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Mohamed SHM, Reissland N, Anand KJS. An Evidence-Based Discussion of Fetal Pain and Stress. Neonatology 2024:1-7. [PMID: 38781940 DOI: 10.1159/000538848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/10/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The concept of fetal pain results from procedures conducted without anesthesia in preterm newborns and fetuses, which indicate that it is possible to examine fetal pain based on stress hormone, metabolic, and behavioral changes. Anatomical and physiological data suggest that fetuses become capable of processing nociceptive stimuli around midgestation, although the associated changes in fetal brain development remain unclear. What constitutes fetal pain remains controversial in the light of the definition of pain adopted by the International Association for the Study of Pain (IASP), which posits pain as an "unpleasant sensory and emotional experience." SUMMARY Here, we examine the notion that human fetuses cannot "experience" pain and potential implications of this claim. We highlight the key scientific evidence related to fetal pain, including clinical studies on pain in fetuses and preterm newborns. We argue that consistent patterns of stress hormones, metabolic changes, body movements, hemodynamic changes, and pain-related facial expressions in fetuses exposed to invasive procedures overcome the need for subjective proof of pain as articulated in the IASP definition. No study to date has conclusively proven the absence of fetal pain beyond the age of viability. KEY MESSAGES Based on the current evidence, we propose that all fetuses receive anesthesia regardless of the invasive procedures being performed to guarantee the least possible pain and physiological, behavioral, or hormonal responses without exposing the mother or her baby to unnecessary complications.
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Affiliation(s)
- Samirah H M Mohamed
- Obstetric Clinic at the Clinics Hospital of the Medical School, The University of São Paulo, São Paulo, Brazil
- Research Department of the Hospital e Maternidade Vitória, São Paulo, Brazil
- Medical Tutor at the University Center of the Faculty of the Americas, São Paulo, Brazil
| | | | - Kanwaljeet J S Anand
- Departments of Pediatrics, Perioperative, and Pain Medicine, Stanford Child Wellness Lab, Maternal & Child Health Research Institute, Stanford University School of Medicine, Stanford, California, USA
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Mencía S, Alonso C, Pallás-Alonso C, López-Herce J. Evaluation and Treatment of Pain in Fetuses, Neonates and Children. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1688. [PMID: 36360416 PMCID: PMC9689143 DOI: 10.3390/children9111688] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 08/03/2023]
Abstract
The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.
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Affiliation(s)
- Santiago Mencía
- Pediatric Intensive Care Service, Gregorio Marañón General University Hospital, Health Research Institute of Gregorio Marañón Madrid, 28029 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
| | - Clara Alonso
- Carlos III Institute, 28029 Madrid, Spain
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Carmen Pallás-Alonso
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Service, Gregorio Marañón General University Hospital, Health Research Institute of Gregorio Marañón Madrid, 28029 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
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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: 39] [Impact Index Per Article: 13.0] [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.
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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
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Knowledge and Practices in Neonatal Pain Management of Nurses Employed in Hospitals with Different Levels of Referral-Multicenter Study. Healthcare (Basel) 2021; 9:healthcare9010048. [PMID: 33466529 PMCID: PMC7824971 DOI: 10.3390/healthcare9010048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
Background: One of the key elements of patient care is the relief and prevention of pain sensations. The importance of pain prevention and treatment has been emphasized by many international organizations. Despite the recommendations and guidelines based on evidence, contemporary research shows that the problem of pain among patients in neonatal intensive care units (NICUs) in various centers is still an important and neglected problem. Aim: The aim of this study was to assess the level of knowledge of the medical personnel and their perception of the issue of pain in neonatal patients. Methods: A quantitative descriptive study carried out in 2019. The study used a nurses’ perceptions of neonatal pain questionnaire. Results: A total of 43 Polish hospitals and 558 respondents participated in the project. 60.9% (n = 340) and 39.1% (n = 218) of respondents were employed in secondary and tertiary referral departments, respectively. Conclusion: Our analyses indicate that despite the availability of pain assessment tools for neonatal patients, only a few centers use standardized tools. The introduction of strategies to promote and extend the personnel’s awareness of neonatal pain monitoring scales is necessary.
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Vitale E, De Angelis LR. Breastfeeding as an analgesic method during vaccinations. ACTA ACUST UNITED AC 2020; 72:229-235. [PMID: 32403917 DOI: 10.23736/s0026-4784.20.04569-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Infants undergo painful stings such as intradermal and intramuscular stings during vaccination. Clinical trial have showed analgesic methods to reduce the painful in both infants and kids. EVIDENCE ACQUISITION There are different types of non-pharmacological interventions which have an analgesic effect in infants during vaccinations such as: breastfeeding, cladding the infants, the skin to skin contact, the use of sweetened substance. EVIDENCE SYNTHESIS A review of the primary and secondary literature was carried out in the database Medline(PubMed). The bibliographic research was focused on the critical reading of the studies of the last ten years. Eight articles, including seven randomized clinical trials and one systematic review have been found. All registered studies report a reduction of the average value of the pain measured through both validated rating scales and through the measurement of the average duration of the cry during and after the vaccination in breastfeed infants. However it hasn't been demonstrated a statistically significant improvement in physiological parameters. CONCLUSIONS It is desirable that the literature produce further studies related to the changes of the vital parameters during the breastfeeding which allow a clear comparison between clinical trials.
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Affiliation(s)
- Elsa Vitale
- Mental Health Center in Modugno, Local Health Company, Bari, Italy - .,Vascular Surgery Ward, Di Venere Hospital, Local Health Company, Bari, Italy -
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Alemdar DK, Tüfekci FG. Effects of smelling amniotic fluid on preterm infant's pain and stress during peripheral cannulation: A randomized controlled trial. Jpn J Nurs Sci 2020; 17:e12317. [PMID: 31957252 DOI: 10.1111/jjns.12317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/27/2019] [Accepted: 12/10/2019] [Indexed: 11/30/2022]
Abstract
AIM To investigate the effect of smelling amniotic fluid on preterm infants' pain and stress caused by peripheral cannulation. METHODS This was a randomized controlled trial. The study sample consisted of 80 preterm infants meeting the case selection criteria and infants were randomly assigned to each group. However, in addition to the infants excluded from the study, total number of the infants in all the groups was 61. Infants in the amniotic fluid group smelled amniotic fluid for 15 min before, during, and after the application of peripheral cannulation while those in the control group received routine care during the procedure. The Premature Infant Pain Profile was used to assess their pain levels, and salivary cortisol analysis was performed to evaluate stress levels. RESULTS Preterm infants in the amniotic fluid and control groups had similar baseline characteristics. However, the pain levels of infants in the amniotic fluid group were significantly lower than of those in the control group during and after the procedure. After the procedure, cortisol levels of the infants in the amniotic fluid group were lower than of those in the control group, although this difference was not significant. CONCLUSION The intervention of smelling amniotic fluid is a practice that can be used for reducing pain and stress of preterm infants during peripheral cannulation.
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Affiliation(s)
- Dilek Küçük Alemdar
- Nursing Department, Faculty of Health Sciences, Ordu University, Ordu, Turkey
| | - Fatma Güdücü Tüfekci
- Pediatric Nursing Department, Nursing Faculty, Ataturk University, Erzurum, Turkey
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The Indonesian version of the Premature Infant Pain Profile-Revised: Translation and adaptation of a neonatal pain assessment. Int J Nurs Sci 2019; 6:439-444. [PMID: 31728398 PMCID: PMC6838999 DOI: 10.1016/j.ijnss.2019.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/12/2019] [Accepted: 06/26/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose Pain assessment is a key component of good pain management in hospitalized infants. This study aimed to translate and adapt a version of pain measurement in infants, the Premature Infant Pain Profile Revised (PIPP-R) into Indonesian. Method The adaptation process of the measuring instrument used a modified Brislin method which included forward translation, back translation 1, group discussion 1, back translation 2, group discussion 2, and pilot testing on neonatal nurses: feasibility test, inter-rater reliability using intraclass correlation (ICC), and internal consistency using Cronbach's α coefficient. Results The PIPP-R version in English has been translated into Indonesian. In general, nurses assessed this measuring instrument as feasible. The inter-rater reliability showed a high agreement (ICC = 0.968, P = 0.001) and this measuring instrument had good internal consistency (Cronbach's α = 0.856). Conclusion The Indonesian version of PIPP-R is easy to use and shows good psychometric properties. The use of this measuring instrument will help nurses and researchers obtain accurate infant pain intensity measurement values.
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Squillaro A, Mahdi EM, Tran N, Lakshmanan A, Kim E, Kelley-Quon LI. Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach. Clin Ther 2019; 41:1701-1713. [PMID: 31431300 PMCID: PMC6790974 DOI: 10.1016/j.clinthera.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain. FINDINGS After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking. IMPLICATIONS The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.
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Affiliation(s)
- Anthony Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Nhu Tran
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Hasenstab KA, Nawaz S, Lang IM, Shaker R, Jadcherla SR. Pharyngoesophageal and cardiorespiratory interactions: potential implications for premature infants at risk of clinically significant cardiorespiratory events. Am J Physiol Gastrointest Liver Physiol 2019; 316:G304-G312. [PMID: 30543445 PMCID: PMC6397335 DOI: 10.1152/ajpgi.00303.2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aims of this study were to 1) examine pharyngoesophageal and cardiorespiratory responses to provoking pharyngeal stimuli, and 2) to determine potential contributory factors impacting heart rate (HR) changes to provide insight into cardiorespiratory events occurring in preterm infants. Forty-eight neonates (19 females and 29 males, born at 27.7 ± 0.5 wk; mean ± SE) pending discharge on full oral feeds were studied at 38.7 ± 0.2 wk postmenstrual age using concurrent pharyngoesophageal manometry, electrocardiography, respiratory inductance plethysmography, and nasal airflow thermistor. Pharyngoesophageal and cardiorespiratory responses (prevalence, latency, and duration) were quantified upon abrupt pharyngeal water stimuli (0.1, 0.3, and 0.5 ml in triplicate). Mixed linear models and generalized estimating equations were used for comparisons between HR changes. Contributory factors included stimulus characteristics and subject characteristics. Of 338 pharyngeal stimuli administered, HR increased in 23 (7%), decreased in 108 (32%), and remained stable in 207 (61%) neonates. HR decrease resulted in repetitive swallowing, increased respiratory-rhythm disturbance, and decreased esophageal propagation rates (all, P < 0.05). HR responses were related to stimulus volume, stimulus flow rate, and extreme prematurity (all, P < 0.05). In preterm infants, HR remains stable in a majority of pharyngeal provocations. HR decrease, due to pharyngeal stimulation, is related to aberrant pharyngoesophageal motility and respiratory dysregulation and is magnified by prematurity. We infer that the observed aberrant responses across digestive, respiratory, and cardiovascular systems are related to maladaptive maturation of the parasympathetic nervous system. These aberrant responses may provide diagnostic clues for risk stratification of infants with troublesome cardiorespiratory events and swallowing difficulty. NEW & NOTEWORTHY Cardiorespiratory rhythms concurrent with pharyngeal, upper esophageal sphincter, and esophageal body responses were examined upon pharyngeal provocation in preterm-born infants who were studied at full-term maturation. Decreased heart rate (HR) was associated with extreme preterm birth and stimulus flow/volume. With HR decrease responses, aerodigestive reflex abnormalities were present, characterized by prolonged respiratory rhythm disturbance, repetitive multiple swallowing, and poor esophageal propagation. Promoting esophageal peristalsis may be a potential therapeutic target.
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Affiliation(s)
- Kathryn A. Hasenstab
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Saira Nawaz
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Ivan M. Lang
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sudarshan R. Jadcherla
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,4Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
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The influence of gestational age in the psychometric testing of the Bernese Pain Scale for Neonates. BMC Pediatr 2019; 19:20. [PMID: 30646872 PMCID: PMC6334397 DOI: 10.1186/s12887-018-1380-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 12/20/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Assessing pain in neonates is challenging because full-term and preterm neonates of different gestational ages (GAs) have widely varied reactions to pain. We validated the Bernese Pain Scale for Neonates (BPSN) by testing its use among a large sample of neonates that represented all GAs. METHODS In this prospective multisite validation study, we assessed 154 neonates between 24 2/7 and 41 4/7 weeks GA, based on the results of 1-5 capillary heel sticks in their first 14 days of life. From each heel stick, we produced three video sequences: baseline; heel stick; and, recovery. Five blinded nurses rated neonates' pain responses according to the BPSN. The underlying factor structure of the BPSN, interrater reliability, concurrent validity with the Premature Infant Pain Profile-Revised (PIPP-R), construct validity, sensitivity and specificity, and the relationship between behavioural and physiological indicators were explored. We considered GA and gender as individual contextual factors. RESULTS The factor analyses resulted in a model where the following behaviours best fit the data: crying; facial expression; and, posture. Pain scores for these behavioural items increased on average more than 1 point during the heel stick phases compared to the baseline and recovery phases (p < 0.001). Among physiological items, heart rate was more sensitive to pain than oxygen saturation. Heart rate averaged 0.646 points higher during the heel stick than the recovery phases (p < 0.001). GA increased along with pain scores: for every additional week of gestation, the average increase of behavioural pain score was 0.063 points (SE = 0.01, t = 5.49); average heart rate increased 0.042 points (SE = 0.01, t = 6.15). Sensitivity and specificity analyses indicated that the cut-off should increase with GA. Modified BPSN showed good concurrent validity with the PIPP-R (r = 0.600-0.758, p < 0.001). Correlations between the modified behavioural subscale and the item heart rate were low (r = 0.102-0.379). CONCLUSIONS The modified BPSN that includes facial expression, crying, posture, and heart rate is a reliable and valid tool for assessing acute pain in full-term and preterm neonates, but our results suggest that adding different cut-off points for different GA-groups will improve the BPSN's clinical usefulness. TRIAL REGISTRATION The study was retrospectively registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461 . Registration date: 12 April 2016.
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Costa HTMDL, Costa TX, Martins RR, Oliveira AG. Use of off-label and unlicensed medicines in neonatal intensive care. PLoS One 2018; 13:e0204427. [PMID: 30252920 PMCID: PMC6155521 DOI: 10.1371/journal.pone.0204427] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/09/2018] [Indexed: 01/18/2023] Open
Abstract
Purpose To evaluate the use of off-label and unlicensed medicines in a neonatal intensive care unit (NICU) of a teaching maternity hospital specialized in high risk pregnancy. Methods A prospective cohort study was conducted between August 2015 and July 2016. All newborns admitted to the NICU who had at least one medication prescribed and a hospital stay longer than 24 hours were included. The classification of off-label and unlicensed drugs for the neonatal population was done according to the information of Food and Drug Administration. Results A total of 17421 medication items were analyzed in 3935 prescriptions of 220 newborns. The proportion of newborns exposed to off-label drugs was 96.4%, and to unlicensed medicines was 66.8%. About one-half (49.3%) of the medication items were off-label and 24.6% were unlicensed. The main reason for off-label and unlicensed classification was, respectively, frequency of administration and the administration of adaptations of pharmaceutical forms. Conclusions Although there are actions to encourage the development of pharmacological studies with neonates, this study observed a high rate of prescription and exposure of newborns to off-label and unlicensed drugs in NICUs and pointed out areas of neonatal therapy that require scientific investment.
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Affiliation(s)
- Haline Tereza Matias de Lima Costa
- Integrated Multiprofessional Health Residency Program—Neonatal Intensive Care Unit, Pharmacy Department, Health Sciences Centre, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
- * E-mail:
| | - Tatiana Xavier Costa
- School Maternity Januário Cicco, Health Sciences Centre, Universidade Federal do Rio Grande Norte, Natal, RN, Brazil
| | - Rand Randall Martins
- Pharmacy Department, Health Sciences Centre, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Antônio Gouveia Oliveira
- Pharmacy Department, Health Sciences Centre, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
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Bhat BV, Plakkal N, Gupta P, Goel D. Editorial. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1262-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Küçük Alemdar D, Güdücü Tüfekcİ F. Effects of maternal heart sounds on pain and comfort during aspiration in preterm infants. Jpn J Nurs Sci 2018; 15:330-339. [DOI: 10.1111/jjns.12202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 09/11/2017] [Accepted: 11/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Dilek Küçük Alemdar
- Department of Midwifery, Faculty of Health Sciences; Giresun University; Giresun Turkey
| | - Fatma Güdücü Tüfekcİ
- Department of Pediatric Nursing, Faculty of Nursing; Atatürk University; Erzurum Turkey
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Alemdar DK, Özdemir FK. Effects of Covering the Eyes versus Playing Intrauterine Sounds on Premature Infants' Pain and Physiological Parameters during Venipuncture. J Pediatr Nurs 2017; 37:e30-e36. [PMID: 28751136 DOI: 10.1016/j.pedn.2017.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/23/2017] [Accepted: 06/24/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a need to assess the impact of initiatives to reduce exposure to environmental light and sound in preterm infants undergoing painful interventions in neonatal intensive care units. OBJECTIVES In this study, we aimed to identify the effect of covering the eyes and playing the intrauterine ambient sounds on premature infants' pain and physiological parameters during venipuncture. METHODS This was a randomized controlled trial. Ninety-four preterm infants were randomly divided into three groups: intrauterine sounds (n=32), covered eyes (n=32), and control (n=30) groups. Data were collected on the Preterm Infant Information Form, Preterm Infant Follow-up Form, and Neonatal Infant Pain Scale (NIPS), used to assess pain. RESULTS A significant difference was found between the intervention and control groups' NIPS score after venipuncture, which was primarily due to covered eyes' group. No significant difference was found between the intervention and control groups' NIPS score during venipuncture. In addition, no significant difference was found between the intervention and control groups of infants physiological parameters before, during, and after venipuncture. The practice of covering preterm infants' eyes during venipuncture positively affected their pain scores after venipuncture. CLINICAL IMPLICATIONS The effect of covering the eyes and playing the intrauterine ambient sounds in preterm infants may be recommended as simple, safe, and supportive stimuli that facilitate positive effects during painful procedures.
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Affiliation(s)
- Dilek Küçük Alemdar
- Giresun University, Faculty of Health Sciences, Midwifery Department, Piraziz, Giresun, Turkey.
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Anand KJS, Eriksson M, Boyle EM, Avila-Alvarez A, Andersen RD, Sarafidis K, Polkki T, Matos C, Lago P, Papadouri T, Attard-Montalto S, Ilmoja ML, Simons S, Tameliene R, van Overmeire B, Berger A, Dobrzanska A, Schroth M, Bergqvist L, Courtois E, Rousseau J, Carbajal R. Assessment of continuous pain in newborns admitted to NICUs in 18 European countries. Acta Paediatr 2017; 106:1248-1259. [PMID: 28257153 DOI: 10.1111/apa.13810] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 02/06/2017] [Accepted: 02/21/2017] [Indexed: 12/25/2022]
Abstract
AIM Continuous pain occurs routinely, even after invasive procedures, or inflammation and surgery, but clinical practices associated with assessments of continuous pain remain unknown. METHODS A prospective cohort study in 243 neonatal intensive care units (NICUs) from 18 European countries recorded the frequency of pain assessments, use of mechanical ventilation, sedation, analgesia or neuromuscular blockade for each neonate for up to 28 days after NICU admission. RESULTS Only 2113 of 6648 (31.8%) of neonates received assessments of continuous pain, occurring variably among tracheal ventilation (TrV, 46.0%), noninvasive ventilation (NiV, 35.0%) and no ventilation (NoV, 20.1%) groups (p < 0.001). Daily assessments for continuous pain occurred in only 10.4% of all neonates (TrV: 14.0%, NiV: 10.7%, NoV: 7.6%; p < 0.001). More frequent assessments of continuous pain occurred in NICUs with pain guidelines, nursing champions and surgical admissions (all p < 0.01), and for newborns <32 weeks gestational age, those requiring ventilation, or opioids, sedatives-hypnotics, general anaesthetics (O-SH-GA) (all p < 0.001), or surgery (p = 0.028). Use of O-SH-GA drugs increased the odds for pain assessment in the TrV (OR:1.60, p < 0.001) and NiV groups (OR:1.40, p < 0.001). CONCLUSION Assessments of continuous pain occurred in less than one-third of NICU admissions and daily in only 10% of neonates. NICU clinical practices should consider including routine assessments of continuous pain in newborns.
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Affiliation(s)
- Kanwaljeet J. S. Anand
- Departments of Pediatrics, Anesthesiology, Perioperative & Pain Medicine; Stanford University School of Medicine; Stanford CA USA
| | - Mats Eriksson
- School of Health Sciences; Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | - Elaine M. Boyle
- Department of Health Sciences; University of Leicester; Leicester UK
| | | | | | - Kosmas Sarafidis
- 1st Department of Neonatology; ‘Hippokrateion’ General Hospital; Aristotle University of Thessaloniki; Thessalokiki Greece
| | - Tarja Polkki
- Children and Women Department; Oulu University Hospital; Oulu Finland
| | | | - Paola Lago
- Department of Woman's and Child's Health; University of Padua; Padua Italy
| | - Thalia Papadouri
- Department of Paediatrics; Arch. Makarios III Hospital; Nicosia Cyprus
| | | | - Mari-Liis Ilmoja
- Department of Paediatrics; Tallinn Children's Hospital; Tallinn Estonia
| | - Sinno Simons
- Department of Pediatrics; Erasmus MC-Sophia Kinderziekenhuis; Rotterdam The Netherlands
| | - Rasa Tameliene
- Department of Neonatology; Kaunas Perinatal Center; Lithuanian University of Health Sciences; Kaunas Lithuania
| | - Bart van Overmeire
- Cliniques Universitaires de Bruxelles; Erasme Hospital; Bruxelles Belgium
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
| | - Anna Dobrzanska
- Department of Neonatology; Children's Memorial Health Institute Warsaw; Warszawa Poland
| | - Michael Schroth
- Department of Paediatrics; Cnopf'sche Kinderklinik; Nürnberg Children's Hospital; Nürenberg Germany
| | - Lena Bergqvist
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Solna Sweden
| | - Emilie Courtois
- Urgences Pédiatriques; Hôpital Armand Trousseau; INSERM U1153; Université Pierre et Marie Curie Paris VI; Paris VI Paris France
| | - Jessica Rousseau
- Urgences Pédiatriques; Hôpital Armand Trousseau; INSERM U1153; Université Pierre et Marie Curie Paris VI; Paris VI Paris France
| | - Ricardo Carbajal
- Urgences Pédiatriques; Hôpital Armand Trousseau; INSERM U1153; Université Pierre et Marie Curie Paris VI; Paris VI Paris France
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EDIN Scale Implemented by Gestational Age for Pain Assessment in Preterms: A Prospective Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9253710. [PMID: 28271074 PMCID: PMC5320371 DOI: 10.1155/2017/9253710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/11/2016] [Accepted: 12/28/2016] [Indexed: 11/17/2022]
Abstract
Background. Chronic neonatal pain can lead to long-term adverse effects on the immature brain. EDIN scale for prolonged pain might not be fully suitable for premature infants. We aimed to test a modified EDIN scale, adding postmenstrual age (PMA) as a sixth item (EDIN6). Methods. In a two-phase prospective study, pain was assessed in all neonates admitted in our NICU. In T1 EDIN was applied; in T2 EDIN6 with additional scores of 2, 1, and 0, respectively, for 25–32, 33–37, and >37 weeks PCA was tested. Scores > 6 suggested pain. The nursing staff was given a questionnaire to evaluate EDIN and EDIN6. Results. A total of 15960 pain assessments were recorded (8693 in T1; 7267 in T2). With EDIN6, cumulative detection of pain almost tripled (117/7267 versus 52/8693, p = 0.001). Main differences were found among less mature categories (50/1472 versus 17/1734, p = 0.001 in PCA 25–32; 26/2606 versus 10/4335, p = 0.001 in PMA 33–37; 41/3189 versus 25/2624, p = 0.26 in PMA > 37). Adequacy of pain assessment in lower PMA was judged “medium-high” in 13,4% of nurses in T1 and 71,4% in T2. Conclusions. EDIN6 may allow improved evaluation of pain in preterm infants.
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de Melo GM, Lélis ALPDA, de Moura AF, Cardoso MVLML, da Silva VM. [Pain assessment scales in newborns: integrative review]. REVISTA PAULISTA DE PEDIATRIA 2016; 32:395-402. [PMID: 25511005 PMCID: PMC4311795 DOI: 10.1016/j.rpped.2014.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 04/03/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To analyze studies on methods used to assess pain in newborns. DATA SOURCES Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5. DATA SYNTHESIS 29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications. CONCLUSION Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.
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Avila-Alvarez A, Carbajal R, Courtois E, Pertega-Diaz S, Anand KJ, Muñiz-Garcia J. Clinical assessment of pain in Spanish Neonatal Intensive Care Units. An Pediatr (Barc) 2016. [DOI: 10.1016/j.anpede.2015.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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The Validity and Clinical Utility of the COVERS Scale and Pain Assessment Tool for Assessing Pain in Neonates Admitted to an Intensive Care Unit. Clin J Pain 2016; 32:51-7. [PMID: 25756556 DOI: 10.1097/ajp.0000000000000228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Infants admitted to a neonatal intensive care unit (NICU) are routinely subject to a range of painful procedures. However, pain assessments in NICUs are under-utilized due to a lack of a gold standard pain measure. In this study we assessed the psychometric properties and clinical utility of the COVERS and Pain Assessment Tool (PAT), in a neonatal unit. METHODS We had 72 nurses use the scales to assess pain at baseline and during a heel-lance procedure in 80 NICU infants. An independent research observer and the infant's mother also completed pain ratings. After the study, we assessed nurse preference and clinical utility ratings for both scales. RESULTS The COVERS had satisfactory internal consistency at baseline (Cronbach α=0.74) and heel lance (α=0.78), as did the PAT (baseline α=0.79, heel lance α=0.85). Intraclass correlation coefficients demonstrated good inter-rater reliability at baseline and heel lance, respectively, for both the COVERS (0.82 and 0.80) and the PAT (0.83 and 0.86). There were strong associations between total scores on the 2 scales at baseline (r=0.81, P<0.001) and heel lance (r=0.91, P<0.001), between researcher's ratings and total COVERS (ρ=0.75, P<0.001) and PAT scores (ρ=0.69, P<0.001), and between maternal ratings and total COVERS (r=0.74, P<0.05) and PAT scores (r=0.65, P<0.05). Both scales were sensitive to pain and nonpain events. Reliability and validity was mostly upheld across gestational age. Most nurses preferred the COVERS (52%) to the PAT (16%), and 32% had no preference. DISCUSSION This study builds on evidence for the COVERS scale and the PAT; both scales were reliable and valid measures of acute pain in neonates as premature as 24-week gestational age.
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Donia AES, Tolba OA. Effect of early procedural pain experience on subsequent pain responses among premature infants. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2016. [DOI: 10.1016/j.epag.2016.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Kothari SY, Dongara AR, Nimbalkar SM, Phatak AG, Nimbalkar AS. Missed Opportunities for Sedation and Pain Management at a Level III Neonatal Intensive Care Unit, India. Front Pediatr 2016; 4:7. [PMID: 26942166 PMCID: PMC4763094 DOI: 10.3389/fped.2016.00007] [Citation(s) in RCA: 6] [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: 11/30/2015] [Accepted: 02/01/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Neonates in the neonatal intensive care unit (NICU) undergo a multitude of painful and stressful procedures during the first days of life. Stress from this pain can lead to neurodevelopmental problems that manifest in later childhood and should be prevented. OBJECTIVE To determine the number of painful procedures performed per day for each neonate, to verify documentation of painful procedures performed, and to, subsequently, note missed opportunities for providing pain relief to neonates. METHODS We conducted a cross-sectional study at a level III NICU located in a rural part of western India. A total of 69 neonates admitted for more than 24 h were included. Twenty-nine neonates were directly observed for a total of 24 h each, and another 40 neonatal records were retrospectively reviewed for the neonate's first 7 days of admission. All stressful and painful procedures performed on the neonate were recorded. Also recorded were any pharmaceutical pain relief agents or central nervous system depressants administered to the neonate before or at the time of the procedures. Average nurse-patient ratio was also calculated. Data were analyzed using descriptive statistics. RESULTS A documentation deficit of 2.2% was observed. The average nurse-patient ratio was 1.53:1. A total of 13711 procedures were recorded, yielding 44.1 (38.1 stressful, 3.8 mildly painful, and 2.2 moderately painful) procedures per patient day. Common stressful procedures were position changing (2501) and temperature recording (2208). Common mildly and moderately painful procedures were heel prick (757) and endotracheal suctioning (526), respectively. Use of pharmacological agents coincided with 33.48% of the procedures. The choice of drug and time of administration were inappropriate, indicating that the pharmacological agents were intended not for pain relief but rather for a coexisting pathology or as sedation from ventilation with no analgesia. CONCLUSION Stressful procedures are common in the NICU; mildly and moderately painful procedures fairly common. Almost two-thirds of the times, no pharmaceutical pain relief methods were used, and when administered, the pharmaceutical agents were seldom intended for pain relief; this implies poor pain management practices and emphasizes the imperative need for educating NICU nurses, residents, fellows, and attendings.
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Affiliation(s)
- Shikha Y Kothari
- Department of Pediatrics, Pramukhswami Medical College , Karamsad-Anand , India
| | - Ashish R Dongara
- Department of Pediatrics, Pramukhswami Medical College , Karamsad-Anand , India
| | - Somashekhar M Nimbalkar
- Department of Pediatrics, Pramukhswami Medical College, Karamsad-Anand, India; Central Research Services, Charutar Arogya Mandal, Karamsad-Anand, India
| | - Ajay G Phatak
- Central Research Services, Charutar Arogya Mandal , Karamsad-Anand , India
| | - Archana S Nimbalkar
- Department of Physiology, Pramukhswami Medical College , Karamsad-Anand , India
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Avila-Alvarez A, Carbajal R, Courtois E, Pertega-Diaz S, Anand KJS, Muñiz-Garcia J. [Clinical assessment of pain in Spanish Neonatal Intensive Care Units]. An Pediatr (Barc) 2015; 85:181-188. [PMID: 26553356 DOI: 10.1016/j.anpedi.2015.09.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/21/2015] [Accepted: 09/27/2015] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Clinical scales are currently the best method to assess pain in the neonate, given the impossibility of self-report in this age group. A study is designed with the aim of determining the current practices as regards the clinical assessment of pain in Spanish Neonatal Units and the factors associated with the use of clinical scales. METHODS A prospective longitudinal observational study was conducted. A total of 30 Units participated and 468 neonates were included. RESULTS Only 13 Units (43.3%) had pain assessment protocols. Pain was evaluated with a scale in 78 neonates (16.7%, 95% CI; 13.1-20.1) and the mean number of pain assessments per patient and per day was 2.3 (Standard Deviation; 4.8), with a median of 0.75. Of the total number of 7,189 patient-days studied, there was at least one pain assessment in 654 (9.1%). No pain assessment was performed with a clinical scale on any patient in 20 (66.7%) Units. Among those that did, a wide variation was observed in the percentage of patients in whom pain was assessed, as well as in the scales used. The CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) scale was that used in most Units. In the multivariate analysis, only invasive mechanical ventilation was associated with receiving a pain assessment with a scale (OR 1.46, P=.042). DISCUSSION The majority of neonates admitted into Intensive Care in Spain do not receive a pain assessment. Many units still do not routinely use clinical scales, and there is a wide variation between those that do use them. These results could serve as a basis for preparing national guidelines as regards pain in the neonate.
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Affiliation(s)
- Alejandro Avila-Alvarez
- Unidad de Neonatología, Servicio de Pediatría, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade de A Coruña (UDC), A Coruña, España.
| | - Ricardo Carbajal
- Service d'Urgences Pédiatriques. Hôpital d'enfants Armand Trousseau, Inserm UMR 1153 Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Université Pierre et Marie Curie, París, Francia
| | - Emilie Courtois
- Service d'Urgences Pédiatriques. Hôpital d'enfants Armand Trousseau, Inserm UMR 1153 Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Université Pierre et Marie Curie, París, Francia
| | - Sonia Pertega-Diaz
- Grupo de Investigación de Epidemiología Clínica y Bioestadística, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade de A Coruña (UDC), A Coruña, España
| | | | - Javier Muñiz-Garcia
- Instituto Universitario de Ciencias de la Salud e Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade de A Coruña (UDC), A Coruña, España
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Hillman BA, Tabrizi MN, Gauda EB, Carson KA, Aucott SW. The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse's assessment of neonates. J Perinatol 2015; 35:128-31. [PMID: 25144158 PMCID: PMC5526063 DOI: 10.1038/jp.2014.154] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 07/11/2014] [Accepted: 07/15/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the reliability of an objective measure of pain, agitation and sedation using the Neonatal Pain, Agitation and Sedation Scale (N-PASS) compared with nursing bedside assessment. STUDY DESIGN Neonates admitted in neonatal intensive care unit over a 6-month period were eligible. Pain and sedation were assessed with N-PASS, and a subjective questionnaire was administered to the bedside nurse. RESULT A total of 218 neonates were eligible (median: gestational age 34.6 weeks, age at assessment 7 days). N-PASS pain score correlated significantly with both nurses' pain score (Spearman coefficient (r)=0.37; P<0.001) and agitation score (r=0.56; P<0.001). N-PASS sedation score correlated with nurses' sedation score (r=-0.39; P<0.001). Adjusting for gestational age, day of life, intrauterine drug exposure and use of high frequency ventilation only slightly attenuated the correlations (r=0.36, 0.55 and -0.31, respectively). CONCLUSION The N-PASS captures nursing assessment of pain, agitation and sedation in this broad population and provides a quantitative assessment of subjective descriptions that often drives patient therapy.
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Affiliation(s)
- BA Hillman
- Charlotte Bloomberg Children’s Center, Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - MN Tabrizi
- Charlotte Bloomberg Children’s Center, Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - EB Gauda
- Charlotte Bloomberg Children’s Center, Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - KA Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - SW Aucott
- Charlotte Bloomberg Children’s Center, Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bellieni CV, Stazzoni G, Tei M, Alagna MG, Iacoponi F, Cornacchione S, Bertrando S, Buonocore G. How painful is a heelprick or a venipuncture in a newborn? J Matern Fetal Neonatal Med 2014; 29:202-6. [DOI: 10.3109/14767058.2014.992334] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- C. V. Bellieni
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
| | - G. Stazzoni
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
| | - M. Tei
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
| | - M. G. Alagna
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
| | - F. Iacoponi
- Istituto Zooprofilattico Sperimentale di Lazio e Toscana, Osservatorio Epidemiologico, Roma, Italy
| | - S. Cornacchione
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
| | - S. Bertrando
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
| | - G. Buonocore
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy and
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Pain assessment scales in newborns: integrative review* *Study conducted at Universidade Federal do Ceará, Fortaleza, CE, Brazil. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/s2359-3482(15)30076-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
As a standard of care for preterm/term newborns effective pain management may improve their clinical and neurodevelopmental outcomes. Neonatal pain is assessed using context-specific, validated, and objective pain methods, despite the limitations of currently available tools. Therapeutic approaches reducing invasive procedures and using pharmacologic, behavioral, or environmental measures are used to manage neonatal pain. Nonpharmacologic approaches like kangaroo care, facilitated tucking, non-nutritive sucking, sucrose, and others can be used for procedural pain or adjunctive therapy. Local/topical anesthetics, opioids, NSAIDs/acetaminophen and other sedative/anesthetic agents can be incorporated into NICU protocols for managing moderate/severe pain or distress in all newborns.
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Melo GMD, Lélis ALPDA, Moura AFD, Cardoso MVLML, Silva VMD. Pain assessment scales in newborns: integrative review. REVISTA PAULISTA DE PEDIATRIA 2014. [DOI: 10.1590/s0103-05822014000400017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To analyze studies on methods used to assess pain in newborns.DATA SOURCES: Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.DATA SYNTHESIS: 29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.CONCLUSION: Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.
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Lundqvist P, Kleberg A, Edberg A, Larsson BA, Hellström‐Westas L, Norman E. Development and psychometric properties of the Swedish ALPS-Neo pain and stress assessment scale for newborn infants. Acta Paediatr 2014; 103:833-9. [PMID: 24813238 PMCID: PMC4368370 DOI: 10.1111/apa.12672] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 03/04/2014] [Accepted: 04/24/2014] [Indexed: 11/26/2022]
Abstract
AIM To validate and evaluate the psychometric properties of the ALPS-Neo, a new pain assessment scale created for the continuous evaluation of pain and stress in preterm and sick term infants. METHODS A unidimensional scale for continuous pain, Astrid Lindgren Children's Hospital Pain Scale (ALPS 1), was developed further to assess continuous pain and stress in infants treated in the neonatal intensive care unit (NICU). The pain scale includes observations of five behaviours. A manual was created, clarifying the scoring criteria. An internal and an external panel assessed face validity. Psychometric properties were evaluated in three different steps. Inter-rater reliability was estimated from video-based assessments (n = 625) using weighted kappa statistics (test I). Inter-rater reliability was further evaluated in test II (n = 125) and test III (n = 96) by real-time assessments using the intraclass correlation coefficient (ICC) and Cronbach's alpha. RESULTS The final inter-rater reliability (test III) was assessed as good with ICC 0.91 for the total score and 0.62-0.81 for the five items. Cronbach's alpha showed 0.95 for the total score. CONCLUSION ALPS-Neo is a new assessment tool for optimising the management of pain and stress in newborn infants in the NICU. It has proved easy to implement and user-friendly, permitting fast, reliable observations with high inter-rater reliability.
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Affiliation(s)
- Pia Lundqvist
- Department of Health Sciences Faculty of Medicine Lund University Lund Sweden
| | - Agneta Kleberg
- Department of Neonatology Karolinska NIDCAP Training Centre Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden
| | - Anna‐Karin Edberg
- Department of Health and Society Kristianstad University Kristianstad Sweden
| | - Björn A Larsson
- Department of Paediatric Anaesthesia and Intensive Care Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden
| | | | - Elisabeth Norman
- Department of Paediatrics Skåne University Hospital and Lund University Lund Sweden
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Vinall J, Miller SP, Bjornson BH, Fitzpatrick KP, Poskitt KJ, Brant R, Synnes AR, Cepeda IL, Grunau RE. Invasive procedures in preterm children: brain and cognitive development at school age. Pediatrics 2014; 133:412-21. [PMID: 24534406 PMCID: PMC3934331 DOI: 10.1542/peds.2013-1863] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Very preterm infants (born 24-32 weeks' gestation) undergo numerous invasive procedures during neonatal care. Repeated skin-breaking procedures in rodents cause neuronal cell death, and in human preterm neonates higher numbers of invasive procedures from birth to term-equivalent age are associated with abnormal brain development, even after controlling for other clinical risk factors. It is unknown whether higher numbers of invasive procedures are associated with long-term alterations in brain microstructure and cognitive outcome at school age in children born very preterm. METHODS Fifty children born very preterm underwent MRI and cognitive testing at median age 7.6 years (interquartile range, 7.5-7.7). T1- and T2-weighted images were assessed for the severity of brain injury. Magnetic resonance diffusion tensor sequences were used to measure fractional anisotropy (FA), an index of white matter (WM) maturation, from 7 anatomically defined WM regions. Child cognition was assessed using the Wechsler Intelligence Scale for Children-IV. Multivariate modeling was used to examine relationships between invasive procedures, brain microstructure, and cognition, adjusting for clinical confounders (eg, infection, ventilation, brain injury). RESULTS Greater numbers of invasive procedures were associated with lower FA values of the WM at age 7 years (P = .01). The interaction between the number of procedures and FA was associated with IQ (P = .02), such that greater numbers of invasive procedures and lower FA of the superior WM were related to lower IQ. CONCLUSIONS Invasive procedures during neonatal care contribute to long-term abnormalities in WM microstructure and lower IQ.
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Affiliation(s)
- Jillian Vinall
- Departments of Neuroscience,,Developmental Neurosciences and Child Health, Child & Family Research Institute
| | - Steven P. Miller
- Pediatrics,,Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Bruce H. Bjornson
- Pediatrics,,Developmental Neurosciences and Child Health, Child & Family Research Institute,,British Columbia Children’s and Women’s Hospitals, Vancouver, British Columbia, Canada
| | | | - Kenneth J. Poskitt
- Pediatrics,,Radiology, and,Developmental Neurosciences and Child Health, Child & Family Research Institute
| | - Rollin Brant
- Statistics, University of British Columbia, Vancouver, British Columbia, Canada;,Developmental Neurosciences and Child Health, Child & Family Research Institute
| | - Anne R. Synnes
- Pediatrics,,Developmental Neurosciences and Child Health, Child & Family Research Institute,,British Columbia Children’s and Women’s Hospitals, Vancouver, British Columbia, Canada
| | - Ivan L. Cepeda
- Developmental Neurosciences and Child Health, Child & Family Research Institute
| | - Ruth E. Grunau
- Departments of Neuroscience,,Pediatrics,,Developmental Neurosciences and Child Health, Child & Family Research Institute,,British Columbia Children’s and Women’s Hospitals, Vancouver, British Columbia, Canada;,School of Nursing & Midwifery, Queen’s University Belfast, Belfast, Northern Ireland; and
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32
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Intubation in the delivery room: experience with nasal midazolam. Early Hum Dev 2014; 90:39-43. [PMID: 24331827 DOI: 10.1016/j.earlhumdev.2013.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/22/2013] [Accepted: 10/29/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.
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Abstract
Pain assessment and measurement are the cornerstones of pain management. Pain assessment connotes a comprehensive multidimensional description. Conversely, pain measurement provides a numeric quantitative description of each factor illustrating pain qualities. Pain scales provide a composite score used to guide practice and research. The type of infant pain instrument chosen is a significant factor in guiding pain management practice. The purpose of this review was to summarize current infant pain measures by introducing a conceptual framework for pain measurement. Although more than 40 infant pain instruments exist, many were devised solely for research purposes; several of the newly developed instruments largely overlap with existing instruments. Integration of pain management into daily practice remains problematic. Understanding how each instrument measures infant pain allows clinicians to make better decisions about what instrument to use with which infant and in what circumstances. In addition, novel new measurement techniques need further testing.
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34
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Gupta A, Khetan V. Continuous mode large spot transpupillary thermotherapy for retinopathy of prematurity. Indian J Ophthalmol 2012; 60:577; author reply 577-8. [PMID: 23202406 PMCID: PMC3545144 DOI: 10.4103/0301-4738.103805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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35
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Skene C, Franck L, Curtis P, Gerrish K. Parental Involvement in Neonatal Comfort Care. J Obstet Gynecol Neonatal Nurs 2012; 41:786-97. [DOI: 10.1111/j.1552-6909.2012.01393.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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36
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Abstract
This article describes developments in pain assessment in critically ill neonates and infants during the last 5 to 6 years. Pain assessment instruments show a redundancy of items and a lack of profound psychometric background. Although most research focuses primarily on acute pain, in clinical practice there is also the challenge of assessing prolonged and/or persisting pain. The effectiveness of pain assessment is still a matter of debate and has recently been challenged as a primary end point in analgesia-related trials. Integration of observation of behavior with reliable and specific neurobiology-based parameters remains a challenge.
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Affiliation(s)
- Monique van Dijk
- Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Room Sk 1276, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
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37
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The Cochrane Libraryand procedural pain in children: an overview of reviews. ACTA ACUST UNITED AC 2012. [DOI: 10.1002/ebch.1864] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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38
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Berde CB, Walco GA, Krane EJ, Anand KJS, Aranda JV, Craig KD, Dampier CD, Finkel JC, Grabois M, Johnston C, Lantos J, Lebel A, Maxwell LG, McGrath P, Oberlander TF, Schanberg LE, Stevens B, Taddio A, von Baeyer CL, Yaster M, Zempsky WT. Pediatric analgesic clinical trial designs, measures, and extrapolation: report of an FDA scientific workshop. Pediatrics 2012; 129:354-64. [PMID: 22250028 PMCID: PMC9923552 DOI: 10.1542/peds.2010-3591] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials.
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Affiliation(s)
- Charles B. Berde
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Children's Hospital, Boston, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts;,Address correspondence to Charles Berde, MD, PhD, Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital, Boston, 333 Longwood Ave, 5th floor, Boston, MA 02115. E-mail:
| | - Gary A. Walco
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington;,University of Washington School of Medicine, Seattle, Washington
| | - Elliot J. Krane
- Stanford University School of Medicine, Stanford, California;,Lucile Packard Children's Hospital, Stanford, California
| | - K. J. S. Anand
- Division of Pediatric Critical Care Medicine, Le Bonheur Children's Hospital, Memphis, Tennessee;,University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jacob V. Aranda
- The Children's Hospital of Brooklyn, State University of New York, New York, New York;,Pediatric Pharmacology Research Unit Network, Children's Hospital of Michigan, Detroit, Michigan
| | - Kenneth D. Craig
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carlton D. Dampier
- Emory University School of Medicine, Atlanta, Georgia;,Atlanta Clinical Translational Science Institute, Atlanta, Georgia
| | - Julia C. Finkel
- Department of Anesthesiology George Washington University, Washington, District of Columbia;,Division of Anesthesiology and Pain Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Martin Grabois
- Baylor College of Medicine, Houston, Texas;,University of Texas Health Science Center-Houston, Houston, Texas
| | | | - John Lantos
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri;,University of Missouri–Kansas City, Kansas City, Missouri
| | - Alyssa Lebel
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Children's Hospital, Boston, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts
| | - Lynne G. Maxwell
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;,Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Patrick McGrath
- IWK Health Centre, Halifax, Nova Scotia, Canada;,Dalhousie University, Halifax, Nova Scotia, Canada
| | - Timothy F. Oberlander
- Division of Developmental Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada;,BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Bonnie Stevens
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anna Taddio
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carl L. von Baeyer
- Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Myron Yaster
- Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Medical and Surgical Center, The Johns Hopkins Hospital, Baltimore, Maryland; and
| | - William T. Zempsky
- Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, Connecticut
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39
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Cerebral near-infrared spectroscopy as a measure of nociceptive evoked activity in critically ill infants. Pain Res Manag 2011; 16:331-6. [PMID: 22059205 DOI: 10.1155/2011/891548] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Signs of pain may be subtle or absent in a critically ill infant. The complex nature of pain may further obscure its identification and measurement. Because the use of monitoring and neuroimaging techniques has become more common in pain research, an understanding of these specialized technologies is important. Near-infrared spectroscopy (NIRS) is a noninvasive technique for monitoring tissue hemodynamics and oxygenation. There are indications that NIRS is capable of detecting the cerebral hemodynamic changes associated with sensory stimuli, including pain, in infants. These developments suggest that NIRS may play an important role in research focusing on pain perception in critically ill infants. The present review briefly describes the cortical responses to noxious stimuli, which parallel cerebral hemodynamic responses to various stimuli. This is followed by an overview of NIRS technology including a summary of the literature on functional studies that have used NIRS in infants. Current NIRS techniques have well-recognized limitations that must be considered carefully during the measurement and interpretation of the signals. Nonetheless, until more advanced NIRS techniques emerge, the current devices have strengths that should be exploited.
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40
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Liaw JJ, Zeng WP, Yang L, Yuh YS, Yin T, Yang MH. Nonnutritive sucking and oral sucrose relieve neonatal pain during intramuscular injection of hepatitis vaccine. J Pain Symptom Manage 2011; 42:918-30. [PMID: 21620644 DOI: 10.1016/j.jpainsymman.2011.02.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 02/08/2011] [Accepted: 02/10/2011] [Indexed: 11/23/2022]
Abstract
CONTEXT Newborns are subject to pain during routine invasive procedures. Pain caused by immunization injections is preventable, but remains untreated in neonates. OBJECTIVES The purpose of the study was to compare the effectiveness of three nonpharmacological pain relief strategies on newborns' pain, physiological parameters, and cry duration before, during, and after hepatitis B intramuscular (IM) injection. METHODS In this prospective, randomized clinical trial, we enrolled 165 newborns (gestational age, ≥36 weeks). The infants received IM injections and were randomized to three treatment groups: nonnutritive sucking (NNS), 20% oral sucrose, or routine care. Pain was measured by the Neonatal Facial Coding System, physiological signals by electrocardiogram monitors, and cry duration using a stopwatch. RESULTS Pain was significantly lower among infants in the NNS (B=-11.27, P<0.001) and sucrose (B=-11.75, P<0.001) groups than that in controls after adjusting for time effects, infant sleep/wake state, number of prior painful experiences, and baseline pain scores. Infants in the NNS and sucrose groups also had significantly lower mean heart and respiratory rates than the controls. Cry duration of infants receiving sucrose was significantly shorter than those in the NNS (Z=-3.36, P<0.001) and control groups (Z=-7.80, P<0.001). CONCLUSION NNS and oral sucrose can provide analgesic effects and need to be given before painful procedures as brief as a one-minute IM injection. Sucrose orally administered two minutes before injection more effectively reduced newborns' pain during injection than NNS. Both nonpharmacological methods more effectively relieved newborns' pain, stabilized physiological parameters, and shortened cry duration during IM hepatitis injection than routine care.
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Affiliation(s)
- Jen-Jiuan Liaw
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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41
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Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain Assessment in the Patient Unable to Self-Report: Position Statement with Clinical Practice Recommendations. Pain Manag Nurs 2011; 12:230-50. [DOI: 10.1016/j.pmn.2011.10.002] [Citation(s) in RCA: 333] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 08/22/2011] [Indexed: 01/16/2023]
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42
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Liaw JJ, Yang L, Chou HL, Yin T, Chao SC, Lee TY. Psychometric analysis of a Taiwan-version pain assessment scale for preterm infants. J Clin Nurs 2011; 21:89-100. [DOI: 10.1111/j.1365-2702.2011.03770.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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43
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Walter-Nicolet E, Annequin D, Biran V, Mitanchez D, Tourniaire B. Pain management in newborns: from prevention to treatment. Paediatr Drugs 2010; 12:353-65. [PMID: 21028915 DOI: 10.2165/11318900-000000000-00000] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
All neonates in the Neonatal Intensive Care Unit (NICU) or during the first days of life undergo painful and stressful procedures. Epidemiologic studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Prevention is the first step of pain management, and practical guidelines should be used in the NICU. Assessment must be done with adequate tools that take into account the infant's pathology and gestational age. Distinguishing between acute and prolonged pain is important for both assessment and treatment. The most common drugs that have been studied for the treatment of pain and stress are opioids, hypnosedatives, and NMDA receptor antagonists. Morphine and fentanyl are most frequently used for acute or prolonged pain in the NICU. They have potent analgesic effects and few immediate or long-term adverse effects. Midazolam is a commonly used hypnosedative, but its adverse effects limit its use. Drugs such as propofol and ketamine have been used for acute painful procedures; however, further research is needed to assess their long-term effects. Use of non-pharmacologic pain management techniques has increased in recent years. These methods are easy, inexpensive, and effective in helping newborns recover from painful procedures. Sweet solutions and non-nutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and facilitated tucking are the most commonly employed and evaluated non-pharmacologic methods. Hospitals should promote and improve parent involvement in pain management. In-service education and well organized hospital teams are crucial for successful implementation of pain protocols in newborns.
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Affiliation(s)
- Elizabeth Walter-Nicolet
- Unité Fonctionnelle de lutte contre la douleur, Hôpital d'enfants Armand Trousseau, Assistance Publique Hôpitaux de Paris, Paris, France
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44
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Durrmeyer X, Vutskits L, Anand KJS, Rimensberger PC. Use of analgesic and sedative drugs in the NICU: integrating clinical trials and laboratory data. Pediatr Res 2010; 67:117-27. [PMID: 20091937 DOI: 10.1203/pdr.0b013e3181c8eef3] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Recent advances in neonatal intensive care include and are partly attributable to growing attention for comfort and pain control in the term and preterm infant requiring intensive care.Limitation of painful procedures is certainly possible, but most critically ill infants require unavoidable painful or stressful procedures such as intubation, mechanical ventilation, or catheterization.Many analgesics (opioids and nonsteroidal anti-inflammatory drugs)and sedatives (benzodiazepines and other anesthetic agents) are available but their use varies considerably among units. This review summarizes current experimental knowledge on the effects of sedative and analgesic drugs on brain development and reviews clinical evidence that speaks for or against the use of common analgesic and sedative drugs in the NICU but avoids any discussion of anesthesia during surgery. Risk/benefit ratios of intermittent boluses or continuous infusions for the commonly used sedative and analgesic agents are discussed in the light of clinical and experimental studies. The limitations of extrapolating experimental results from animals to humans must be considered while making practical recommendations based on the currently available evidence.
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Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil 94000, France
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45
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Kim JS, Lee EJ, Ham EH, Kim JH, Yi YH. Pain Response to Procedural Pain in Premature Infants. ACTA ACUST UNITED AC 2010. [DOI: 10.4094/jkachn.2010.16.4.352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jung Sook Kim
- Nursing Director, Neonatal Intensive Care Unit, Samsung Medical Center, Seoul, Korea
| | - Eun Jung Lee
- Advanced Practice Nurse, Neonatal Intensive Care Unit, Samsung Medical Center, Seoul, Korea
| | - Eun Ha Ham
- Registered Nurse, Neonatal Intensive Care Unit, Samsung Medical Center, Seoul, Korea
| | - Ji Hyun Kim
- Registered Nurse, Neonatal Intensive Care Unit, Samsung Medical Center, Seoul, Korea
| | - Young Hee Yi
- Clinical Associate Professor, Graduate School of Clinical Nursing Science, Sungkyungkwan University, Seoul, Korea
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46
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van Dijk M, Roofthooft DWE, Anand KJS, Guldemond F, de Graaf J, Simons S, de Jager Y, van Goudoever JB, Tibboel D. Taking Up the Challenge of Measuring Prolonged Pain in (Premature) Neonates. Clin J Pain 2009; 25:607-16. [DOI: 10.1097/ajp.0b013e3181a5b52a] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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47
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Abstract
PURPOSE This study investigates the impact of the length of the examination, the insertion of eyelid specula, and the indentation of the globe on the pain and stress sensation of premature infants. METHODS Ninety-two premature infants in three neonatal wards were included. In two wards, the patients were examined using eyelid specula and scleral indentation as recommended in the official guidelines. In the third ward, the investigation time was minimized and ophthalmoscopy was performed without eyelid specula and scleral indentation. Physical and mental disturbance of the patients was assessed by the Neonatal Infant Pain Score and by monitoring the heart rate. The results were divided into two groups: in the one, eyelid specula and scleral indentation were used, whereas in the other one, they were not used. An independent-samples t-test was performed, which allowed us to calculate the correlation between the way the examination was executed and the condition of the patients. RESULTS Demographic data and baseline values of heart rate and pain score did not differ between the two groups. Heart rate and pain score during and after the investigation were significantly higher and increased significantly with the duration of the examination for the patients who were investigated using lid specula and scleral indentation. CONCLUSION Our study shows that indirect ophthalmoscopy without specula causes significantly less stress to infants than screening with lid specula and scleral indentation.
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48
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Norman E, Rosén I, Vanhatalo S, Stjernqvist K, Okland O, Fellman V, Hellström-Westas L. Electroencephalographic response to procedural pain in healthy term newborn infants. Pediatr Res 2008; 64:429-34. [PMID: 18594483 DOI: 10.1203/pdr.0b013e3181825487] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The current study aimed to characterize changes in EEG-related measures after noxious stimuli in neonates and to assess their potential utility as measures of pain and/or discomfort during neonatal intensive care. Seventy-two healthy term infants were investigated: Twenty-eight had a non-skin-breaking pin-prick on the heel, randomized to receive either oral glucose (n = 16) or water (n = 12) before the stimulus. Twenty-one infants were studied during a venous blood sample from the dorsum of the hand, 23 infants during a capillary heel stick. Behavioral pain responses were assessed with the Premature Infant Pain Profile Scale. The stimulus evoked a significant increase in higher frequency components (10-30 Hz) which also correlated to behavioral measures. The frontotemporal localization of the increased activity with frequency bands similar to electromuscular artifacts and the relation to behavioral measures confirmed that this activity corresponds to an increase in muscle tone. There was no change in frontal EEG asymmetry in any of the groups. The present results indicate that responses in cortical activity recorded by EEG are not useful for clinical assessment of infants' responses to noxious stimuli.
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Affiliation(s)
- Elisabeth Norman
- Department of Pediatrics, Lund University Hospital, Lund SE-22185, Sweden.
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49
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Buscemi N, Vandermeer B, Curtis S. The Cochrane Library and Procedural Pain in Children: An Overview of Reviews. ACTA ACUST UNITED AC 2008. [DOI: 10.1002/ebch.225] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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50
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Abstract
Although over 40 methods of pain assessment in infants are available for use in clinical practice, unrecognized and under-treated pain remains one of the most commonly reported problems within the Neonatal Intensive Care Units. A number of factors have been found to account for differences in the robustness of the pain response in neonates of varying gestational ages. Discrepancies between behavioral and physiological pain indicators have also been reported. With newer technologies, there is an opportunity not only to verify infant pain perception, but these tools may allow an identification of which of the observed indicators are most sensitive in particular clinical situations. The current controversies regarding pain assessment in preterm and term infants are reviewed to define the most important issues and to develop a dialogue for future directions.
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Affiliation(s)
- Manon Ranger
- McGill University, School of Nursing, Montreal, Canada.
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