Missed Opportunities for Sedation and Pain Management at a Level III Neonatal Intensive Care Unit, India

The relationship between neonatal stress in preterm infants and developmental outcomes at the corrected age of 24-30 months

Aim

The aim of research was to study the relationship between the stress experienced by preterm infants in the neonatal intensive care unit (NICU) and developmental status in the follow up, and to establish factors, associated with their neurodevelopment.

Methods

The first stage of research involved measuring stress markers (cortisol, melatonin) in infants (n = 56) during their NICU stay; the second phase assessed the developmental status at the corrected age of 24-30 months.

Results

The total ASQ-3 score, communication, problem solving, and personal-social skills scores at the corrected age of 24-30 months were positively correlated with melatonin level determined in the neonatal period (r = 0.31, p = 0.026; r = 0.36, p = 0.009; r = 0.30, p = 0.033, and r = 0.32; p = 0.022 respectively). In the same time, ASQ-3 communication and personal-social scores were negatively correlated with cortisol level (r = -0.31, p = 0.043; r = -0.35, p = 0.022). The ROC-curve analysis revealed that a decrease of melatonin below 3.44 ng/mL and 3.71 ng/mL during the neonatal period could predict communication and problem-solving delay, respectively. An increase in cortisol above 0.64 mcg/dl is predictive in personal-social delay. Negative correlation was identified between the NICU and total hospital stay duration and ASQ-3 communication scores in the follow-up (r = -0.27; p = 0.049 and r = -0.41; p = 0.002, respectively). The duration of mechanical ventilation was negatively correlated with gross motor scores (r = -0.46; p = 0.043). Apgar score was positively correlated with ASQ-3 communication (r = 0.29; p = 0.032) and personal-social scores (r = 0.28; p = 0.034); maternal age-with ASQ-3 total (r = 0.29; p = 0.034), communication (r = 0.37; p = 0.006), and personal-social scores (r = 0.29; p = 0.041). Positive correlations were observed between gestational age and communication scores (r = 0.28; p = 0.033). Infants who suffered neonatal sepsis had significantly often delay of communication (p = 0.014) and gross motor skills (p = 0.016). Children who required mechanical ventilation were more likely to have communication delay (p = 0.034).

Conclusion

Developmental outcomes in preterm infants at the corrected age of 24-30 months were associated with neonatal stress. Correlations between the communication, problem-solving and personal-social development in the follow up and cortisol and melatonin levels determined in the neonatal period supported this evidence. Factors as low gestational age, duration of hospital and NICU stay, mechanical ventilation, and sepsis were associated with more frequent delays in communication, gross motor and problems-solving skills.

Neonatal Intensive Care Nurses' Knowledge of Neonatal Pain Assessment in Private and Public Hospitals in Jeddah, Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Neonatal Intensive Care Unit (NICU) nurses with adequate neonatal pain assessment knowledge are crucial in effective neonatal pain management. There is limited research that assessed the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

OBJECTIVE

To assess the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

DESIGN AND METHODS

 A cross-sectional design using an online survey was conducted to capture information regarding neonatal pain assessment knowledge from 125 NICU nurses in Saudi Arabia. Knowledge of pain assessment was assessed using a modified version of the knowledge, attitudes, and practice scale. Knowledge scores were classified as high, average, and low.

RESULTS

Participants' knowledge regarding neonatal pain assessment was inadequate (Mean = 63/100). The majority of the participants had a low to average level of knowledge (n= 97, 78%).

CONCLUSION

A significant proportion of NICU nurses had inadequate knowledge regarding neonatal pain assessment, which can be improved. Educational interventions are needed to boost these nurses' knowledge regarding neonatal pain assessment.

Skin-to-skin contact-An effective intervention on pain and stress reduction in preterm infants

Introduction

The outcomes of pain and stress in preterm infants in the neonatal intensive care units (NICUs) compel the continued search for pain- and stress-reducing interventions.

The objective of the study

To investigate how skin-to-skin contact (SSC) influences chronic pain and stress in preterm infants in the NICU.

Materials and methods

The study included 140 preterm infants in the NICU with gestational age less than 34 weeks. The overall design was a baseline-response design. Urine and saliva were collected before (baseline) and after SSC to measure pain and stress markers by enzyme immunoassay method. The behavioral indicators of chronic pain were assessed using the EDIN (Échelle Douleur Inconfort Nouveau-Né-neonatal pain and discomfort).

Results

There was a significant decrease in the dopamine level in preterm infants after SSC in comparison with baseline values (85.99 [69.35; 112.20] pg/ml vs. 132.20 [104.80; 183.70] pg/ml), p < 0.001. The β-endorphin and serotonin levels increased after SSC (40.09 [26.81; 70.63] pg/ml vs. 29.87 [20.61; 46.94] pg/ml, p = 0.009 and 25.49 [20.45; 40.08] ng/ml vs. 22.30 [15.13; 31.65] ng/ml, p = 0.011, respectively). A significant decrease in cortisol levels in saliva and urine after SSC in comparison with baseline values (0.125 [0.079; 0.225] μg/dl vs. 0.371 [0.188; 1.002] μg/dl, p = 0.000 and 27.06 [14.59; 35.35] ng/ml vs. 35.25 [19.78; 61.94] ng/ml, p = 0.001, with a simultaneous increase of oxytocin level (57.00 [36.55; 88.49] pg/ml vs. 38.20 [28.78; 56.04] pg/ml, p = 0.009 were revealed. The total pain EDIN score in infants after SSC was below 6 points, significantly decreasing compared to the baseline (p < 0.05).

Conclusion

Preterm infants in the NICU experience stress and pain, which were confirmed by the EDIN pain scale and laboratory markers. The level of dopamine and cortisol as pain and stress hormones were reliably high, and normalized after regular SSC. Simultaneously, pain-relieving and anti-stress markers of oxytocin, β-endorphin and serotonin reliably increased in preterm infants in response to the SSC.

Procedural Analgesia in the Neonatal Intensive Care Unit: A Quality Improvement Initiative

OBJECTIVE

Neonates perceive pain which also has adverse long-term consequences. Newborns experience several painful procedures a day. Various methods of analgesia may be used but are underutilized. The SMART aim of this project was to increase the use of procedural analgesia from 11.5 to 75% in 6 months by using quality improvement principles.

STUDY DESIGN

After a baseline audit, a root cause analysis was done. Based on this, a series of interventions were done as Plan-Do-Study-Act (PDSA) cycles. These included posters on analgesia, display of the pain protocol, orders for analgesia, a written test, small power point presentations on the importance of analgesia, and reminders on the trays used for procedures. At the end of each PDSA cycle, an audit was done to determine the proportion of times analgesia was used. Process indicators were also used when possible. Analysis was done by using the Chi-square test and the paired t-test.

RESULTS

At baseline 11% of procedures were done after giving analgesia. This significantly improved to 40% at the end of the first PDSA, and 81% after third PDSA. This was sustained at 75% over the next 2 months.

CONCLUSION

Procedural analgesia can improve and be sustained by using simple interventions.

KEY POINTS

· Procedural pain in neonates can be decreased by the use of analgesia.. · However, most units do not utilize analgesia appropriately.. · This QI showed that simple interventions can optimize use of procedural analgesia..

The role of the mucin-glycan foraging Ruminococcus gnavus in the communication between the gut and the brain

Ruminococcus gnavus is a prevalent member of the human gut microbiota, which is over-represented in inflammatory bowel disease and neurological disorders. We previously showed that the ability of R. gnavus to forage on mucins is strain-dependent and associated with sialic acid metabolism. Here, we showed that mice monocolonized with R. gnavus ATCC 29149 (Rg-mice) display changes in major sialic acid derivatives in their cecum content, blood, and brain, which is accompanied by a significant decrease in the percentage of sialylated residues in intestinal mucins relative to germ-free (GF) mice. Changes in metabolites associated with brain function such as tryptamine, indolacetate, and trimethylamine N-oxide were also detected in the cecal content of Rg-mice when compared to GF mice. Next, we investigated the effect of R. gnavus monocolonization on hippocampus cell proliferation and behavior. We observed a significant decrease of PSA-NCAM immunoreactive granule cells in the dentate gyrus (DG) of Rg-mice as compared to GF mice and recruitment of phagocytic microglia in the vicinity. Behavioral assessments suggested an improvement of the spatial working memory in Rg-mice but no change in other cognitive functions. These results were also supported by a significant upregulation of genes involved in proliferation and neuroplasticity. Collectively, these data provide first insights into how R. gnavus metabolites may influence brain regulation and function through modulation of granule cell development and synaptic plasticity in the adult hippocampus. This work has implications for further understanding the mechanisms underpinning the role of R. gnavus in neurological disorders.

Non-pharmaceutical intervention and pain management situation for neonatal analgesia

Neonatal pain management is an important issue which should have great attention. More and more researches have proved that neonates can feel pain when undergoes painful procedures such as vaccination, heel stick, and so on, and it will result in short-term and long-term outcomes. So it is very important to manage neonatal pain. This article summarized some non-pharmaceutical interventions, including sucrose or glucose, non-nutritional sucking (NNS), breastfeeding, facilitated tucking (FT), kangaroo mother care (KMC), swaddling, heel warming, sensorial saturation (SS), and music therapy, which showed obvious effects for neonatal pain. In addition, this article summarized the progress of neonatal pain intervention in various countries and showed that many countries have not paid enough attention to this problem, while some countries have carried out promotion programs for neonatal pain management which give some clinical enlightenment to our country that we need to pay more attention to this problem.

Pain profile of premature infants during routine procedures in neonatal intensive care: An observational study

Background:

Premature neonates receive a large number of painful procedures during their stay in the neonatal intensive care unit (NICU). However, there are many other processes that happen in the NICU, which may not be considered painful but can cause discomfort and/or stress to the neonate.

Method:

Pain profile during routine procedures in NICU was assessed using the premature infant pain profile (PIPP) score. Neonates of gestational age >26 weeks, less than 7 days old and admitted for less than 7 days in the NICU were included.

Results:

A total of 662 procedures were observed in 132 (78 M, 54 F) neonates. The mean (SD) age of the neonates was 2.4 (1.8) days and the mean (SD) birth weight was 2.3 (0.6) kg. 63 (54.5%) were of low birth weight (LBW), 85 (64.39%) were full term. High PIPP score was noted in blood sampling, heel prick, suction, and weight measurement. Significant differences were observed in the PIPP score during blood sampling and suction across gender. Some ordinary and non-stressful procedures also scored very high on the PIPP scale.

Conclusions:

The validity of PIPP needs to be reexamined. Our understanding of pain during routine procedures may need to be revisited.

Systematic review and meta-analysis suggest that varying prevalence of non-acute pain in critically ill infants may be due to different definitions

AIM

Our aim was to quantify the prevalence of non-acute pain in critically ill infants and to identify how non-acute pain was described, defined and assessed.

METHODS

This systematic review and meta-analysis used multiple electronic databases to search for papers published in any language to March 2018: 2029 papers were identified, and 68 full texts were screened. Studies reporting the prevalence of non-acute pain in infants younger than 2 years and admitted to critical care units were included. The extracted data included the use of non-acute pain descriptions, definitions and pain assessment tools.

RESULTS

We included 11 studies published between 2002 and 2018 that comprised 1204 infants from Europe, the USA, Canada and India. They were prospective observational (n = 7) and retrospective observational (n = 1) studies and randomised controlled trials (n = 3). The prevalence of non-acute pain was 0%-76% (median 11%). Various pain assessment tools were used, and only two could be pooled. This gave a pooled prevalence of 3.7%-39.8%. A number of different descriptors were used for non-acute pain, and all of these were poorly defined.

CONCLUSION

The prevalence of non-acute pain in infants admitted to critical care units varied considerably. This could have been because all the studies used different definitions of non-acute pain.

The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU

BACKGROUND

Vulnerable preterm infants experience repeated and prolonged pain/stress stimulation during a critical period in their development while in the neonatal intensive care unit (NICU). The contribution of cumulative pain/stressors to altered neurodevelopment remains unclear. The study purpose was to investigate the impact of early life painful/stressful experiences on neurobehavioral outcomes of preterm infants in the NICU.

METHODS

A prospective exploratory study was conducted with fifty preterm infants (28 0/7-32 6/7weeks gestational age) recruited at birth and followed for four weeks. Cumulative pain/stressors (NICU Infant Stressor Scale) were measured daily and neurodevelopmental outcomes (NICU Network Neurobehavioral Scale) were examined at 36-37weeks post-menstrual age. Data analyses were conducted on the distribution of pain/stressors experienced over time and the linkages among pain/stressors and neurobehavioral outcomes.

RESULTS

Preterm infants experienced a high degree of pain/stressors in the NICU, both in numbers of daily acute events (22.97±2.30 procedures) and cumulative times of chronic/stressful exposure (42.59±15.02h). Both acute and chronic pain/stress experienced during early life significantly contributed to the neurobehavioral outcomes, particularly in stress/abstinence (p<0.05) and habituation responses (p<0.01), meanwhile, direct breastfeeding and skin-to-skin holding were also significantly associated with habituation (p<0.01-0.05).

CONCLUSION

Understanding mechanisms by which early life experience alters neurodevelopment will assist clinicians in developing targeted neuroprotective strategies and individualized interventions to improve infant developmental outcomes.