and discusses the implications for farm animal welfare. Rodents exposed to early life inflammation show a hypo-/hyper-responsive profile to pain-, fear-, and anxiety-inducing stimuli, manifesting as an initial attenuation in responses that transitions into hyperresponsivity with increasing age or cumulative stress. Neonatal inflammation also predisposes rodents to cognitive, social, and reproductive deficits, and there is some evidence that adverse effects may be passed to offspring. The outcomes of neonatal inflammation are modulated by injury etiology, age at the time of injury and time of testing, sex, pain management, and rearing environment. Equivalent research examining long-term phenotypic consequences of early life painful procedures in farm animals is greatly lacking, despite obvious implications for welfare and performance. Improved understanding of how these procedures shape phenotypes will inform efforts to mitigate negative outcomes through reduction, replacement, and refinement of current practices.
Collapse
|
26
|
Pre- and Postnatal Maturation are Important for Fentanyl Exposure in Preterm and Term Newborns: A Pooled Population Pharmacokinetic Study. Clin Pharmacokinet 2021; 61:401-412. [PMID: 34773609 PMCID: PMC8891207 DOI: 10.1007/s40262-021-01076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Fentanyl is an opioid commonly used to prevent and treat severe pain in neonates; however, its use is off label and mostly based on bodyweight. Given the limited pharmacokinetic information across the entire neonatal age range, we characterized the pharmacokinetics of fentanyl across preterm and term neonates to individualize dosing. METHODS We pooled data from two previous studies on 164 newborns with a median gestational age of 29.0 weeks (range 23.9-42.3), birthweight of 1055 g (range 390-4245), and postnatal age (PNA) of 1 day (range 0-68). In total, 673 plasma samples upon bolus dosing (69 patients; median dose 2.1 μg/kg, median 2 boluses per patient) or continuous infusions (95 patients; median dose 1.1 μg/kg/h for 30 h) with and without boluses were used for population pharmacokinetic modeling in NONMEM® 7.4. RESULTS Clearance in neonates with birthweight of 2000 and 3000 g was 2.8- and 5.0-fold the clearance in a neonate with birthweight of 1000 g, respectively. Fentanyl clearance at PNA of 7, 14, and 21 days was 2.7-fold, 3.8-fold, and 4.6-fold the clearance at 1 day, respectively. Bodyweight-based dosing resulted in large differences in fentanyl concentrations. Depending on PNA and birthweight, fentanyl concentrations increased slowly after the start of therapy for both intermittent boluses and continuous infusion and reached a maximum concentration at 12-48 h. CONCLUSIONS As both prenatal and postnatal maturation are important for fentanyl exposure, we propose a birthweight- and PNA-based dosage regimen. To provide rapid analgesia in the first 24 h of treatment, additional loading doses need to be considered.
Collapse
|
27
|
Gomes CI, Barr GA. Local injury and systemic infection in infants alter later nociception and pain affect during early life and adulthood. Brain Behav Immun Health 2021; 9:100175. [PMID: 34589906 PMCID: PMC8474633 DOI: 10.1016/j.bbih.2020.100175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 10/25/2022] Open
Abstract
Newborns in intensive care are regularly exposed to minor painful procedures at developmental time points when noxious stimulation would be normally absent. Pain from these interventions is inconsistently treated and often exists concurrently with systemic infection, a common comorbidity of prematurity. Our understanding of the independent and combined effects of early painful experiences and infection on pain response is incomplete. The main goals of this research therefore were to understand how pain and infection experienced early in life influence future nociceptive and affective responses to painful stimuli. Rat pups were infected with E-coli on postnatal day 2 (PN2) and had left hind paw injury with carrageenan on PN3. Standard thermal tests for acute pain, formalin tests for inflammatory pain, and conditioned place aversion testing were performed at different ages to assess the nociceptive and affective components of the pain response. Early E-coli infection and early inflammatory injury with carrageenan both independently increased pain scores following hind paw reinjury with formalin on PN8, with effects persisting into adulthood in the carrageenan exposed group. When experienced concurrently, early E-coli infection and carrageenan exposure also increased conditioned aversion to pain in adults. Effect of sex was significant only in formalin testing, with males showing higher pain scores in infancy and females showing higher pain scores as adults. These findings demonstrate that infection experienced early in life can alter both the nociceptive and affective components of the pain response and that there is a cumulative effect of local and systemic pro-inflammatory processes on the aversive component of pain.
Collapse
Affiliation(s)
- Carly I Gomes
- Department of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gordon A Barr
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, 3615 Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Psychology, University of Pennsylvania, 425 S. University Avenue, Stephen A. Levin Building, Philadelphia, PA, USA
| |
Collapse
|
28
|
van Dokkum NH, de Kroon MLA, Reijneveld SA, Bos AF. Neonatal Stress, Health, and Development in Preterms: A Systematic Review. Pediatrics 2021; 148:peds.2021-050414. [PMID: 34548378 DOI: 10.1542/peds.2021-050414] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/31/2022] Open
Abstract
CONTEXT An overview of the full range of neonatal stressors and the associated clinical, laboratory, and imaging outcomes regarding infants' health and development may contribute to the improvement of neonatal care. OBJECTIVE To systematically review existing literature on the associations between all kinds of neonatal stressors and the health and development of preterm infants. DATA SOURCES Data sources included Embase, Medline, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, and reference lists. STUDY SELECTION Studies were eligible if they included a measure of neonatal stress during the NICU stay, reported clinical, laboratory, and/or imaging outcomes regarding health and/or development on discharge from the NICU or thereafter, included preterm infants, and were written in English or Dutch. DATA EXTRACTION Two reviewers independently screened the sources and extracted data on health and development. Study quality was assessed by using the Newcastle-Ottawa Quality Assessment Scale. RESULTS We identified 20 articles that reported on neonatal stress associated negatively with clinical outcomes, including cognitive, motor, and emotional development, and laboratory and imaging outcomes, including epigenetic alterations, hypothalamic-pituitary-adrenal axis functioning, and structural brain development. We found no evidence regarding associations with growth, cardiovascular health, parent-infant interaction, the neonatal immune system, and the neonatal microbiome. LIMITATIONS The studies were all observational and used different definitions of neonatal stress. CONCLUSIONS Neonatal stress has a profound impact on the health and development of preterm infants, and physicians involved in their treatment and follow-up should be aware of this fact.
Collapse
Affiliation(s)
- Nienke H van Dokkum
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital .,Department of Health Sciences, University Medical Center Groningen and University of Groningen, Groningen, Netherlands
| | - Marlou L A de Kroon
- Department of Health Sciences, University Medical Center Groningen and University of Groningen, Groningen, Netherlands
| | - Sijmen A Reijneveld
- Department of Health Sciences, University Medical Center Groningen and University of Groningen, Groningen, Netherlands
| | - Arend F Bos
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital
| |
Collapse
|
29
|
Walas W, Latka-Grot J, Maroszyńska I, Malinowska E, Rutkowska M, Piotrowski A, Wrońska M, Szczapa T, Kubiaczyk A, Skrzypek M, De Jonckheere J, Halaba ZP. Newborn Infant Parasympathetic Evaluation Index for the Assessment of Procedural Pain in Nonanesthetized Infants: A Multicenter Pilot Study. Am J Perinatol 2021; 38:e224-e230. [PMID: 32276281 DOI: 10.1055/s-0040-1709458] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the ability of the Newborn Infant Parasympathetic Evaluation (NIPE) index to detect the response to nociceptive stimuli in nonanesthetized infants and to compare these results to simultaneous scoring by behavioral scales. STUDY DESIGN Thirty-six nonanesthetized infants admitted to neonatal/pediatric intensive care unit (N/PICUs) were enrolled to the study. Due to faulty records of the data, three patients had to be excluded. To detect pain caused by noxious stimuli, the heart-rate-variability-derived NIPE index and behavioral pain scales designed for measuring procedural pain in nonverbal children were used. RESULTS Forty-one painful events were available for analysis. We observed in the whole group a statistically significant decrease in NIPE values at 1, 2, and 3 minutes after a painful stimulus, in comparison to the NIPE value at rest and the statistically significant differences between the minimum NIPE value within 3 minutes after the stimulus in comparison to NIPE value at rest in the whole group, as well as in the subgroups of moderate and severe pain. Receiver operating characteristic (ROC) analysis has shown the strong sensitivity and specificity of the NIPE in detecting the noxious stimuli (ROC AUC: 0.767). We also found that the stronger the sensation of pain was, the more rapidly NIPE reached its lowest value. DISCUSSION Our study indicates that the painful procedures are associated with a significant decrease in the NIPE value within 3 minutes after a noxious stimulus. Based on our observation, the minimum value within 3 minutes from the painful procedure seems to be the most distinctive value.
Collapse
Affiliation(s)
- Wojciech Walas
- Paediatric and Neonatal Intensive Care Unit, University Hospital in Opole, Opole, Poland
| | - Julita Latka-Grot
- Department of Neonatal, Children's Memorial Health Institute, Warszawa, Poland
| | - Iwona Maroszyńska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Ewelina Malinowska
- Department of Intensive Care and Congenital Malformations of Newborns and Infants, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | | | - Andrzej Piotrowski
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
| | - Monika Wrońska
- Department of Anaesthesiology and Intensive Care, Children's Memorial Health Institute, Warszawa, Poland
| | - Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznań University of Medical Sciences, Poznań, Poznań, Poland
| | - Agata Kubiaczyk
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznań University of Medical Sciences, Poznań, Poznań, Poland
| | - Michał Skrzypek
- Department of Biostatistics, School of Public Health in Bytom, Medical University of Silesia, Bytom, Poland
| | - Julien De Jonckheere
- Clinical Investigation Center-Technological Innovation (CIC-IT) 1403, University Hospital Center (UHC) Lille, Lille, France
| | - Zenon P Halaba
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| |
Collapse
|
30
|
Wang Y, Zhang L, Dong W, Zhang R. Effects of Kangaroo Mother Care on Repeated Procedural Pain and Cerebral Oxygenation in Preterm Infants. Am J Perinatol 2021; 40:867-873. [PMID: 34192768 DOI: 10.1055/s-0041-1731650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The study aimed to investigate the effects of kangaroo mother care (KMC) on repeated procedural pain and cerebral oxygenation in preterm infants. STUDY DESIGN Preterm infants of 31 to 33 weeks of gestational age were randomly divided into an intervention group (n = 36) and a control group (n = 37). Premature infant pain profile (PIPP) scores, heart rate, oxygen saturation, regional cerebral tissue oxygenation saturation (rcSO2), and cerebral fractional tissue oxygen extraction (cFTOE) were evaluated during repeated heel stick procedures. Each heel stick procedure included three phases: baseline, blood collection, and recovery. KMC was given to the intervention group 30 minutes before baseline until the end of the recovery phase. RESULTS Compared with the control group, the intervention group showed lower PIPP scores and heart rates, higher oxygen saturation, and rcSO2 from the blood collection to recovery phases during repeated heel sticks. Moreover, there were significant changes in cFTOE for the control group, but not the intervention group associated with repeated heel stick procedures. CONCLUSION The analgesic effect of KMC is sustained over repeated painful procedures in preterm infants, and it is conducive to stabilizing cerebral oxygenation, which may protect the development of brain function. KEY POINTS · KMC stabilizes cerebral oxygenation during repeated heel sticks in preterm infants.. · The analgesic effect of KMC is sustained over repeated painful procedures in preterm infants.. · KMC may protect the development of brain function..
Collapse
Affiliation(s)
- Yu Wang
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Linping Zhang
- Pediatrics Teaching and Research Section, Southwest Medical University, Luzhou, China
| | - Wenbin Dong
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Rong Zhang
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| |
Collapse
|
31
|
Kinoshita M, Stempel KS, Borges do Nascimento IJ, Bruschettini M. Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates. Cochrane Database Syst Rev 2021. [DOI: 10.1002/14651858.cd014876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Mari Kinoshita
- Fetal Medicine Research Center; University of Barcelona; Barcelona Spain
- Department of Pediatrics; Lund University; Lund Sweden
| | | | - Israel Junior Borges do Nascimento
- School of Medicine and University Hospital; Universidade Federal de Minas Gerais (UFMG); Belo Horizonte Brazil
- Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin USA
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
| |
Collapse
|
32
|
Bellù R, Romantsik O, Nava C, de Waal KA, Zanini R, Bruschettini M. Opioids for newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev 2021; 3:CD013732. [PMID: 33729556 PMCID: PMC8121090 DOI: 10.1002/14651858.cd013732.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mechanical ventilation is a potentially painful and discomforting intervention that is widely used in neonatal intensive care. Newborn infants demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes. OBJECTIVES To determine the benefits and harms of opioid analgesics for neonates (term or preterm) receiving mechanical ventilation compared to placebo or no drug, other opioids, or other analgesics or sedatives. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 9), in the Cochrane Library; MEDLINE via PubMed (1966 to 29 September 2020); Embase (1980 to 29 September 2020); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 29 September 2020). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials comparing opioids to placebo or no drug, to other opioids, or to other analgesics or sedatives in newborn infants on mechanical ventilation. We excluded cross-over trials. We included term (≥ 37 weeks' gestational age) and preterm (< 37 weeks' gestational age) newborn infants on mechanical ventilation. We included any duration of drug treatment and any dosage given continuously or as bolus; we excluded studies that gave opioids to ventilated infants for procedures. DATA COLLECTION AND ANALYSIS For each of the included trials, we independently extracted data (e.g. number of participants, birth weight, gestational age, types of opioids) using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 23 studies (enrolling 2023 infants) published between 1992 and 2019. Fifteen studies (1632 infants) compared the use of morphine or fentanyl versus placebo or no intervention. Four studies included both term and preterm infants, and one study only term infants; all other studies included only preterm infants, with five studies including only very preterm infants. We are uncertain whether opioids have an effect on the Premature Infant Pain Profile (PIPP) Scale in the first 12 hours after infusion (MD -5.74, 95% confidence interval (CI) -6.88 to -4.59; 50 participants, 2 studies) and between 12 and 48 hours after infusion (MD -0.98, 95% CI -1.35 to -0.61; 963 participants, 3 studies) because of limitations in study design, high heterogeneity (inconsistency), and imprecision of estimates (very low-certainty evidence - GRADE). The use of morphine or fentanyl probably has little or no effect in reducing duration of mechanical ventilation (MD 0.23 days, 95% CI -0.38 to 0.83; 1259 participants, 7 studies; moderate-certainty evidence because of unclear risk of bias in most studies) and neonatal mortality (RR 1.12, 95% CI 0.80 to 1.55; 1189 participants, 5 studies; moderate-certainty evidence because of imprecision of estimates). We are uncertain whether opioids have an effect on neurodevelopmental outcomes at 18 to 24 months (RR 2.00, 95% CI 0.39 to 10.29; 78 participants, 1 study; very low-certainty evidence because of serious imprecision of the estimates and indirectness). Limited data were available for the other comparisons (i.e. two studies (54 infants) on morphine versus midazolam, three (222 infants) on morphine versus fentanyl, and one each on morphine versus diamorphine (88 infants), morphine versus remifentanil (20 infants), fentanyl versus sufentanil (20 infants), and fentanyl versus remifentanil (24 infants)). For these comparisons, no meta-analysis was conducted because outcomes were reported by one study. AUTHORS' CONCLUSIONS We are uncertain whether opioids have an effect on pain and neurodevelopmental outcomes at 18 to 24 months; the use of morphine or fentanyl probably has little or no effect in reducing the duration of mechanical ventilation and neonatal mortality. Data on the other comparisons planned in this review (opioids versus analgesics; opioids versus other opioids) are extremely limited and do not allow any conclusions. In the absence of firm evidence to support a routine policy, opioids should be used selectively - based on clinical judgement and evaluation of pain indicators - although pain measurement in newborns has limitations.
Collapse
Affiliation(s)
- Roberto Bellù
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Koert A de Waal
- Neonatology, John Hunter Children's Hospital, New Lambton, Australia
| | - Rinaldo Zanini
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
33
|
McPherson C, Ortinau CM, Vesoulis Z. Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
Collapse
Affiliation(s)
- Christopher McPherson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, MO, USA.
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Zachary Vesoulis
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
34
|
O'Connor TL. Premedication for Nonemergent Intubation in the NICU: A Call for Standardized Practice. Neonatal Netw 2021; 40:8-13. [PMID: 33479006 DOI: 10.1891/0730-0832/11-t-668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 11/25/2022]
Abstract
This paper discusses neonatal endotracheal intubation and the need for standardization in practice regarding the use of premedication. Intubation is common in the NICU because of resuscitation, surfactant administration, congenital anomalies, apnea, and sedation for procedures or surgery. Intubation is both painful and stressful. Unmedicated intubation is associated with several adverse outcomes including repeat and prolonged attempts, airway trauma, bradycardia, severe desaturation, and need for resuscitation. Most providers believe intubation is painful and that premedication should be provided; however, there is still resistance to provide premedication and inconsistency in doing so. Reasons for not providing premedication include concerns about medication side effects such as chest wall rigidity or prolonged respiratory depression inhibiting immediate extubation after surfactant administration. Premedication should include an opioid analgesic for pain, a benzodiazepine for an adjuvant sedation, a vagolytic to decrease bradycardia, and the optional use of a muscle relaxant for paralysis.
Collapse
|
35
|
Lammertink F, Vinkers CH, Tataranno ML, Benders MJNL. Premature Birth and Developmental Programming: Mechanisms of Resilience and Vulnerability. Front Psychiatry 2021; 11:531571. [PMID: 33488409 PMCID: PMC7820177 DOI: 10.3389/fpsyt.2020.531571] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 12/01/2020] [Indexed: 12/14/2022] Open
Abstract
The third trimester of pregnancy represents a sensitive phase for infant brain plasticity when a series of fast-developing cellular events (synaptogenesis, neuronal migration, and myelination) regulates the development of neural circuits. Throughout this dynamic period of growth and development, the human brain is susceptible to stress. Preterm infants are born with an immature brain and are, while admitted to the neonatal intensive care unit, precociously exposed to stressful procedures. Postnatal stress may contribute to altered programming of the brain, including key systems such as the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. These neurobiological systems are promising markers for the etiology of several affective and social psychopathologies. As preterm birth interferes with early development of stress-regulatory systems, early interventions might strengthen resilience factors and might help reduce the detrimental effects of chronic stress exposure. Here we will review the impact of stress following premature birth on the programming of neurobiological systems and discuss possible stress-related neural circuits and pathways involved in resilience and vulnerability. Finally, we discuss opportunities for early intervention and future studies.
Collapse
Affiliation(s)
- Femke Lammertink
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Christiaan H. Vinkers
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Anatomy & Neurosciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Maria L. Tataranno
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Manon J. N. L. Benders
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| |
Collapse
|
36
|
Abushanab D, Abounahia FF, Alsoukhni O, Abdelaal M, Al-Badriyeh D. Clinical and Economic Evaluation of the Impact of Midazolam on Morphine Therapy for Pain Relief in Critically Ill Ventilated Infants with Respiratory Distress Syndrome. Paediatr Drugs 2021; 23:143-157. [PMID: 33354750 PMCID: PMC7755454 DOI: 10.1007/s40272-020-00432-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND The impact of midazolam on the overall performance of morphine therapy for pain in ventilated neonates with respiratory distress syndrome (RDS) has never been investigated. OBJECTIVE This study is a clinical and economic analysis of morphine monotherapy versus morphine plus midazolam in ventilated infants with RDS. METHODS A decision-analytic model from the hospital perspective was developed to follow the consequences of the use of the study drugs. Clinical and resource utilization data were extracted based on a retrospective cohort study of 104 neonates with RDS receiving morphine alone versus in combination with midazolam at the main neonatal intensive care unit (NICU) in Qatar, from 2014 to 2019. Primary outcome measures were the analgesia success rate, via the Premature Infant Pain Profile scale, and overall costs of therapies. Multivariate statistical analyses confirmed no significant variations in baseline characteristics between study groups. RESULTS With 0.05 significance and 80% power, morphine had a higher rate of successful analgesia (65.4 vs. 34.6%; risk ratio 1.91; 95% confidence interval 1.11-3.28; p = 0.019). Overall costs were also in favor of morphine compared with its combination with midazolam, with cost savings of 40,959 Qatari Riyal ($US11,222), year 2019/20 values. The Monte Carlo analyses confirmed the economic advantage of morphine alone in 100% of cases and demonstrated that it is not sensitive to uncertainties in study model inputs. CONCLUSIONS Morphine monotherapy enabled enhanced pain relief over its combination with midazolam in the NICU, at a reduced overall cost. Morphine alone, therefore, seems to be a dominant analgesia strategy.
Collapse
Affiliation(s)
- Dina Abushanab
- grid.413548.f0000 0004 0571 546XDrug Information Department, Hamad Medical Corporation, Doha, Qatar
| | - Fouad F. Abounahia
- grid.413548.f0000 0004 0571 546XNeonatal Intensive Care Unit Department, Hamad Medical Corporation, Doha, Qatar
| | - Omar Alsoukhni
- Pharmacy Department, Al Jalila Children’s Specialty Hospital, Dubai, United Arab Emirates
| | - Mohammed Abdelaal
- grid.498619.bPharmacy and Drug Control, Ministry of Public Health, Doha, Qatar
| | | |
Collapse
|
37
|
Barbour T, O'Keefe S, Mace SE. Topical Refrigerant Spray for IVs: Patient/Provider Responses - Prospective, Double-blind, Randomized Study. West J Nurs Res 2020; 43:762-769. [PMID: 33292081 DOI: 10.1177/0193945920976061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Painful procedures are common. Patients prefer analgesia for painful procedures. Studies indicate that use of a topical refrigerant spray (TRS) prior to needlestick procedures decreases needlestick pain. TRS is easy to apply, inexpensive, has fast onset, and avoids needlestick pain and anxiety, and needlestick injury risk. Patient and health care provider (HCP) acceptance of any technique is essential before it is adopted. This study evaluated the decrease in pain with TRS and the patient and HCP satisfaction and acceptance of TRS for peripheral intravenous (PIV) placement. Adults (N = 300) randomized to placebo or TRS and HCPs (N = 300) placing PIVs answered questionnaires. Patients had significantly less pain than with prior PIVs, and were satisfied with and would use TRS in the future (P < 0.001). HCP felt that patients had significantly (P < 0.001) less pain with TRS than the placebo, and were satisfied with the TRS, and would use TRS in the future.Registered at Clinicaltrials.gov NCT01670487.
Collapse
Affiliation(s)
- Tracy Barbour
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sharon O'Keefe
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sharon E Mace
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.,MetroHealth Medical Center/Cleveland Clinic Emergency Residency, Cleveland, OH, USA
| |
Collapse
|
38
|
Castillo Barrio B, Rasines Rodríguez A, Aneiros Suanzes C, Royuela Vicente A, Ortiz Movilla R, Marín Gabriel MA. A survey of procedural pain assessment and non-pharmacologic analgesic interventions in neonates in Spanish public maternity units. J Perinatol 2020; 40:1764-1769. [PMID: 32873906 DOI: 10.1038/s41372-020-00800-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/27/2020] [Accepted: 08/25/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To qualify and quantify clinical practices related to pain assessment and non-pharmacologic analgesia (NPA) in newborns in Spanish public maternity hospitals STUDY DESIGN: We surveyed providers online regarding their use of pain assessment scales, NPA interventions in neonates undergoing procedures, as well parents' presence or absence during interventions. RESULTS The number of painful procedures and the subjective grading of pain from the responding physicians were similar in all hospitals. Only 12.5% of hospitals used pain scales. No NPA was employed in 37.7% of procedures, with less NPA used in the lower complexity hospitals for venous extraction (p < 0.001) and gastric lavage (p = 0.001). Respondents reported parents' absence during 56.1% of procedures. CONCLUSIONS Available pain assessment scales and NPA interventions to mitigate pain are being underused. The presence of the parents during painful interventions is low despite the evidence that this may help to reduce newborns' perception of pain.
Collapse
Affiliation(s)
| | | | | | - Ana Royuela Vicente
- Clinical Biostatistics Unit, Puerta de Hierro Majadahonda University Hospital, Instituto de Investigación Puerta de Hierro (IDIPHIM), Madrid, Spain
| | - Roberto Ortiz Movilla
- Department of Pediatrics, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Miguel A Marín Gabriel
- Department of Pediatrics, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain. .,Department of Pediatrics, Autónoma University, Madrid, Spain.
| |
Collapse
|
39
|
Procaccini D, Lobner K, Azamfirei R, Kudchadkar SR. Melatonin for anaesthetic indications in paediatric patients: a systematic review. Anaesthesia 2020; 76:837-849. [PMID: 32935858 DOI: 10.1111/anae.15249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 02/06/2023]
Abstract
The favourable safety profile and ubiquitous nature of melatonin has led to an increase in its use in various clinical settings in adults and children. We performed a systematic review of published studies on the use of melatonin for anaesthetic indications in paediatric patients. To identify relevant articles, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Scopus databases were searched. Study title and abstract screening, and full text review were performed by two reviewers. Twenty-seven eligible studies investigating melatonin use for anaesthetic indications were identified. Due to significant heterogeneity in study methodology, a quantitative synthesis of the published findings was not possible. The identified studies were therefore categorised by the indication for melatonin: analgesia, diagnostic sedation and as an anaesthetic adjunct. Melatonin use for anaesthetic-related indications is safe; may provide analgesia for inflammatory-associated pain in neonates and children before venepuncture; may decrease the need for, or replace, general anaesthesia for diagnostic procedures; and may serve as an anaesthesia adjunct before induction in paediatric patients.
Collapse
Affiliation(s)
- D Procaccini
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Lobner
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Azamfirei
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S R Kudchadkar
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, Pediatrics, and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
40
|
Kinoshita M, Stempel K, do Nascimento IJB, Vejayaram DN, Norman E, Bruschettini M. Opioids and alpha-2-agonists for analgesia and sedation in newborn infants: protocol of a systematic review. Syst Rev 2020; 9:183. [PMID: 32819417 PMCID: PMC7441710 DOI: 10.1186/s13643-020-01436-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hospitalized newborn infants may require analgesia and sedation either for the management of procedural pain, during or after surgery, and other painful conditions. The benefits and harms of opioids administered at different doses and routes of administration have been reported in numerous trials and systematic reviews. The use of alpha-2-agonists such as clonidine and dexmedetomidine in newborn infants is more recent, and they might be prescribed to reduce the total amount of opioids which are thought to have more side effects. Moreover, alpha-2-agonists might play an important role in the management of agitation and discomfort. METHODS We will conduct a systematic review and meta-analysis on the use of opioids, alpha-2-agonists, or the combination of both drugs. We will include randomized controlled trials to assess benefits and harms and observational studies to assess adverse events and pharmacokinetics; preterm and term infants; studies on any opioids or alpha-2-agonists administered for any indication and by any route except spinal, intraosseous, or administration for nerve blocks and wound infusions. The use of opioids or alpha-2-agonists will be compared to no intervention; placebo with normal saline or other non-sedative, non-analgesic drug; control with oral sugar solution or non-pharmacological intervention; same drug of different dose or route; or a different drug (not limiting to opioids and alpha-2-agonists) or combinations of such drugs. The primary outcomes for this review will be all-cause mortality during initial hospitalization and hypotension requiring medical therapy. We will conduct a search in the following databases: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, Embase, and CINAHL. Two review authors will independently screen records for inclusion, undertake data abstraction using a data extraction form and assess the risk of bias of all included trials using the Cochrane "Risk of bias" tool. DISCUSSION This systematic review will summarize and update our knowledge about neonatal analgesia and sedation including pharmacokinetics/pharmacodynamics, and provide a platform for developing evidence-based guidelines that we can immediately apply to our clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2020 CRD42020170852.
Collapse
Affiliation(s)
- Mari Kinoshita
- Faculty of Medicine, Lund University, Lund, Sweden
- Keio University School of Medicine, Tokyo, Japan
| | | | - Israel Junior Borges do Nascimento
- School of Medicine at Universidade Federal de Minas Gerais, Minas Gerais Belo Horizonte, Brazil
- Medical College of Wisconsin, Milwaukee, WI USA
| | | | - Elisabeth Norman
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden
| | | |
Collapse
|
41
|
Al-Mouqdad MM, Khalil TM, Asfour SS. Retrospective study of short-term complications associated with early morphine use in intubated premature infants. Sci Rep 2020; 10:10874. [PMID: 32616894 PMCID: PMC7331726 DOI: 10.1038/s41598-020-67891-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/10/2020] [Indexed: 11/15/2022] Open
Abstract
Relieving neonatal pain is essential for the management of premature infants. Morphine is the most frequently used analgesic in neonatal intensive care. Here we report the relationship between early morphine infusion and the composite outcome of intraventricular hemorrhage and/or death in intubated premature infants. Infants (gestational age ≤ 32 weeks and birth weight < 1,500 g) intubated on admission were retrospectively evaluated in a large tertiary neonatal intensive care unit. Modified log-Poisson regression with robust variance estimator and Cox regression was applied to adjust the relative risk for infants’ outcomes. Of 420 premature infants, 230 (54.7%) received continuous morphine infusion in the first 72 h. Of these, 153 were < 28 gestational weeks; of the 190 patients who did not receive morphine, 63 were < 28 gestational weeks. The analysis revealed that infants < 28 gestational weeks who received morphine were significantly associated with an increased risk for IVH and/or death [adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.1–1.71)], and mortality (aRR 1.83, 95% CI 1.17–2.89). Moreover, in infants < 28 gestational weeks, survival was low in those infants who were exposed to morphine infusion in the first 72 h (hazard ratio 2.11; 95% CI 1.19–3.73). Early morphine infusion is associated with an increased risk for IVH and/or death; however, further studies are required to verify our findings.
Collapse
Affiliation(s)
- Mountasser M Al-Mouqdad
- Neonatal Intensive Care, NICU Department, Hospital of Paediatrics, King Saud Medical City, Al Imam Abdul Aziz Ibn Muhammad Ibn Saud, Riyadh, 12746, Saudi Arabia.
| | - Thanaa M Khalil
- Obstetric and Gynecology Department, Maternity Hospital, King Saud Medical City, Riyadh, Saudi Arabia
| | - Suzan S Asfour
- Clinical Pharmacy Department, Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
42
|
Lien R. Neurocritical care of premature infants. Biomed J 2020; 43:259-267. [PMID: 32333994 PMCID: PMC7424083 DOI: 10.1016/j.bj.2020.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/17/2022] Open
Abstract
Neurocritical care is an approach of comprehensive care through multidisciplinary coordination and implementation of neuroprotective strategies to reduce the risk of neurologic injury among critically ill patients. Premature infants are at a special risk of sustaining brain injury and having adverse neurodevelopmental outcome. The pathogenesis of "encephalopathy of prematurity" is tightly linked to hemodynamic instability during postnatal transition, immaturity of the cerebral vascular bed and nervous system, and the commonly encountered inflammation in an intensive care setting. Clinical assessment aided by renewed monitoring techniques, together with therapies supported by best available evidence may provide opportunities to salvage these vulnerable brains. Indeed, to promote optimal brain development and to ensure neurodevelopmental intact survival is of imperial priority in the modern care of preterm infants.
Collapse
Affiliation(s)
- Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
43
|
Johnson Rolfes J, Christensen K, Gershan LA. Acceptance of Traditional Chinese Medicine in the Neonatal Intensive Care Unit: A Launching Point. Glob Adv Health Med 2020; 9:2164956120924644. [PMID: 32426181 PMCID: PMC7218323 DOI: 10.1177/2164956120924644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/06/2020] [Accepted: 04/07/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Because neonatology is a relatively new medical specialty, it is host to on-going, rapid adaptation and evolution of medical treatments and practices. This process has almost exclusively focused on Western, biomedical treatment modalities, without inclusion of potentially beneficial Traditional Chinese Medicine practices. It is unclear how receptive health-care providers in the neonatal intensive care unit (NICU) and families of NICU patients would be to the introduction of adapted Traditional Chinese Medicine treatments into the NICU environment. OBJECTIVE To assess the potential for engagement of patients, families, and staff in the NICU with Traditional Chinese Medicine therapies and to provide targeted education and low-risk Traditional Chinese Medicine treatments to support the health and well-being of those 3 groups. METHODS A feasibility pilot study including weekly walk-in Traditional Chinese Medicine sessions within the NICU for parents and staff, and neonatal patient consultations, both of which included hands-on therapies and education tailored to each participant's unique needs. Pre- and postsurveys were administered over 3 phases. RESULTS Walk-in sessions were attended by 83 adults and participants reported benefits, with no ill effects. There were 5 neonatal consultations with staff expressing an interest in more. Several obstacles to accessing Traditional Chinese Medicine modalities were identified in pre-surveys and were addressed with education and preemptive modifications to the therapies offered. CONCLUSION Acceptance of Traditional Chinese Medicine modalities in the NICU opens the door to future studies implementing integrative health services into the NICU care model.
Collapse
Affiliation(s)
- Julie Johnson Rolfes
- Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Kimberly Christensen
- Division of Hematology-Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
- Pediatric Integrative Health and Wellbeing, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Lynn A Gershan
- Division of Hematology-Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
- Pediatric Integrative Health and Wellbeing, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| |
Collapse
|
44
|
Alburaey AM, Al-Qurashi FO, Aljohar AY, Almubayedh KA, Ahmed NA, Alabdullatif HA, Alowayshiq HM. Pain Assessment and Management in Neonatal Intensive Care Units in the Eastern Province of Saudi Arabia: A Survey of Doctors and Nurses. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:140-145. [PMID: 32587496 PMCID: PMC7305675 DOI: 10.4103/sjmms.sjmms_7_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 11/25/2019] [Accepted: 03/02/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite its importance, no study from the Middle East has assessed the neonatal pain knowledge of health-care providers in neonatal intensive care units (NICUs). OBJECTIVES To evaluate the knowledge and attitudes of pediatricians and nurses in Saudi Arabia toward procedural pain assessment and its management in neonates. MATERIALS AND METHODS This questionnaire-based, cross-sectional study was conducted between March and June 2015 at three NICUs in the Eastern Province of Saudi Arabia, namely, King Fahd Hospital of the University, Al Khobar; Security Forces Hospital, Dammam; and King Fahd Medical Military Complex, Dhahran. All pediatricians/neonatologists and nurses in these units were included, and a previously validated questionnaire was distributed and collected by an assigned clinician. The questionnaire elicited pain-related knowledge of seven procedures using a 10-point Likert scale. RESULTS A total of 150 questionnaires were distributed, from which 107 complete responses were obtained (nurses: 81 [75.7%]; doctors: 26 [24.3%]). The overall knowledge scores were high (mean ± standard deviation = 77.3% ±11.6%). The mean pain rankings of doctors (7.2) were higher than those of nurses (6.5) for all procedures. Nurses reported more frequent use of analgesia than doctors (15.4% vs. 11.5%). Doctors often did not use comfort measures for any procedures, except during procedures on term to 28-day-old neonates. The use of pain tools was reported by only 12 (11%) clinicians. CONCLUSION This study found that despite adequate knowledge about pain perception by neonates, the use of analgesia for procedural pain relief is low among doctors in the NICUs of the Eastern Province of Saudi Arabia. In addition, there is underutilization of pain assessment tools, thereby indicating the need to address this knowledge-practice gap.
Collapse
Affiliation(s)
- Abdullah Mohammed Alburaey
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Faisal Othman Al-Qurashi
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Aeshah Yousef Aljohar
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Kawther Ahmed Almubayedh
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nadia Abdullah Ahmed
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Hamad Mohammed Alowayshiq
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
45
|
Howard C, Powell AS, Pavlidis E, Pavel A, Finn D, Allen A, Olavarria‐Ramirez L, Clarke G, Livingstone V, Boylan GB, Dempsey EM. No effect of a musical intervention on stress response to venepuncture in a neonatal population. Acta Paediatr 2020; 109:511-517. [PMID: 31532835 DOI: 10.1111/apa.15018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/04/2019] [Accepted: 09/16/2019] [Indexed: 11/29/2022]
Abstract
AIM To investigate the effect of a musical intervention on neonatal stress response to venepuncture as measured by salivary cortisol levels and pain profile scores. METHODS In a randomised control crossover trial, participants were randomised to both a control arm (sucrose) and intervention arm (sucrose and music) for routine venepuncture procedures. Salivary swabs were collected at baseline, 20 minutes post-venepuncture and 4 hours post-venepuncture. Pain levels were assessed using the Premature Infant Pain Profile (PIPP). A total of 16 preterm neonates participated in both arms to complete the study. RESULTS Cortisol values were elevated at all timepoints in the intervention arm (baseline, 20 minutes, and 4 hours post-procedure) but not significantly so (P = .056, P = .3, and P = .575, respectively). Median change in cortisol values from baseline was +128.48 pg/mL (-47.66 to 517.02) at 20 minutes and +393.52 pg/mL (47.88-1221.34) at 4 hours post-procedure in the control arm compared to -69.564 pg/mL (-860.96 to 397.289) and +100.48 pg/mL (-560.46 to 842.99) at 20 minutes and 4 hours post-procedure in the intervention arm. There was no statistically significant difference observed between groups (P = .311 at 20 minutes, and P = .203 at 4 hours post-procedure). PIPP scores were not significantly different between study arms. CONCLUSION Our findings did not support the additional benefit of music intervention on neonatal stress response to venepuncture in preterm infants.
Collapse
Affiliation(s)
- Caoimhe Howard
- Department of Paediatrics and Child Health Neonatal Intensive Care Unit Cork University Maternity Hospital Cork Ireland
| | - Anna S. Powell
- Department of Paediatrics and Child Health Neonatal Intensive Care Unit Cork University Maternity Hospital Cork Ireland
| | - Elena Pavlidis
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
| | - Andreea Pavel
- Department of Paediatrics and Child Health Neonatal Intensive Care Unit Cork University Maternity Hospital Cork Ireland
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
| | - Daragh Finn
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
| | - Andrew Allen
- APC Microbiome Ireland Biosciences Institute University College Cork Cork Ireland
| | | | - Gerard Clarke
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
- APC Microbiome Ireland Biosciences Institute University College Cork Cork Ireland
- Department of Psychiatry and Neurobehavioural Science University College Cork Cork Ireland
| | - Vicki Livingstone
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
| | - Geraldine B. Boylan
- Department of Paediatrics and Child Health Neonatal Intensive Care Unit Cork University Maternity Hospital Cork Ireland
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
| | - Eugene M. Dempsey
- Department of Paediatrics and Child Health Neonatal Intensive Care Unit Cork University Maternity Hospital Cork Ireland
- INFANT Irish Centre for Fetal and Neonatal Translational Research University College Cork Cork Ireland
| |
Collapse
|
46
|
Williams MD, Lascelles BDX. Early Neonatal Pain-A Review of Clinical and Experimental Implications on Painful Conditions Later in Life. Front Pediatr 2020; 8:30. [PMID: 32117835 PMCID: PMC7020755 DOI: 10.3389/fped.2020.00030] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/20/2020] [Indexed: 12/13/2022] Open
Abstract
Modern health care has brought our society innumerable benefits but has also introduced the experience of pain very early in life. For example, it is now routine care for newborns to receive various injections or have blood drawn within 24 h of life. For infants who are sick or premature, the pain experiences inherent in the required medical care are frequent and often severe, with neonates requiring intensive care admission encountering approximately fourteen painful procedures daily in the hospital. Given that much of the world has seen a steady increase in preterm births for the last several decades, an ever-growing number of babies experience multiple painful events before even leaving the hospital. These noxious events occur during a critical period of neurodevelopment when the nervous system is very vulnerable due to immaturity and neuroplasticity. Here, we provide a narrative review of the literature pertaining to the idea that early life pain has significant long-term effects on neurosensory, cognition, behavior, pain processing, and health outcomes that persist into childhood and even adulthood. We refer to clinical and pre-clinical studies investigating how early life pain impacts acute pain later in life, focusing on animal model correlates that have been used to better understand this relationship. Current knowledge around the proposed underlying mechanisms responsible for the long-lasting consequences of neonatal pain, its neurobiological and behavioral effects, and its influence on later pain states are discussed. We conclude by highlighting that another important consequence of early life pain may be the impact it has on later chronic pain states-an area of research that has received little attention.
Collapse
Affiliation(s)
- Morika D. Williams
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Translational Research in Pain Program, North Carolina State University, Raleigh, NC, United States
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
| | - B. Duncan X. Lascelles
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Translational Research in Pain Program, North Carolina State University, Raleigh, NC, United States
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for Translational Pain Medicine, Duke University, Durham, NC, United States
| |
Collapse
|
47
|
Abstract
Purpose of review: Despite advances in technology and treatment options, over 15,000 neonates die each year in the United States. The majority of the deaths, with some estimates as high as 80%, are the result of a planned redirection of care or comfort measures only approach to care. When curative or life-prolonging interventions are not available or have been exhausted, parents focus on preserving quality of life and eliminating needless suffering. Parents hope their child will have a peaceful death and will not feel pain. A significant component of end-of-life care is high quality symptom evaluation and management. It is important that neonatal providers are knowledgeable in symptom management to address common sources of suffering and distress for babies and their families at the end-of-life (EOL). Recent findings: Medically complex neonates with life-threatening conditions are a unique patient population and there is little research on end-of-life symptom assessment and management. While there are tools available to assess symptoms for adolescents and adults, there is not a recognized set of tools for the neonatal population. Nonetheless, it is widely accepted that neonates experience significant symptoms at end-of-life. Most commonly acknowledged manifestations are pain, dyspnea, agitation, and secretions. In the absence of data and established guidelines, there is variability in their clinical management. This contributes to provider discomfort and inadequate symptom control. Summary: End-of-life symptom assessment and management is an important component of neonatal end-of-life care. While there remains a paucity of studies and data, it is prudent that providers adequately manage symptoms. Likewise, it is important that providers are educated so that they can effectively guide families through the dying process by discussing disease progression, physical changes, and providing empathetic support. In this review, the authors make recommendations for non-pharmacological and pharmacological management of end-of-life symptoms in neonates.
Collapse
Affiliation(s)
- DonnaMaria E Cortezzo
- Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Mark Meyer
- Division of Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| |
Collapse
|
48
|
McPherson C, Miller SP, El-Dib M, Massaro AN, Inder TE. The influence of pain, agitation, and their management on the immature brain. Pediatr Res 2020; 88:168-175. [PMID: 31896130 PMCID: PMC7223850 DOI: 10.1038/s41390-019-0744-6] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/11/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct.
Collapse
Affiliation(s)
- Christopher McPherson
- 0000 0000 9953 7617grid.416775.6Department of Pharmacy, St. Louis Children’s Hospital, St. Louis, MO USA ,0000 0001 2355 7002grid.4367.6Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA
| | - Steven P. Miller
- 0000 0004 0473 9646grid.42327.30Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON Canada
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - An N. Massaro
- 0000 0004 1936 9510grid.253615.6Department of Pediatrics—Neonatology Division, The George Washington University School of Medicine and Children’s National Health System, Washington, DC USA
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| |
Collapse
|
49
|
Gu D, Deng S, Zheng Q, Liang C, Wu J. Impacts of case-based health knowledge system in hospital management: The mediating role of group effectiveness. INFORMATION & MANAGEMENT 2019. [DOI: 10.1016/j.im.2019.04.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Alpay A, Canturk Ugurbas S, Aydemir C. Efficiency and safety of phenylephrine and tropicamide used in premature retinopathy: a prospective observational study. BMC Pediatr 2019; 19:415. [PMID: 31690284 PMCID: PMC6833165 DOI: 10.1186/s12887-019-1757-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background To determine effects and side effects of topical application of phenylephrine 2.5% and tropicamide 0.5% combination in preterm infants. Methods In this prospective observational study, 60 infants undergoing retinopathy of prematurity (ROP) screening were prospectively observed. Pupillary diameter, blood pressure, heart rate, and oxygen saturation were monitored before and after up to 24 h during ROP screening examinations. Results The mean pupillary diameter 1 h after the instillation of drops was 5.58 ± 0.75 mm for both eyes. The mean systolic and diastolic pressure and oxygen saturation of infants did not change statistically until the end of the study. The average heart rate decreased by a mean of 4.96 beats/minute from the baseline following eye drops instillation. General condition deterioration, fall in oxygen saturation and bradycardia were observed in 4 infants that already had respiratory distress syndrome. Conclusion The phenylephrine 2.5% plus tropicamide 0.5% drop is effective and safe as mydriatic combination for retinopathy of prematurity screening. In infants with an additional systemic disease such as respiratory distress syndrome, the side effects of mydriatic drops may be more common. Such babies should be kept under close observation. Trial registration The trial was retrospectively registered on 28 February 2018. The ClinicalTrials.gov Identifier is NCT03448640.
Collapse
Affiliation(s)
- Atilla Alpay
- Department of Ophthalmology, Zonguldak Bülent Ecevit University, the School of Medicine, 67600, Zonguldak, Kozlu, Turkey.
| | - Sılay Canturk Ugurbas
- Department of Ophthalmology, Zonguldak Bülent Ecevit University, the School of Medicine, 67600, Zonguldak, Kozlu, Turkey
| | - Cumhur Aydemir
- Department of Pediatrics, Division of Neonatology, Zonguldak Bülent Ecevit University, the School of Medicine, Zonguldak, 67600, Kozlu, Turkey
| |
Collapse
|