Evaluation of prolonged pain in preterm infants with pneumothorax using heart rate variability analysis and EDIN (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) scores

The Newborn Infant Parasympathetic Evaluation Index for Assessment of Procedural Pain and Discomfort in Mechanically Ventilated Pediatric Intensive Care Patients: A Prospective, Exploratory, Observational Study

BACKGROUND

The heart rate variability-based Newborn Infant Parasympathetic Evaluation (NIPE) Index is a continuous noninvasive tool for the assessment of pain and discomfort in infants. Little is known about its performance in the pediatric intensive care unit (PICU) setting, where assessment of pain/discomfort is usually based on discontinuous observational scoring systems or personal experience of medical staff.

AIM

Evaluation of the performance of NIPE as an indicator of procedural pain and/or discomfort in conscious mechanically ventilated PICU patients.

METHODS

Procedural pain/discomfort was simultaneously assessed during pain- or stressful procedures by two validated discontinuous clinical scoring systems (FLACC and COMFORT-B scale) and the NIPE.

RESULTS

NIPE values, FLACC- and COMFORT-B scores were recorded in 17 infants with a mean age of 1.2 (range 0.8-5.9) months. NIPE values associated with positive FLACC- (≥ 4; indicative of pain) and/or COMFORT-B (≥ 17, indicative of discomfort) scores were lower (p < 0.001) than when associated with negative FLACC (< 4) and/or COMFORT-B (< 17) scores with 95% CI's of a difference of -14 to -11 (FLACC), -13 to -11 (COMFORT-B) and -14 to -11 (FLACC and COMFORT-B), with significant interindividual variability in NIPE values. Logistic regression analyses revealed odds ratios between 0.84 and 0.85; the adjacent receiver operating curve analyses showed areas under the curve between 0.83 and 0.88. NIPE data recording failure occurred during 49.3% of the periods with a FLACC ≥ 4% and 40.7% with a COMFORT-B ≥ 17.

CONCLUSIONS

The NIPE detects procedural pain and discomfort in conscious mechanically ventilated infants with an accuracy comparable to established clinical scoring systems. However, because of significant interindividual variability of NIPE values and frequent data recording failure associated with patient movement, we believe it is premature to recommend its use in conscious infants.

Pain and heart rate variability in neonates receiving dexmedetomidine

INTRODUCTION

Neonates in a NICU experience pain. Based on the cardiovascular and nociceptive systems link, a Newborn Infant Parasympathetic Evaluation (NIPE) monitor was designed to assess pain. The use of α2-agonists as analgesic-sedative drugs has increased in neonates. Given their effect on the autonomic system, we hypothesized that their use may alter NIPE's measurement capacity.

METHODS

Data were prospectively collected. The included patients were evaluated using combined pain assessment systems.

RESULTS

Sixteen newborns requiring sedoanalgesia underwent a total of 84 pain assessments. A good correlation was found between the NIPE-index and the COMFORT-neo and the crSO2 (cerebral regional oxygen saturation). No correlation was found in premature infants. By sedation group, the correlation remained in those receiving α2-agonist.

CONCLUSION

NIPE is a reliable tool for pain assessment. Further studies in premature infants are needed. The use of α2-agonist does not alter the measuring capacity of NIPE. The correlation between NIPE-index and crSO2 was also demonstrated.

Prolonged pain in premature neonates hospitalised in neonatal intensive care units: A scoping review

BACKGROUND

Exposure to repetitive pain during the neonatal period has been shown to have important short and long-term effects on the neurodevelopment of the premature neonate and can contribute to experienced prolonged pain. A uniform taxonomy of neonatal prolonged pain is still lacking to this day which contributes to suboptimal prolonged pain management in neonatal intensive care units. Accordingly, a scoping review exploring the state of knowledge about prolonged pain in preterm neonates hospitalised in the neonatal intensive care unit will contribute to the developing field of neonatal prolonged pain and provide recommendations for clinical prolonged pain management.

OBJECTIVE

To determine the scope, extent, and nature of the available literature on prolonged pain in premature neonates hospitalised in neonatal intensive care units.

DESIGN

Scoping review.

METHODS

An electronic search was conducted from inception to November 2023 in the databases of CINAHL, PubMed, Medline, Web of Science, GeryLit.org and Grey Source Index. Included studies discussed concepts related to neonatal prolonged pain such as definitions of prolonged pain, indicators of prolonged pain, contexts that result in prolonged pain, prolonged pain evaluation tools, consequences of prolonged pain and interventions for prolonged pain management.

RESULTS

Key concepts of neonatal prolonged pain were identified in the 86 included articles of this scoping review such as definitions (n = 26), indicators (n = 39), contexts (n = 49), scales (n = 56), consequences of prolonged pain (n = 30) and possible interventions for prolonged pain management (n = 22). Whilst a consensus on a definition has yet to be achieved, no proximate event was shown to cause prolonged pain and a time criterion was identified by authors as being relevant in defining prolonged pain. Interestingly, the context of hospitalisation was identified as being the most indicative of prolonged pain in premature neonates and should guide its evaluation and management, whilst only limited pain management interventions and consequences were discussed.

CONCLUSION

The findings of this scoping review contribute to the foundation of growing knowledge in neonatal prolonged pain and shed light on the ambiguity that currently exists on this topic in the scientific literature. This review summarises knowledge of key concepts necessary for a better understanding of prolonged pain and stresses the importance of considering contexts of hospitalisation for prolonged pain evaluation and management in neonatal intensive care units, with the objective of improving developmental outcomes of premature neonates.

TWEETABLE ABSTRACT

A scoping review reveals that the contexts of prolonged pain in premature neonates hospitalised in the neonatal intensive care unit are essential in guiding its evaluation and management.

Sensitivity and Specificity of the Newborn Infant Parasympathetic Evaluation Index in Pain Assessment of Very Low Birth Weight Infants

OBJECTIVE

This article describes the results of a study investigating the sensitivity and specificity of the Newborn Infant Parasympathetic Evaluation (NIPE) index for detecting the physiological changes resulting from nociception in painful procedures in very low birth weight (VLBW) infants.

STUDY DESIGN

A prospective observational study was carried on of 44 newborns at 23 to 32 weeks' gestational age. The sensitivity and specificity of the NIPE index are analyzed using a receiver operating characteristic curve. Most of the painful procedures performed were skin-lancing and venipunctures. Nonpainful procedures consist of no intervention, with an interval of at least 1 hour with painful procedures in each newborn.

RESULTS

The accuracy of the NIPE index to diagnose mild nociceptive stimulation in VLBW newborns is 73.2%.

CONCLUSION

The NIPE index is a useful technique for assessing nociceptive stimulation in newborns, presenting less observer-dependent variability than other pain assessment scales.

KEY POINTS

· The NIPE index offers an objective assessment of pain.. · Moderate-high sensitivity of the NIPE index in the evaluation of pain in premature newborns.. · Painful procedures in VLBW newborns are reflected as a decrease in the NIPE score..

Newborn and Infant Parasympathetic Evaluation (NIPE™) Monitor for Assessing Pain During Surgery and Interventional Procedures: A Systematic Review

BACKGROUND

The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) monitor has been designed to be an objective, non-invasive tool for the assessment of pain and discomfort in children under 2 years of age. The aim of this systematic review was to evaluate the ability of NIPE to assess pain in neonates and infants during surgical and/or painful procedures.

METHODS

A systematic review (2010-2023) was conducted using PRISMA guidelines. Studies containing children above 2-years-old were excluded. The ROBINS-I (Risk of Bias in Non-randomised Studies of Interventions) tool was used to assess the quality of included studies.

RESULTS

9 databases were searched identifying 470 articles, 460 did not meet the inclusion criteria and were excluded; therefore, 10 studies with 548 participants were included. NIPE was used to assess intraoperative and postoperative pain for surgery under general anaesthesia (5 studies), as well as acute and prolonged pain from other interventional procedures (5 studies). For surgery under general anaesthesia: NIPE has shown to detect nociceptive events (e.g., skin incision, intubation), insufficient analgesia intraoperatively and to predict early postoperative pain. For painful interventional procedures: NIPE has shown to detect acute pain with a high sensitivity and negative predictive value.

CONCLUSION

NIPE has been used to assess pain in surgery and for various painful procedures. NIPE can detect intraoperative pain and reflect early postoperative pain. NIPE may be useful in evaluating procedural pain, however with heterogenous outcomes, more studies are required to confirm its efficacy.

TYPE OF STUDY

Systematic Review.

LEVEL OF EVIDENCE

Level II.

Biomarkers for assessing pain and pain relief in the neonatal intensive care unit

Newborns admitted to the neonatal intensive care unit (NICU) regularly undergo painful procedures and may face various painful conditions such as postoperative pain. Optimal management of pain in these vulnerable preterm and term born neonates is crucial to ensure their comfort and prevent negative consequences of neonatal pain. This entails accurate and timely identification of pain, non-pharmacological pain treatment and if needed administration of analgesic therapy, evaluation of treatment effectiveness, and monitoring of adverse effects. Despite the widely recognized importance of pain management, pain assessment in neonates has thus far proven to be a challenge. As self-report, the gold standard for pain assessment, is not possible in neonates, other methods are needed. Several observational pain scales have been developed, but these often rely on snapshot and largely subjective observations and may fail to capture pain in certain conditions. Incorporation of biomarkers alongside observational pain scores holds promise in enhancing pain assessment and, by extension, optimizing pain treatment and neonatal outcomes. This review explores the possibilities of integrating biomarkers in pain assessment in the NICU.

Methods for analyzing infant heart rate variability: A preliminary study

Heart rate (HR) and heart rate variability (HRV) reflect autonomic development in infants. To better understand the autonomic response in infants, reliable HRV recordings are vital, yet no protocol exists. The purpose of this paper is to present reliability of a common procedure for analysis from two different file types. In the procedure, continuous electrocardiograph recordings of 5-10 min are obtained at rest in infants at 1 month of age by using a Hexoskin Shirt-Junior's (Carre Technologies Inc., Montreal, QC, Canada). Electrocardiograph (ECG; .wav) and R-R interval (RRi; .csv) files are extracted. The RRi of the ECG signal is generated by VivoSense (Great Lakes NeuroTechnologies, Independence, OH). Two MATLAB (The MathWorks, Inc., Natick, MA) scripts converted files for analysis with Kubios HRV Premium (Kubios Oy, Kuopio, Finland). A comparison was made between RRi and ECG files for HR and HRV parameters, and then tested with t tests and correlations via SPSS. There are significant differences in root mean squared successive differences between recording types, with only HR and low-frequency measures significantly correlated together. Recording with Hexoskin and analysis with MATLAB and Kubios enable infant HRV analysis. Differences in outcomes exist between procedures, and standard methodology for infant HR analysis is needed.

The Newborn Infant Parasympathetic Evaluation (NIPE™) monitor predicts post-operative pain in children undergoing day-procedures: A prospective observational study

BACKGROUND

Pain assessment is essential for the administration of appropriate analgesia. Currently, clinicians use surrogate methods, such as heart rate or behavioural pain scales, to estimate pain in neonates and infants. The Newborn and Infant Parasympathetic Evaluation (NIPE™) monitor aims to provide an objective numeric value (NIPE index) of pain through a continuous assessment of the patient's parasympathetic activity. The aim of this study was to determine if the intraoperative NIPE index monitoring could predict postoperative pain in neonates and infants.

METHODS

This prospective observational pilot study included neonates and infants undergoing elective day-surgical procedures (n = 50). Intraoperatively, NIPE indices at 0 (NIPE0), 10 (NIPE10), 20 (NIPE20), 30 (NIPE30) minutes and at completion of surgery (NIPEe), were recorded; the median NIPE index (NIPEm) was calculated for the entire procedure. Postoperative Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were calculated by the nursing staff blinded to the intraoperative NIPE indices.

RESULTS

Linear regression documented an association between the NIPEm and postoperative FLACC score at 0 (r = 0.31, p = 0.03) and 10 min (r = 0.36, p = 0.01). No significant associations were observed for FLACC scores at 20 (r = 0.21, p = 0.2) and 30 min (r = 0.36, p > 0.9). Multiple regression analysis revealed that intraoperative NIPE10, NIPE20, NIPE30 and NIPEe also predicted the FLACC score at 0 min (p = 0.003).

CONCLUSION

The intraoperative NIPE index is predictive of pain in the immediate postoperative period. This association was lost at 20 min likely due to nursing intervention to administer analgesia. NIPE monitoring could be useful in facilitating postoperative pain management in infants.

LEVEL OF EVIDENCE

II.

TYPE OF STUDY

Study of Diagnostic Test.

Monitoring of analgesia level during general anesthesia in children

PURPOSE OF REVIEW

Monitoring of intraoperative nociception has made substantial progress in adult anesthesia during the last 10 years. Several monitors have been validated and their use has been associated with intraoperative or postoperative benefits in the adult population. In pediatric anesthesia, less data are available. However, several recent publications have assessed the performance of nociception monitors in children, and investigated their potential benefits in this context. This review will describe the main validated intraoperative nociception monitors, summarize adult findings and describe the available pediatric data.

RECENT FINDINGS

Six intraoperative nociception indices were included in this review. Among them, four have shown promising results in children: Surgical Pleth Index (GE-Healthcare, Helsinki, Finland), Analgesia-Nociception Index (Mdoloris Medical Systems, Loos, France), Newborn-Infant Parasympathetic Evaluation (Mdoloris Medical Systems), and Pupillometry (IDMED, Marseille, France). The relevance of Skin Conductance (MedStorm innovations, AS, Oslo, Norway) under general anesthesia could not be established. Finally, the Nociception Level (Medasense, Ramat Gan, Israel) still requires to be investigated in children.

SUMMARY

To date, four monitors may provide a relevant assessment of intraoperative nociception in children. However, the potential clinical benefits associated with their use to guide analgesia remain to be demonstrated.

Usefulness of two types of pain monitors in newborns treated in NICU, in the opinion of experts: Results of the survey

Pain experienced in the neonatal period has been shown to have serious short- and long-term consequences. It is also known that painkillers have side effects and should not be abused. The basis of proper pain management is assessment of pain, which in newborns is very difficult due to the lack of verbal communication. In these patients, behavioural scales are used to assess pain, but they have numerous shortcomings. For this reason, many newborns treated in the ICU are at risk of pain, so instrumental methods of detecting and assessing the severity of pain are being sought. During three months, seven Polish NICUs conducted research with the use of NIPE and SCA monitors. After this time, the heads of these departments filled in questionnaires regarding their individual opinions on the usefulness of these devices. All respondents found pain monitors useful in the NICU. The NIPE monitor was rated slightly higher, as its usefulness in assessing the effectiveness of analgosedation and in the management of patients in the postoperative period was better rated. The high acceptance of both devices by legal guardians of newborns is noteworthy. It should be stated that in newborns, any way to improve pain monitoring is valuable. In the opinion of Polish experts, pain monitors are useful in NICU. The NIPE monitor was assessed a little higher and was considered useful in the assessment of analgosedation and in postoperative treatment. Pain monitors can provide valuable support for pain assessment in newborns treated in the NICU.

Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications

BACKGROUND

Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies.

OBJECTIVES

To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed.

ELIGIBILITY CRITERIA

Human neonates ≤1 month of corrected age.

SOURCES OF EVIDENCE

A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020.

CHARTING METHODS

A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction).

RESULTS

Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band.

CONCLUSIONS

Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.

Available Instruments to Assess Pain in Infants

Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.

The newborn infant parasympathetic evaluation in pediatric and neonatology: a literature review

PURPOSE

The Newborn Infant Parasympathetic Evaluation (NIPE) is a heart rate variability-based technology for assessing pain and comfort in neonates and infants under 2-years-old. This review aims to investigate the clinical utility of the NIPE.

METHODS

Two investigators screened Pubmed/Medline and Google Scholar for relevant studies, independently. One investigator extracted data, which were reviewed by a second investigator.

RESULTS

The NIPE was used during/after painful stimuli (6 studies), in the context of general anaesthesia (2 studies), and for comfort assessment (6 studies). A) Evaluation of procedural pain/distress: 2 studies reported that the mean-NIPE could be used for reliable monitoring of prolonged pain, and one study reported the association between instant-NIPE and pain after a stimulus but the instant-NIPE represents the NIPE average over 3 min. Two studies found no correlation between the NIPE and comfort behavior/pain scales, but they mainly differed in patients' gestational age and evaluation methodology. B) There are only 2 studies for the evaluation of nociception during surgery under general anaesthesia with contradictory results. C) Studies assessing neonates' comfort reported increased NIPE scores during skin-to-skin contact and during facilitated tucking associated with a human voice. No effect on NIPE scores of facilitated tucking during echocardiography was reported in preterm infants. One study reported significantly different NIPE scores with 2 surfactant therapy protocols. Overall, study populations were small and heterogeneous.

CONCLUSION

The results regarding NIPE's performances differ between studies. Given the limited number of studies and the heterogeneous outcomes, more studies are required to confirm the NIPE usefulness in the different clinical settings.

Newborn infant parasympathetic evaluation for the assessment of analgosedation adequacy in infants treated by mechanical ventilation - a multicenter pilot study

INTRODUCTION

Adequate analgosedation is important in infants treated in pediatric/neonatal intensive care units (P/NICUs), because both too deep and insufficient analgosedation is disadvantageous. To assess the severity of pain, several behavioral and behavioral-physiological scales are used, but their usefulness is limited. It is therefore justified to search for additional methods to assess the adequacy of analgosedation in these patients. The aim of the present study is to evaluate the usefulness of Newborn Infant Parasympathetic Evaluation (NIPE) in the assessment of analgosedation quality in infants requiring mechanical ventilation, who are treated in P/NICUs.

MATERIAL AND METHODS

We performed simultaneously 180 COMFORT-B assessments and heart rate variability measurements using a NIPE monitor in 30 mechanically ventilated infants receiving analgosedation. A generalized linear mixed model with the logit link function was used in order to perform logistic regression analysis to assess the relationship between NIPEi/NIPEm and deep sedation.

RESULTS

The multivariable logistic regression model showed that NIPEi and NIPEm values were higher when analgosedation was deep as compared to when it was moderate or insufficient (OR (95% CI): NIPEm - 1.065 (1.007-1.126), p = 0.03; NIPEi - 1.068 (1.016-1.123), p = 0.01).

CONCLUSIONS

The NIPE indexes are significantly higher in patients whose assessment on the behavioral scale indicates deep analgosedation as compared to those in whom it indicates moderate or insufficient analgosedation. Allowing continuous monitoring, the NIPE device may be a valuable assisting tool in the assessment of analgosedation quality in mechanically ventilated newborns and infants.

Procedural Pain Assessment in Infants Without Analgosedation: Comparison of Newborn Infant Parasympathetic Evaluation and Skin Conductance Activity - A Pilot Study

Objective: New technologies to measure pain responses, such as heart rate variability and skin conductance hold promise in the development of tools that can be reliable and quantifiable of detecting pain. The main objective of this study was to assess the capability of two monitors i.e., Newborn Infant Parasympathetic Evaluation (NIPE) and Skin Conductance Algesimeter for detecting procedural pain in non-anesthetized infants. Materials and Methods: Thirty-three non-anesthetized infants were enrolled to the study. To detect pain caused by heel stick, NIPE, and Skin Conductance monitors and behavioral pain scales were used. Three minutes before and just after heel stick, pain was evaluated by behavioral scales, and simultaneously over the whole period by NIPE and SCA. Results: A statistically significant decrease of NIPE Index and an increase of SCA values were found after the HS procedure. There were no statistically significant differences between the decrease in NIPEi values and the increase in PPS values between subgroups based on pain assessment by behavioral-scale scores. Conclusion: Both NIPE and SCA can be useful for detection of procedural pain and may constitue an additional valuable tool for better handling of pain among patients treated in NICUs. More studies on larger groups of patients are needed.

Assessment of Procedural Distress in Sedated/Intubated Children Under 3 Years Old Using the Newborn Infant Parasympathetic Evaluation: A Diagnostic Accuracy Pilot Study

OBJECTIVES

Newborn infant parasympathetic evaluation index is based on heart rate variability and is related to the autonomic response to pain or stress. The Comfort Behavior Scale is used to assess distress intensity in sedated intubated children. The objective of this study was to assess the validity and performance of newborn infant parasympathetic evaluation as a distress indicator during procedural distress.

DESIGN

Monocentric, prospective, noninterventional pilot study of diagnostic accuracy between October 1, 2017, and April 30, 2019.

SETTING

PICU in a tertiary care university hospital.

PATIENTS

Sedated intubated children under 3 years old.

INTERVENTIONS

We continuously obtained mean newborn infant parasympathetic evaluation and instantaneous newborn infant parasympathetic evaluation scores and compared them to Comfort Behavior scores obtained before (T1 period), during (T2 period), and after (T3 period) care procedures.

MEASUREMENTS AND MAIN RESULTS

We obtained 54 measurements from 32 patients. The median age was 4 months (23 d to 31 mo). Between T1 and T2, there was a significant decrease in the instantaneous newborn infant parasympathetic evaluation and mean newborn infant parasympathetic evaluation scores (64 ± 2 to 42 ± 1 [p 0.0001] and 64 ± 1 to 59 ± 1 [p = 0.007], respectively) and a significant increase in the Comfort Behavior scores (from 12 ± 0 to 16 ± 1; p 0.0001). Comfort Behavior scores and instantaneous newborn infant parasympathetic evaluation and mean newborn infant parasympathetic evaluation scores were significantly inversely correlated (r = -0.44, p 0.0001 and r = -0.19, p = 0.01, respectively). With a instantaneous newborn infant parasympathetic evaluation score threshold of 53, the sensitivity, specificity, positive predictive, and negative predictive values to predict a Comfort Behavior Scale up to 17 were 80.0%, 73.5%, 43.8%, and 93.5%, respectively.

CONCLUSIONS

Instantaneous newborn infant parasympathetic evaluation is valid for assessing distress in sedated/intubated children in the PICU. Further studies are needed to confirm these results and for newborn infant parasympathetic evaluation-based comparisons of sedation-analgesia protocols.

Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review

Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.

Assessment of Pain in the Newborn: An Update

Preterm and term neonate pain assessment in neonatal intensive care units is vitally important because of the prevalence of procedural and postoperative pain. Of the 40 plus tools available, a few should be chosen for different populations and contexts (2 have been validated in premature infants). Preterm neonates do not display pain behaviors and physiologic indicators as reliably and specifically as full-term infants, and are vulnerable to long-term sequelae of painful experiences. Brain-oriented approaches may become available in the future; meanwhile, neonatal pain assessment tools must be taught, implemented, and their use optimized for consistent, reproducible, safe, and effective treatment.