Are there long-term consequences of pain in newborn or very young infants?

Artificial Intelligence-Driven Diagnostic Processes and Comprehensive Multimodal Models in Pain Medicine

Pain diagnosis remains a challenging task due to its subjective nature, the variability in pain expression among individuals, and the difficult assessment of the underlying biopsychosocial factors. In this complex scenario, artificial intelligence (AI) can offer the potential to enhance diagnostic accuracy, predict treatment outcomes, and personalize pain management strategies. This review aims to dissect the current literature on computer-aided diagnosis methods. It also discusses how AI-driven diagnostic strategies can be integrated into multimodal models that combine various data sources, such as facial expression analysis, neuroimaging, and physiological signals, with advanced AI techniques. Despite the significant advancements in AI technology, its widespread adoption in clinical settings faces crucial challenges. The main issues are ethical considerations related to patient privacy, biases, and the lack of reliability and generalizability. Furthermore, there is a need for high-quality real-world validation and the development of standardized protocols and policies to guide the implementation of these technologies in diverse clinical settings.

An examination of questioning methods and the influence of child maltreatment on paediatric pain assessments: Perspectives of healthcare providers

AIMS AND OBJECTIVES

Children with a history of maltreatment have underestimated and undertreated pain; however, it is unknown if healthcare providers consider maltreatment when assessing children's pain. The current study aimed to address this issue by investigating healthcare providers' pain assessment practices, and specifically, their consideration of child maltreatment.

METHOD

Healthcare providers (N = 100) completed a survey, asking them to reflect upon their pediatric pain assessment practices (e.g., methods and questions used to assess pain) through self-report and case vignette questions.

RESULTS

Participants who received continuing education about child maltreatment were more likely to consider maltreatment in several areas of their pediatric pain assessment practice, whereas participants who received continuing education about pediatric pain, were not. Participants were also more likely to report that they would consider maltreatment in vignette responses than in questions regarding their daily practice.

CONCLUSION

Findings indicate healthcare providers use multidimensional methods when assessing children's pain, although it is unclear when or how they use open-ended vs. option posing questions. Healthcare providers also tended to consider the effects of child maltreatment on children's ability to communicate their pain more so when the history of maltreatment was known to them.

Long-term Effects of Cannabidiol and/or Fentanyl Exposure in Rats Submitted to Neonatal Pain

The current study aimed to evaluate anxiety behavior, hippocampal ionized calcium-binding adaptor molecule 1 (Iba1) and cannabinoid receptor 1 (CB1) gene expression, and nociceptive response in adulthood after a combination of fentanyl and cannabidiol (CBD) for nociceptive stimuli induced during the first week of life in rats. Complete Freund's adjuvant-induced inflammatory nociceptive insult on postnatal day (PN) 1 and PN3. Both fentanyl and CBD were used alone or in combination from PN1 to PN7. Behavioral and nociceptive tests were performed at PN60 and PN62. The expression of the microglial calcium-binding proteins Iba1 and CB1 was detected in the hippocampus using reverse Quantitative polymerase chain reaction (qPCR) and immunohistochemistry. Our results suggest that the anxiety behavior response and immune activation in adult life depend on the CBD dose combined with fentanyl for the nociceptive stimuli induced during the first week of life. Treatment of neonatal nociceptive insult with CBD and opioids showed significant dose-dependent and male-female differences. The increased gene expression in the hippocampus of the analyzed cannabinoid gene supports this data. In addition, treatment with fentanyl led to an increase in CB1 protein expression. Moreover, the expression of Iba1 varied according to the administered dose of CBD and may or may not be associated with the opioid. A lower dose of CBD during the inflammatory period was associated with enhanced anxiety in adult life. PERSPECTIVE: The treatment of nociceptive stimuli with CBD and opioids during the first week of life demonstrated significant sex differences in adult life on anxiety behavior and supraspinal pain sensitivity.

Effects of Early Exposure to Isoflurane on Susceptibility to Chronic Pain Are Mediated by Increased Neural Activity Due to Actions of the Mammalian Target of the Rapamycin Pathway

Patients who have undergone surgery in early life may be at elevated risk for suffering neuropathic pain in later life. The risk factors for this susceptibility are not fully understood. Here, we used a mouse chronic pain model to test the hypothesis that early exposure to the general anesthetic (GA) Isoflurane causes cellular and molecular alterations in dorsal spinal cord (DSC) and dorsal root ganglion (DRG) that produces a predisposition to neuropathic pain via an upregulation of the mammalian target of the rapamycin (mTOR) signaling pathway. Mice were exposed to isoflurane at postnatal day 7 (P7) and underwent spared nerve injury at P28 which causes chronic pain. Selected groups were treated with rapamycin, an mTOR inhibitor, for eight weeks. Behavioral tests showed that early isoflurane exposure enhanced susceptibility to chronic pain, and rapamycin treatment improved outcomes. Immunohistochemistry, Western blotting, and q-PCR indicated that isoflurane upregulated mTOR expression and neural activity in DSC and DRG. Accompanying upregulation of mTOR and rapamycin-reversible changes in chronic pain-associated markers, including N-cadherin, cAMP response element-binding protein (CREB), purinergic P2Y12 receptor, glial fibrillary acidic protein (GFAP) in DSC; and connexin 43, phospho-extracellular signal-regulated kinase (p-ERK), GFAP, Iba1 in DRG, were observed. We concluded that early GA exposure, at least with isoflurane, alters the development of pain circuits such that mice are subsequently more vulnerable to chronic neuropathic pain states.

A nationwide survey on producer and veterinarian perceptions of the painfulness of procedures and disease states in dairy and beef cattle

Failure to adequately manage pain in cattle causes suffering and is thus a welfare concern for the livestock industry. The objectives of this study were to summarize caregiver perceptions of the painfulness of various procedures and disease conditions in cattle. This survey also assessed factors that impact the perception of painfulness and determined relationships between pain perception and mitigation in producers and veterinarians in the United States beef and dairy cattle industries. An online survey was distributed via organization listservs and social media groups representing beef and dairy veterinarians and producers. The survey included questions about respondent demographics and pain perception and frequency of pain mitigation use for a variety of common husbandry procedures and disease conditions in cattle less than 2 months, 2-12 months, and greater than 12 months of age. Descriptive statistics were generated, and ordinal logistic regressions were used to assess the relationship between perceived pain level, frequency of pain mitigation use, and respondent demographic factors (e.g., gender, age, and role). There was a relatively low percentage of respondents that identified there was "no pain" associated with the listed procedures and conditions. Across the majority of procedures and conditions and cattle age categories, men perceived procedures to be less painful than women (P < 0.05). Veterinarians and producer-veterinarians perceived procedures to be more painful than producers (P < 0.05) for the majority of procedures and conditions. There were some differences identified between respondent age groups in pain perception but the trends were not consistent across procedures and conditions. There was a significant positive linear trend, with greater perceived pain associated with greater likelihood of providing local and systemic analgesia for all procedures and conditions across all cattle age categories (P ≤ 0.02). Perception of pain is complex and multifactorial, and it influences the likelihood to treat pain in cattle. This research highlighted the importance of understanding how these factors may play a role in increasing the use of pain mitigation within the beef and dairy industries.

Body size and brain volumetry in the rat following prolonged morphine administration in infancy and adulthood

Background

Prolonged morphine treatment in infancy is associated with a high incidence of opioid tolerance and dependence, but our knowledge of the long-term consequences of this treatment is sparse. Using a rodent model, we examined the (1) short- and (2) long-term effects of prolonged morphine administration in infancy on body weight and brain volume, and (3) we evaluated if subsequent dosing in adulthood poses an increased brain vulnerability.

Methods

Newborn rats received subcutaneous injections of either morphine or equal volume of saline twice daily for the first two weeks of life. In adulthood, animals received an additional two weeks of saline or morphine injections before undergoing structural brain MRI. After completion of treatment, structural T2-weigthed MRI images were acquired on a 7 T preclinical scanner (Bruker) using a RARE FSE sequence. Total and regional brain volumes were manually extracted from the MRI images using ITK-SNAP (v.3.6). Regions of interest included the brainstem, the cerebellum, as well as the forebrain and its components: the cerebral cortex, hippocampus, and deep gray matter (including basal ganglia, thalamus, hypothalamus, ventral tegmental area). Absolute (cm³) and normalized (as % total brain volume) values were compared using a one-way ANOVA with Tukey HSD post-hoc test.

Results

Prolonged morphine administration in infancy was associated with lower body weight and globally smaller brain volumes, which was not different between the sexes. In adulthood, females had lower body weights than males, but no difference was observed in brain volumes between treatment groups. Our results are suggestive of no long-term effect of prolonged morphine treatment in infancy with respect to body weight and brain size in either sex. Interestingly, prolonged morphine administration in adulthood was associated with smaller brain volumes that differed by sex only in case of previous exposure to morphine in infancy. Specifically, we report significantly smaller total brain volume of female rats on account of decreased volumes of forebrain and cortex.

Conclusions

Our study provides insight into the short- and long-term consequences of prolonged morphine administration in an infant rat model and suggests brain vulnerability to subsequent exposure in adulthood that might differ with sex.

Time for Action: Understanding Health Care Professionals Views on Pain and Pain Management in a Pediatric Hospital

BACKGROUND

Children admitted to the hospital experience pain. ChildKind International (CKI) is an organization dedicated to improving the quality of pediatric pain care worldwide. In 2019, BC Children hospital (BCCH) clinicians set out to achieve this certification. A qualitative study was performed in order to fully comprehend the current state of pain assessment and management at BCCH.

AIM

The objective of this study is to characterize the perceptions of health care professionals (HCPs) about pediatric pain and pain management in a pediatric hospital.

METHODS

We choose a quantitative methodology as it allows us to delve more deeply into the HCPs' personal experience with pain and pain management of children in the hospital. We interviewed 31 pediatric healthcare professionals (N = 31).

RESULTS

HCPs believe there is a significant lack of resources, especially educational resources, to adequately assess and treat pain in children. There is a lack of time to evaluate each patient appropriately and use pain tools consistently for both verbal and non-verbal children. HCPs varied in their opinions as to whether a procedure is painful or uncomfortable, and this opinion often differs from the perception of the child. Additionally, staff recognize that cultural diversity of both staff and patients can influence pain assessment and management in children. Therefore, there is a need for increased cultural diversity training for staff.

CONCLUSIONS

Pain management and treatment of children in the hospital remain inconsistent and inadequate. ChildKind certification will help hospitals to address this gap in their clinical practice.

Procedural Pain Management During Tenotomy for Congenital Talipes Equinovarus

The majority of infants with congenital talipes equinovarus (CTEV) require tenotomy of the tendoachilles. The pain response of this procedure in the awake infant has not been previously reported. In this observational study, multimodal pain management strategies, including oral sucrose, oral paracetamol, topical anesthetic, local anesthetic, a pacifier (dummy), and swaddling, were used. Physiological responses and pain were recorded. Pain was rated out of 10 at regular intervals, using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Ninety-one infants (65 men, mean age = 53 days, range = 19-217 days) were observed. At baseline, median FLACC, heart rate (HR), and oxygen saturation (Spo₂) were 1, 159, and 97% respectively. Peak median FLACC and HR were 9 and 200, respectively, and lowest median Spo₂ was 92%. The median (interquartile range) time for FLACC to return to 3 or less was 2 (2-5) minutes. Achilles tenotomy for CTEV in the awake infant is associated with high pain levels despite provision of multimodal pain relief measures.

ASAD: A Novel Audification Console for Assessment and Communication of Pain and Discomfort

Pain and discomfort are subjective perceptions that are difficult to quantify. Various methods and scales have been developed to find an optimal manner to describe them; however, these are difficult to use with some categories of patients. Audification of pain has been utilized as feedback in rehabilitation settings to enhance motor perception and motor control, but not in assessment and communication settings. We present a novel tool, the Audification-console for Self-Assessment of Discomfort (ASAD), for assessing and communicating pain and discomfort through sound. The console is a sequence of increasing pitch and frequencies triggered at the press of buttons and displayed as a matrix that can be associated with the subjective perception of pain and discomfort. The ASAD has been evaluated in its ability to capture and communicate discomfort, following a fatigue test in the lower limbs with thirty healthy volunteers, and compared to the most common self-reported methods used in the NHS. (The National Health Service (NHS) is the publicly funded healthcare system in England and one of the four National Health Service systems in the United Kingdom.) This was a qualitative, within subjects and across groups experiment study. The console provides a more accurate assessment than other scales and clearly recognizable patterns of sounds, indicating increased discomfort, significantly localized in specific frequency ranges, thus easily recognizable across subjects and in different instances of the same subject. The results suggest a possible use of the ASAD for a more precise and automatic assessment of pain and discomfort in health settings. Future studies might assess if this is easier to use for patients with communication or interpretation difficulties with the traditional tools.

Comparison of adjuvant pharmaceuticals for caudal block in pediatric lower abdominal and urological surgeries: A network meta-analysis

STUDY OBJECTIVE

Caudal block helps relieve pain after sub-umbilical surgery in pediatric patients; however, the duration for which it exerts its analgesic effect is limited. The addition of certain adjuvant agents to local anesthetics (LAs) that are used to administer caudal block can prolong postoperative analgesia. Therefore, we aimed to compare the efficiencies and side effects of caudal adjuvants in the settings of pediatric lower abdominal and urological surgeries.

DESIGN

A network meta-analysis (NMA).

PATIENTS

One hundred and twelve randomized controlled trials (RCTs) involving 6800 pediatric patients were included in the final analysis.

INTERVENTIONS

Different adjuvant agents, namely clonidine, dexamethasone, dexmedetomidine, fentanyl, ketamine, magnesium, midazolam, morphine, neostigmine, and tramadol.

MEASUREMENTS

The primary outcome was the duration of analgesia. The secondary outcomes included the requirement for additional analgesia, analgesic consumption, and postoperative complications. The effects and rankings were evaluated using NMA and the surface under the cumulative ranking curve scores, respectively.

RESULTS

Neostigmine, dexmedetomidine, and dexamethasone were found to be the three most effective adjuvants that prolong the duration of analgesia for caudal block, and these adjuvants extended this duration by 8.9 h (95% confidence interval [CI], 7.1-10.7), 7.3 h (95% CI, 6.0-8.6), and 5.9 h (95% CI, 4.0-7.7), respectively. Caudal neostigmine was associated with an increase in the incidence of postoperative nausea and vomiting, whereas dexmedetomidine and dexamethasone showed no postoperative complications.

CONCLUSIONS

This NMA provided evidence and suggested that dexmedetomidine and dexamethasone may be the most beneficial adjuvant pharmaceutics adding to LAs for caudal block in children. However, given the off-label status of caudal dexmedetomidine and dexamethasone, further high-quality RCTs are still warranted, especially to determine whether delayed neurological complications will occur.

What is the medical evidence on non-therapeutic child circumcision?

Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.

Decreasing Complete Blood Count Clotting Rates: An Improvement Project in an Academic Neonatal Intensive Care Unit

BACKGROUND

In premature and critically ill infants, a complete blood count (CBC) is commonly collected via the heel-stick method, which is preferred because of the ongoing requirements to preserve intravenous sites. However, because of sample clotting, these specimens are often rejected, leading to unnecessary repeat heel sticks, painful stimuli, and increased costs.

PURPOSE

The purpose of this quality improvement project was to decrease the rate of clotted CBC samples obtained from neonates admitted in the neonatal intensive care unit.

METHODS

The RE-AIM translation model, which stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance, was adopted to decrease the rate of clotted CBC samples through staff education, randomized audits of the staff's heel-stick technique, and the development and implementation of a standardized capillary blood sampling protocol. The primary outcome measure was the rate of clotted CBC samples, which was defined as the proportion of clotted CBC samples.

RESULTS

CBC clotted sample rates decreased by 27%, resulting in a cost saving of $1136, and overall CBC rejection rates decreased by 23%.

IMPLICATIONS FOR PRACTICE

All hospital units should provide staff with an evidence-based resource, recurrent education, and evaluation of skills to avoid unnecessary repeat heel sticks and prevent increased pain sensitivity, social hypervigilance, and avoidance behavior in early infancy.

IMPLICATIONS FOR RESEARCH

Future efforts should focus on the long-term benefits of routine education and its effects on clotted sample rates and whether samples drawn by laboratory phlebotomy staff versus registered nurses/patient care technicians result in disproportionate rejection rates.

Camera-based discomfort detection using multi-channel attention 3D-CNN for hospitalized infants

Background

Detecting discomfort in infants is an important topic for their well-being and development. In this paper, we present an automatic and continuous video-based system for monitoring and detecting discomfort in infants.

Methods

The proposed system employs a novel and efficient 3D convolutional neural network (CNN), which achieves an end-to-end solution without the conventional face detection and tracking steps. In the scheme of this study, we thoroughly investigate the video characteristics (e.g., intensity images and motion images) and CNN architectures (e.g., 2D and 3D) for infant discomfort detection. The realized improvements of the 3D-CNN are based on capturing both the motion and the facial expression information of the infants.

Results

The performance of the system is assessed using videos recorded from 24 hospitalized infants by visualizing receiver operating characteristic (ROC) curves and measuring the values of area under the ROC curve (AUC). Additional performance metrics (labeling accuracy) are also calculated. Experimental results show that the proposed system achieves an AUC of 0.99, while the overall labeling accuracy is 0.98.

Conclusions

These results confirms the robustness by using the 3D-CNN for infant discomfort monitoring and capturing both motion and facial expressions simultaneously.

Antinociceptive effect of vapocoolant medium stream spray on hotplate latency in rat pups

BACKGROUND

Heel sticks account for most blood tests performed in neonates without analgesia because topical local anesthetics are ineffective on heel glabrous skin. We investigated the antinociceptive effect of an alternative topical analgesic, a vapocoolant spray, on hind paw glabrous skin of rat pups. The spray was applied by two methods: method 1 for 4 s at a distance of 8 cm and method 2 for 10 s at a distance of 18 cm.

METHODS

The rat pups were randomized to either method 1 (n = 32) or method 2 (n = 31). Vapocoolant spray was applied to one hind paw randomly, and saline spray was applied to the contralateral paw. The paws were exposed to a hotplate test to measure withdrawal latency time before and 30 s after the spray applications. Additionally, rat pups were tested for tissue toxicity in method 1 (n = 20) and method 2 (n = 20) after application of the vapocoolant spray before heel sticks three times a day for two consecutive days. Analyses of spray and method effects on hotplate withdrawal latency time were determined by nonparametric Wilcoxon tests to assess paired difference between vapocoolant spray and saline spray and to compare difference in medians between the two methods.

RESULTS

Method 1 and method 2 vapocoolant spray applications significantly prolonged the withdrawal latency time compared with saline, a median difference of 0.6 s (IQR 0.1-1.2) for method 1 and 9.5 s (IQR 5.5-10.7) for method 2 (a 15-fold longer latency time with method 2). Method-2 produced significantly longer withdrawal latency time than method 1 with a difference in median time of 8.9 s (CI: 95% 7.3-10.4 s, P < .0001). No histopathological changes were detected.

CONCLUSIONS

Compared with method- 1, the vapocoolant spray in method 2 produced significantly longer withdrawal latency time that is clinically applicable to collecting blood samples after a heel stick.

Neonatal male circumcision is associated with altered adult socio-affective processing

BACKGROUND

Neonatal male circumcision is a painful skin-breaking procedure that may affect infant physiological and behavioral stress responses as well as mother-infant interaction. Due to the plasticity of the developing nociceptive system, neonatal pain might carry long-term consequences on adult behavior. In this study, we examined whether infant male circumcision is associated with long-term psychological effects on adult socio-affective processing.

METHODS

We recruited 408 men circumcised within the first month of life and 211 non-circumcised men and measured socio-affective behaviors and stress via a battery of validated psychometric scales.

RESULTS

Early-circumcised men reported lower attachment security and lower emotional stability while no differences in empathy or trust were found. Early circumcision was also associated with stronger sexual drive and less restricted socio-sexuality along with higher perceived stress and sensation seeking.

LIMITATIONS

This is a cross-sectional study relying on self-reported measures from a US population.

CONCLUSIONS

Our findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior.

A child in pain: A psychologist’s perspective on changing priorities in scientific understanding and clinical care

My research and clinical career followed a trajectory of increasing appreciation for the importance of social factors as determinants of pain experience and expression. The social contexts of children’s lives determine whether infants and children are exposed to pain, how socialization in family and ethnocultural contexts lead to pain as a social experience, comprised of thoughts and feelings as well as sensory input, how others shape pain experience and expression, less so for automatic/reflexive features than purposeful representations, and how other's appraisals of children’s pain reflect the observer's unique background and capacities for intervening in the child’s interests. A greater understanding of the social dimensions of pain, as reflected in the social communication model of pain, would support innovation of psychological and social interventions.

Bereaved Parents' Perceptions of Infant Suffering in the NICU

CONTEXT

It is challenging to provide supportive intensive care to infants in the neonatal intensive care unit (NICU), giving them every chance for survival, while also trying to minimize suffering for both the infant and parents. Parents who believe their infant is suffering may alter treatment goals based on their perceptions; however, it is unknown how parents come to believe that their infant may be suffering.

OBJECTIVES

To examine bereaved parents' perceptions of infant suffering in the NICU.

METHODS

Parents completed a qualitative interview exploring their perceptions of the level of suffering that their infant experienced at the end of life. Parents whose infant died in a large Midwestern Level IV regional referral NICU from July 2009 to July 2014 were invited to participate. Thirty mothers and 16 fathers from 31 families (31 of 249) participated in telephone interviews between three months and five years after their infant's death.

RESULTS

Four themes emerged from the qualitative analysis: 1) the presence/absence of suffering, 2) indicators of suffering, 3) temporal components of suffering (trajectory), and 4) influence of perceived suffering on parents, infants, and clinical decision making.

CONCLUSION

Parents used signs exhibited by infants, as well as information they received from the health care team to form their perceptions of suffering. Perceived suffering followed different trajectories and influenced the decisions that parents made for their infant. Soliciting parent perspectives may lead to improvements in the understanding of infant well-being, particularly suffering, as well as how parents rely on these perceptions to make treatment decisions for their infant.

Neurophysiological and behavioral measures of pain during neonatal hip examination

Introduction

The aim of this study was to test the hypothesis that neonatal hip examination causes pain in newborns. Pain assessment using instruments such as the Premature Infant Pain Profile‐Revised (PIPP‐R) scale is recommended, but recently physiological and neurophysiological measures, for example, near‐infrared spectroscopy (NIRS) and galvanic skin response (GSR), have been used as well.

Methods

Heart auscultation and hip examination were performed, and the response of the newborn was registered by NIRS optodes, GSR electrodes, and a pulse oximeter probe attached to the infant. The face of the newborn was filmed. Heart auscultation was used as a nonpainful reference.

Results

The pain scores for hip examination were higher than for the heart auscultation. Near‐infrared spectroscopy showed a significant higher increase from baseline in oxygenated hemoglobin (HbO₂) on both sides of the cortex at hip examination compared with at heart auscultation (P = .011 and P = .017). Mean PIPP‐R scores for the hip examination compared with heart auscultation increased from 3.0 to 8.1 (P = .000). The GSR analyses of hip examination compared with heart auscultation showed a significant increase in area under small peaks during the hip examination (P = .016), however, not when measured in peaks per second (P = .104). Interrater reliability was calculated for the NIRS interpretations, with an intraclass correlation coefficient (ICC) range of 0.93‐1.0 (P = .000).

Discussion

Pain in newborns can have negative consequences, and pain prevention and treatment are therefore important. We conclude that neonatal hip examinations are painful and that the pain should be treated, for example, with oral sweet solution. This is a change from present routines during neonatal hip examination and is hoped to lead to a change in national guidelines.

Postoperative pain: factors and tools to improve pain management in children

Outpatient surgery has made it increasingly common for parents to manage pain in the home setting. Studies have shown that parents often under treat pain, leaving children vulnerable to the negative side effects of suboptimal pain management. Multiple factors affect pain management like child’s age and developmental stage, language, cultural values like stoicism, parental beliefs about medication, biological differences among groups, etc. Understanding all the factors involved can help healthcare providers and parents better understand pain and contribute to optimal pain management. Multiple tools and technological interventions have been created to help create a better understanding of pain and a holistic approach to care.

Oral sweet solution to prevent pain during neonatal hip examination: a randomised controlled trial

Aim

To determine if oral glucose can have a pain‐relieving effect during routine hip examinations in newborn infants.

Methods

In this randomised controlled study 100 newborn infants undergoing the routine physical examination including the potentially painful hip examination were included between March 2016 and April 2017. Fifty infants were randomised to water (control) and 50 to oral glucose (intervention) before their examination. Pain was assessed using crying time, Astrid Lindgren and Lund Children's Hospital Pain and Stress Assessment Scale (ALPS‐Neo) and Visual analogue scale (VAS).

Results

Total crying time (p = 0.006), crying time during the hip examination (p = 0.026), ALPS‐Neo (p = 0.004) and VAS (p = 0.006) (when assessed by the physician) were all significantly decreased in the group of infants receiving glucose. VAS assessment made by the parents did not reach statistical significance (p = 0.127).

Conclusion

Oral glucose given before the examination has a pain‐relieving effect during the hip examination in healthy newborn infants.

Pharmacokinetics and physiologic/behavioral effects of buprenorphine administered sublingually and intravenously to neonatal foals

Buprenorphine is absorbed following sublingual administration, which would be a low-stress delivery route in foals. However, the pharmacokinetics/pharmacodynamics are not described in foals. Six healthy foals <21 days of age participated in a blinded, randomized, 3-period, 5-sequence, 3-treatment crossover prospective study. Foals received 0.01-0.02 mg/kg buprenorphine administered SL or IV with an equivalent volume of saline administered by the opposite route. Blood was collected from the cephalic vein for pharmacokinetic analysis. Physiologic parameters (HR, RR, body temperature, GI sounds), locomotion (pedometer), and behavioral data (activity level, nursing time, response to humans) were recorded. Plasma concentration of buprenorphine exceeded a presumed analgesic level (0.6 ng/ml) in five foals in the IV group and one in the SL group but only for a very brief time. Pharmacokinetic analysis following IV administration demonstrated a short elimination half-life (t_1/2β 1.95 ± 0.7 hr), large volume of distribution (6.46 ± 1.54 L/kg), and a high total clearance (55.83 ± 23.75 ml/kg/min), which differs from adult horses. Following SL administration, maximum concentrations reached were 0.61 ± 0.11 ng/ml and bioavailability was 25.1% ± 10.9%. In both groups, there were minor statistical differences in HR, RR, body temperature, locomotion, and time spent nursing. However, these differences were clinically insignificant in this single dose study, and excitement, sedation, or colic did not occur.

Factors Associated With Infant Pain Severity Undergoing Immunization Injections

PURPOSE

Factors influencing infants' behavioral and vocal (cry) response to painful stimuli are explored to improve pain management plans for infants undergoing immunizations.

DESIGN AND METHODS

An observational study design was used. Pain responses of 60 to 75 days-old infants (44% male vs 56% female) undergoing two-month immunization injections were videotaped and coded using the Modified Behavioral Pain Scale (MBPS), and duration of total crying time during injection was recorded. The influences of five factors (gender, caregiver attendance, previous experience of nociception (circumcision), mode of delivery), and weight (birth and current) were examined at baseline, during and post-immunization.

RESULTS

Higher birth weight was the most significant factor that reduced pain responses during (p = 0.001) and post-immunization (p = 0.03). A higher birth weight reduced full lung crying (p = 0.04), which reflects crying during injection as compared to total crying time. Vaginal delivery had a significant effect on behavioral pain responses of infants only post-immunization (p = 0.006). Parent's presence in the immunization room significantly reduced total crying time (p = 0.03). Uncircumcised male infants had a significant reduction in behavioral pain responses during immunization (p = 0.01) compared to circumcised infants.

CONCLUSIONS

The literature well supports the acknowledgement of early pain experience and its psychological consequences. Knowing and controlling for each of mentioned factors early in life during every painful procedure could improve coping mechanisms of infants for any painful procedures later in life.

PRACTICE IMPLICATIONS

Control of certain factors during early life experiences can modify pain of immunization.

Effects of Perinatal Factors on Body Mass Index and Physical Fitness of School-age Children

Objective

To examine the effects of various maternal and neonatal perinatal factors on the child’s body mass index (BMI) and physical fitness at school-age.

Methods

Data from two registries, the SLOfit database (a national surveillance system of children’s motor and physical development) and Slovenian National Perinatal Information System (NPIS) were analysed. Perinatal data for 2,929 children born in 2008 were linked to results of SLOfit testing of these children in 2016. Linear regression analysis was used to assess the potential relationship between several perinatal factors (very preterm birth, birth mass, maternal age, hypertensive disorders of pregnancy, gestational diabetes, parity, plurality, maternal pre-pregnancy BMI, mode of delivery, presentation, Apgar score at 5 minutes, and admission to a neonatal intensive care unit (NICU)) and child’s BMI or child’s physical fitness index (PFI) at the age of eight years. We also included child’s school grade and maternal educational level in the analysis. A p value <0.05 was considered statistically significant.

Results

Children born to mothers with lower pre-pregnancy BMI and higher education had lower BMI and higher PFI (p<0.001) at school-age. Physical fitness was also inversely associated with nulliparity (p<0.001) and NICU admission (p=0.020).

Conclusions

Among all perinatal factors studied, higher maternal education and lower pre-pregnancy BMI seem to be the most significant determinants of child’s BMI and physical fitness at school-age.

A review of factors affecting analgesic selection in large animals undergoing translational research

The widespread physiological effects of pain in experimental animals are likely to reduce the validity of data except when pain itself is studied. Appropriately prescribed analgesics will limit pain and improve the welfare of animals undergoing noxious experimental procedures. However, their injudicious use may also introduce variability in data and limit study reproducibility. Optimizing both animal welfare and the value of scientific data from experimental studies requires the ability to identify, quantify and treat animal pain by applying a knowledge of analgesic pharmacology that is sympathetic to study objectives. This review first examines the reasons for promoting analgesic use in translational animal research and, in focussing on pigs and small ruminants, then identifies factors that should be considered when devising analgesic plans.

Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients

INTRODUCTION

Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.

A Review of Automated Pain Assessment in Infants: Features, Classification Tasks, and Databases

Bedside caregivers assess infants' pain at constant intervals by observing specific behavioral and physiological signs of pain. This standard has two main limitations. The first limitation is the intermittent assessment of pain, which might lead to missing pain when the infants are left unattended. Second, it is inconsistent since it depends on the observer's subjective judgment and differs between observers. Intermittent and inconsistent assessment can induce poor treatment and, therefore, cause serious long-term consequences. To mitigate these limitations, the current standard can be augmented by an automated system that monitors infants continuously and provides quantitative and consistent assessment of pain. Several automated methods have been introduced to assess infants' pain automatically based on analysis of behavioral or physiological pain indicators. This paper comprehensively reviews the automated approaches (i.e., approaches to feature extraction) for analyzing infants' pain and the current efforts in automatic pain recognition. In addition, it reviews the databases available to the research community and discusses the current limitations of the automated pain assessment.

Neonatal inflammatory pain and systemic inflammatory responses as possible environmental factors in the development of autism spectrum disorder of juvenile rats

Background

Autism spectrum disorder (ASD) affects many children and juveniles. The pathogenesis of ASD is not well understood. Environmental factors may play important roles in the development of ASD. We examined a possible relationship of inflammatory pain in neonates and the development of ASD in juveniles.

Methods

Acute inflammation pain was induced by 5 % formalin (5 μl/day) subcutaneous injection into two hindpaws of postnatal day 3 to 5 (P3–P5) rat pups. Western blot, immunohistochemical, and behavioral examinations were performed at different time points after the insult.

Results

Formalin injection caused acute and chronic inflammatory responses including transient local edema, increased levels of inflammatory cytokines, TNF-α, and IL-1β in the blood as well as in the brain, and increased microglia in the brain. One day after the pain insult, there was significant cell death in the cortex and hippocampus. Two weeks later, although the hindpaw local reaction subsided, impaired axonal growth and demyelization were seen in the brain of P21 juvenile rats. The number of bromodeoxyuridine (BrdU) and doublecortin (DCX) double-positive cells in the hippocampal dentate gyrus of P21 rats was significantly lower than that in controls, indicating reduced neurogenesis. In the P21 rat’s brain of the formalin group, the expression of autism-related gene neurexin 1 (NRXN1), fragile X mental retardation 1 (FMR1), and oxytocin was significantly downregulated, consistent with the gene alteration in ASD. Juvenile rats in the formalin group showed hyperalgesia, repetitive behaviors, abnormal locomotion, sleep disorder, and distinct deficits in social memory and social activities. These alterations in neuroinflammatory reactions, gene expression, and behaviors were more evident in male than in female rats. Importantly, an anti-inflammation treatment using indomethacin (10 mg/kg, i.p.) at the time of formalin injections suppressed inflammatory responses and neuronal cell death and prevented alterations in ASD-related genes and the development of abnormal behaviors.

Conclusions

These novel observations indicate that severe inflammatory pain in neonates and persistent inflammatory reactions may predispose premature infants to development delays and psychiatric disorders including ASD. The prevention of pain stimuli and prompt treatments of inflammation during development appear vitally important in disrupting possible evolution of ASD syndromes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12974-016-0575-x) contains supplementary material, which is available to authorized users.

Does Pain in the Neonatal Period Influence Motor and Sensory Functions in a Similar Way for Males and Females During Post-Natal Development in Rats?

OBJECTIVE : Early pain experiences can lead to disruption in the long-term responses to pain and in abnormal development and behavior in rodents. We evaluated the sensory and motor development of Wistar rats after exposure to painful stimulation (repetitive needle prickling) immediately after birth. METHODS : Male and female rats were followed up to 6 months of life, and sensory and motor functions were investigated by testing paw withdrawal with von Frey filaments, calibrated forceps (CF), and grip strength (GS) tests. RESULTS : Body weight increased with age and tended to be smaller in pain groups compared with their controls of the same sex. GS values also increased with age in controls but were stable and even decreased in pain groups from 120 up to 180 days. The von Frey filaments test showed higher values on the nonstimulated paws in male and female pain groups, with no differences between sides on the controls. The CF test showed smaller values on the stimulated paws in the pain group, with no differences between sides on the controls. CONCLUSIONS : Pain in the neonatal period influences sensory and motor functions negatively during development in male and female rats, even long term after the painful stimulus is ceased. The neonatal injury-induced hypersensitivity is persistent, and male and female rats respond similarly to the stimulus.

Age-dependent sensitization of cutaneous nociceptors during developmental inflammation

BACKGROUND

It is well-documented that neonates can experience pain after injury. However, the contribution of individual populations of sensory neurons to neonatal pain is not clearly understood. Here we characterized the functional response properties and neurochemical phenotypes of single primary afferents after injection of carrageenan into the hairy hindpaw skin using a neonatal ex vivo recording preparation.

RESULTS

During normal development, we found that individual afferent response properties are generally unaltered. However, at the time period in which some sensory neurons switch their neurotrophic factor responsiveness, we observe a functional switch in slowly conducting, broad spiking fibers ("C"-fiber nociceptors) from mechanically sensitive and thermally insensitive (CM) to polymodal (CPM). Cutaneous inflammation induced prior to this switch (postnatal day 7) specifically altered mechanical and heat responsiveness, and heat thresholds in fast conducting, broad spiking ("A"-fiber) afferents. Furthermore, hairy skin inflammation at P7 transiently delayed the functional shift from CM to CPM. Conversely, induction of cutaneous inflammation after the functional switch (at P14) caused an increase in mechanical and thermal responsiveness exclusively in the CM and CPM neurons. Immunocytochemical analysis showed that inflammation at either time point induced TRPV1 expression in normally non-TRPV1 expressing CPMs. Realtime PCR and western blotting analyses revealed that specific receptors/channels involved in sensory transduction were differentially altered in the DRGs depending on whether inflammation was induced prior to or after the functional changes in afferent prevalence.

CONCLUSION

These data suggest that the mechanisms of neonatal pain development may be generated by different afferent subtypes and receptors/channels in an age-related manner.

Expressed breast milk for procedural pain in preterm neonates: a randomized, double-blind, placebo-controlled trial

AIM

To determine whether expressed breast milk (milk) reduces procedural pain associated with heel lancing in preterm neonates.

METHODS

In this placebo-controlled trial, preterm neonates received 5 mL of distilled water as placebo (water, n = 44), 25% glucose water (glucose, n = 39) or milk (n = 40). Heel lancing was performed 2 min later. The primary outcome was the duration of first cry after lancing.

RESULTS

Participants had similar baseline demographic and clinical characteristics. There was a significant difference in the median duration of first cry among the groups: water = 70.5 sec [interquartile range (IQR) = 5.5-104.5]; glucose = 2.0 sec (IQR = 0.0-45.0); milk = 29.5 sec (IQR = 0.0-65.0). Specifically, the duration of first cry was significantly shorter in the glucose group compared with the water group (Bonferroni adjustment, p = 0.011). Pain scores were significantly lower in the glucose and milk groups compared with the water group 1, 2 and 3 min after heel lancing (p < 0.05).

CONCLUSIONS

Although milk did not significantly reduce crying time, our finding that pain scores were significantly lower in the milk group suggests that milk may reduce pain associated with heel lancing in preterm neonates.

Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age

BACKGROUND

Administration of oral sucrose or glucose with and without non-nutritive sucking is frequently used as a non-pharmacological intervention for needle-related procedural pain relief in infants.

OBJECTIVES

To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data.

SELECTION CRITERIA

Randomised-controlled trials using a sweet-tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle-related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra-pubic bladder aspiration were not included as they are more severe and painful than needle-related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet-tasting solution, a pharmacological pain-relieving method (e.g. paracetamol, topical anaesthetic cream), non-pharmacological pain-relieving method (e.g. distraction method, non-nutritive sucking).

DATA COLLECTION AND ANALYSIS

Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed-effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi(2) test and I(2) statistic were used to assess between-study heterogeneity.

MAIN RESULTS

Sixty-five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet-tasting solution [MD -13.47 (95% CI -16.80 to -10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I(2) = 94%) that we were unable to explain. Meta-analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine-prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet-tasting solutions in infants aged one to 12 months. Further large RCTs are needed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to confidently judge the effectiveness of sweet-tasting solutions in reducing needle-related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta-analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects.