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ten Barge JA, Baudat M, Meesters NJ, Kindt A, Joosten EA, Reiss IK, Simons SH, van den Bosch GE. Biomarkers for assessing pain and pain relief in the neonatal intensive care unit. Front Pain Res (Lausanne) 2024; 5:1343551. [PMID: 38426011 PMCID: PMC10902154 DOI: 10.3389/fpain.2024.1343551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
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.
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Affiliation(s)
- Judith A. ten Barge
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Mathilde Baudat
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Naomi J. Meesters
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Alida Kindt
- Metabolomics and Analytics Center, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Elbert A. Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Irwin K.M. Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Sinno H.P. Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Gerbrich E. van den Bosch
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
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Rondagh M, Kortenbout AJ, de Munck S, van den Bosch GE, Dudink J, Vos HJ, Bosch JG, de Graaff JC. A comparison of ultrafast and conventional spectral Doppler ultrasound to measure cerebral blood flow velocity during inguinal hernia repair in infants. J Clin Anesth 2024; 92:111312. [PMID: 37926064 DOI: 10.1016/j.jclinane.2023.111312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/13/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Ultrafast cerebral Doppler ultrasound enables simultaneous quantification and visualization of cerebral blood flow velocity. The aim of this study is to compare the use of conventional and ultrafast spectral Doppler during anesthesia and their potential to show the effect of anesthesiologic procedures on cerebral blood flow velocities, in relation to blood pressure and cerebral oxygenation in infants undergoing inguinal hernia repair. METHODS A single-center prospective observational cohort study in infants up to six months of age. We evaluated conventional and ultrafast spectral Doppler cerebral ultrasound measurements in terms of number of successful measurements during the induction of anesthesia, after sevoflurane induction, administration of caudal analgesia, a fluid bolus and emergence of anesthesia. Cerebral blood flow velocity was quantified in pial arteries using conventional spectral Doppler and in the cerebral cortex using ultrafast Doppler by peak systolic velocity, end diastolic velocity and resistivity index. RESULTS Twenty infants were included with useable conventional spectral Doppler images in 72/100 measurements and ultrafast Doppler images in 51/100 measurements. Intraoperatively, the success rates were 53/60 (88.3%) and 41/60 (68.3%), respectively. Cerebral blood flow velocity increased after emergence for both conventional (end diastolic velocity, from 2.01 to 2.75 cm/s, p < 0.001) and ultrafast spectral Doppler (end diastolic velocity, from 0.59 to 0.94 cm/s), whereas cerebral oxygenation showed a reverse pattern with a decrease after the emergence of the infant (85% to 68%, p < 0.001). CONCLUSION It is possible to quantify cortical blood flow velocity during general anesthesia using conventional and ultrafast spectral Doppler cerebral ultrasound. Cerebral blood flow velocity and blood pressure decreased, while regional cerebral oxygenation increased during general anesthesia. Ultrafast spectral Doppler ultrasound offers novel insights into perfusion within the cerebral cortex, unattainable through conventional spectral ultrasound. Yet, ultrafast Doppler is curtailed by a lower success rate and a more rigorous learning curve compared to conventional method.
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Affiliation(s)
- Mathies Rondagh
- Department of Anesthesiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Anna J Kortenbout
- Department of Biomedical Engineering, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Sophie de Munck
- Department of Surgery, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Neonatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jeroen Dudink
- Department of Neonatology, UMC Utrecht University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Hendrik J Vos
- Department of Biomedical Engineering, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Johan G Bosch
- Department of Biomedical Engineering, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Anesthesiology, Adrz - Erasmus MC, Goes, the Netherlands; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States of America.
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Ten Barge JA, Moelchand M, van Dijk M, Simons SHP, van Rosmalen J, van den Akker ELT, Tibboel D, van den Bosch GE. The influence of intensive care treatment in infancy on cortisol levels in childhood and adolescence. Early Hum Dev 2023; 184:105823. [PMID: 37478692 DOI: 10.1016/j.earlhumdev.2023.105823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/09/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Infants admitted to the intensive care unit experience numerous early-life stressors, which may have long-term effects on hypothalamic-pituitary-adrenal axis functioning. AIMS To determine the effects of intensive care treatment and related exposure to stress, pain, and opioids in infancy on cortisol levels in childhood and adolescence. STUDY DESIGN Cross-sectional study. SUBJECTS Children and adolescents aged 8 to 18 years with a history of intensive care treatment in infancy and healthy controls. The intensive care treatment cohort consisted of four subgroups with varying levels of exposure to stress, pain, and opioids in infancy. They received either mechanical ventilation, extracorporeal membrane oxygenation, major surgery, or excochleation of a giant congenital melanocytic nevus. OUTCOME MEASURES Between-group differences in stress reactivity to a study visit consisting of pain threshold testing and an MRI examination and diurnal cortisol levels, as measured in saliva. RESULTS After adjustment for age, sex, and gestational age, the diurnal cortisol output (AUCg) in the overall intensive care group (N = 76) was 18 % (approximately 1000 nmol/L) (95 % CI [-31 %, -3 %], P = 0.022) lower than that in the control group (N = 67). Cortisol awakening response, diurnal decline, and stress reactivity neither differed significantly between the overall intensive care group and control group, nor between the intensive care subgroups and control group. CONCLUSION Children and adolescents with a history of intensive care treatment in infancy have similar cortisol profiles to those of healthy controls, except for an 18 % lower diurnal cortisol output. The clinical relevance of this reduction is yet to be determined.
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Affiliation(s)
- Judith A Ten Barge
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Madhvi Moelchand
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
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Horn-Oudshoorn EJJ, Blekherov AM, van den Bosch GE, Simons SHP, Knol R, Te Pas A, Reiss IKM, DeKoninck PLJ. Sedation Prior to Intubation at Birth in Infants with Congenital Diaphragmatic Hernia: An International Survey on Current Practices. Neonatology 2023; 120:434-440. [PMID: 37279703 PMCID: PMC10614521 DOI: 10.1159/000530573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/27/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Infants with congenital diaphragmatic hernia (CDH) are commonly intubated immediately after birth. Consensus on whether to provide sedation prior to intubation in the delivery room is lacking, although avoidance of stress is especially important in this population with high risk of pulmonary hypertension. We aimed at obtaining an overview of local pharmacological interventions and at providing guidance on delivery room management. METHODS An electronic survey was sent to international clinicians in referral centres for prenatal and postnatally diagnosed infants with CDH. This survey addressed demographic information, use of sedation and/or muscle relaxant prior to intubation, and use of pain scales in the delivery room. RESULTS We received 93 relevant responses from 59 centres. Most centres were from Europe (n = 33, 56%), followed by North America (n = 16, 27%), Asia (n = 6, 10%), Australia (n = 2, 3%), and South America (n = 2, 3%). A total of 19% (11/59) of the centres routinely provided sedation prior to intubation in the delivery room, with midazolam and fentanyl being most often used. Methods of administration varied for all medications provided. Only 5 of 11 centres using sedation reported an adequate sedative effect prior to intubation. Muscle relaxants prior to intubation were used in 12% (7/59) of the centres, although not always in combination with sedation. CONCLUSION This international survey shows a substantial variation in sedation practices in the delivery room and scarce use of both sedative agents and muscle relaxants prior to intubation of CDH infants. We provide guidance on developing protocols for pre-intubation medication in this population.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands,
| | - Alisa M Blekherov
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arjan Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Meesters NJ, Dilles T, van Rosmalen J, van den Bosch GE, Simons SHP, van Dijk M. COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates? J Perinatol 2023; 43:595-600. [PMID: 36746985 DOI: 10.1038/s41372-023-01628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain. STUDY DESIGN This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity. RESULT Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively. CONCLUSION The COMFORTneo can be used to reliably and validly assess pain in NICU patients.
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Affiliation(s)
- Naomi J Meesters
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Tinne Dilles
- Nursing and Midwifery Sciences, Centre for Research and Innovation in Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
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de Bruin R, van Dalen SL, Franx SJ, Simons SH, Flint RB, van den Bosch GE. Risk for neonatal hypoglycaemia and bradycardia after beta-blocker use during pregnancy or lactation: a systematic review and meta-analysis protocol. BMJ Open 2022; 12:e055292. [PMID: 36008071 PMCID: PMC9422831 DOI: 10.1136/bmjopen-2021-055292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Beta-blockers are often used during pregnancy to treat diseases such as pre-existing hypertension, arrhythmias or pregnancy-related hypertension. Since beta-blockers are able to cross the placenta and can pass into breast milk, they could potentially harm the neonate. Known potential neonatal side effects of maternal beta-blocker use are hypoglycaemia and bradycardia. This systematic review and meta-analysis aims to investigate the risk for neonatal hypoglycaemia and bradycardia after exposure to beta-blockers in utero or through lactation. METHODS AND ANALYSIS We will conduct a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic electronic search will be conducted using EMBASE, Medline, Cochrane Central Register of Trials and Web of Science from initiation to April 2021. Our primary outcome will be the risk for hypoglycaemia or bradycardia in neonates exposed to beta-blockers in utero or through lactation in comparison with unexposed neonates. All articles will be screened by title and abstract twice by different independent review authors. Next, standardised methodological quality assessment will be conducted for each included article and finally a meta-analysis will be performed. ETHICS AND DISSEMINATION Ethical approval is not required. The results of this study will help to assess the need for postnatal glucose and heart rate monitoring of the neonate after maternal beta-blocker exposure. Our findings will be communicated to the target audience through peer-reviewed publication. PROSPERO REGISTRATION NUMBER CRD42021264269.
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Affiliation(s)
- Rosalie de Bruin
- Faculty of Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sarah L van Dalen
- Faculty of Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Shamaya J Franx
- Faculty of Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sinno Hp Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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ten Barge JA, Vermeulen MJ, Simons SHP, van den Bosch GE. Pain management for necrotizing enterocolitis: getting the balance right. Pediatr Res 2022; 92:1423-1431. [PMID: 35169278 PMCID: PMC9700516 DOI: 10.1038/s41390-022-01968-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/06/2021] [Accepted: 01/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adequate pain management for preterm born neonates suffering from the extremely painful disease necrotizing enterocolitis (NEC) is essential, since neonatal exposure to pain is related to negative short-term and long-term consequences. The aim of this study was to describe the current pain management and its effectiveness in NEC patients. METHODS In this single-center, retrospective study, neonates (gestational age < 32 weeks and/or birth weight < 1500 g) with NEC Bell's stage II or III were included. Information on pain (based on COMFORTneo and NRS scores) and analgesic therapy was collected and analyzed for the acute disease period. RESULTS Of 79 patients included, 74 (94%) received intravenous analgesic therapy: most commonly morphine, fentanyl, and acetaminophen. The median COMFORTneo score was 11 (IQR 10-11), however, 49 patients had at least one COMFORTneo score ≥ 14 indicating pain. Nineteen patients had persistent high pain scores ≥ 14 with a median duration of 7.2 h (IQR 2.8-14.0). CONCLUSIONS This study showed that despite analgesic therapy, most NEC patients showed signs of pain, and in some, pain persisted for several hours. It suggests that current analgesic therapy frequently failed to prevent pain and existing pain was often insufficiently treated. This supports the urgent need for individualized pain management guidelines for NEC patients. IMPACT This study is unique in reporting on pain management in neonates suffering from necrotizing enterocolitis (NEC) during the full acute disease period. Despite analgesic therapy, the majority of NEC patients experience pain, and in some patients, pain persists for several hours. These findings highlight the need for improvement of neonatal pain management in NEC patients, including better pain monitoring and guidelines for individualized analgesic therapy. Improved pain management guidelines may help to prevent short-term and long-term consequences of neonatal exposure to pain, as well as excessive exposure to opioids.
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Affiliation(s)
| | - Marijn J. Vermeulen
- grid.416135.40000 0004 0649 0805Division of Neonatology, Department of Pediatrics, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Sinno H. P. Simons
- grid.416135.40000 0004 0649 0805Division of Neonatology, Department of Pediatrics, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Gerbrich E. van den Bosch
- grid.416135.40000 0004 0649 0805Division of Neonatology, Department of Pediatrics, Sophia Children’s Hospital, Rotterdam, The Netherlands
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Meesters N, van Dijk M, Sampaio de Carvalho F, Haverman L, Reiss IKM, Simons SHP, van den Bosch GE. COVID-19 lockdown impacts the wellbeing of parents with infants on a Dutch neonatal intensive care unit. J Pediatr Nurs 2022; 62:106-112. [PMID: 34642075 PMCID: PMC8482115 DOI: 10.1016/j.pedn.2021.09.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Parents of infants admitted to a neonatal intensive care unit (NICU) experience additional stress due to restrictions on their presence and visits by other family members during the COVID-19 pandemic. Our study aims to describe how this impacted parents and how NICU staff could support them. DESIGN AND METHODS This was a cross-sectional study in which 25 parents (16 mothers, 9 fathers) of infants admitted to our NICU during the first COVID-19 lockdown completed online questionnaires with socio-demographic questions, the Parental Stressor Scale:NICU (PSS:NICU) and questions related to COVID-19. RESULTS Being separated from, and not being able to hold their infant at all times were among the most important PSS:NICU stressors. Parents experienced additional stress because other family members were not allowed to visit. They indicated that NICU staff could support them by clearly explaining the reasons for visitor restrictions and by ensuring that they felt heard. Most parents supported the restrictions, but also mentioned that less strict measures would really help them. CONCLUSIONS Parents who participated in this study found it very stressful that they could not be with their infant together with their partner and other family members. Furthermore, parents recommended the hospital management to continuously reconsider whether particular restrictions could be lifted in case of a new lockdown. Together with clear communication, this would result in less parenteral stress. PRACTICE IMPLICATIONS Hospital management should be cautious on restricting the presence of parents and other family members and scale restrictions back whenever possible.
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Affiliation(s)
- Naomi Meesters
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Fernanda Sampaio de Carvalho
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Lotte Haverman
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Pediatrics, Division of Neonatology, Erasmus MC -Sophia Children's Hospital, Rotterdam, the Netherlands
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van den Bosch GE, Tibboel D, de Graaff JC, El Marroun H, van der Lugt A, White T, van Dijk M. Neonatal Pain, Opioid, and Anesthetic Exposure; What Remains in the Human Brain After the Wheels of Time? Front Pediatr 2022; 10:825725. [PMID: 35633952 PMCID: PMC9132108 DOI: 10.3389/fped.2022.825725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/18/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate possible negative long-term effects of neonatal exposure to pain, opioids and anesthetics in children and adolescents. STUDY DESIGN We studied five unique groups of children recruited from well-documented neonatal cohorts with a history of neonatal exposure to pain, opioids or anesthetics at different points along the continuum from no pain to intense pain and from no opioid exposure to very high opioid exposure in the presence or absence of anesthetics. We evaluated children who underwent major surgery (group 1 and 2), extracorporeal membrane oxygenation (group 3), preterm birth (group 4) and prenatal opioid exposure (group 5) in comparison to healthy controls. Neuropsychological functioning, thermal detection and pain thresholds and high-resolution structural and task-based functional magnetic resonance imaging during pain were assessed. In total 94 cases were included and compared to their own control groups. RESULTS Children and adolescents in groups 3 and 5 showed worse neuropsychological functioning after high opioid exposure. A thicker cortex was found in group 1 (pain, opioid and anesthetic exposure) in only the left rostral-middle-frontal-cortex compared to controls. We found no differences in other brain volumes, pain thresholds or brain activity during pain in pain related brain regions between the other groups and their controls. CONCLUSIONS No major effects of neonatal pain, opioid or anesthetic exposure were observed in humans 8-19 years after exposure in early life, apart from neuropsychological effects in the groups with the highest opioid exposure that warrants further investigation. Studies with larger sample sizes are needed to confirm our findings and test for less pronounced differences between exposed and unexposed children.
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Hanan El Marroun
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Psychology, Education and Child Studies, Erasmus University, Rotterdam, Netherlands
| | | | - Tonya White
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands
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van den Hoogen NJ, de Kort AR, Allegaert KM, Joosten EA, Simons SHP, Tibboel D, van den Bosch GE. Developmental neurobiology as a guide for pharmacological management of pain in neonates. Semin Fetal Neonatal Med 2019; 24:101012. [PMID: 31221544 DOI: 10.1016/j.siny.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pain in newborn children should be prevented due to negative short- and long-term consequences. A good understanding of the development of the nociceptive system in newborns is necessary to enable optimal pain assessment, and most importantly to treat and prevent pain adequately in neonates. So far, preclinical juvenile animal studies have led to a tremendous amount of information regarding the development of the nociceptive system. In addition, they have made clear that the developmental stage of the nociceptive system may influence the mechanism of action of different classes of analgesics. Age specific analgesic therapy, based on post-menstrual age, should therefore be considered by incorporating information on the developmental stages of the nociceptive system in combination with knowledge from pharmacokinetic and -dynamic studies in neonates.
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Affiliation(s)
- Nynke J van den Hoogen
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Anne R de Kort
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Karel M Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Development and Regeneration, KU, Leuven, Leuven, Belgium
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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11
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van den Bosch GE, Dijk MV, Tibboel D, de Graaff JC. Long-term Effects of Early Exposure to Stress, Pain, Opioids and Anaesthetics on Pain Sensitivity and Neurocognition. Curr Pharm Des 2019; 23:5879-5886. [PMID: 28950826 DOI: 10.2174/1381612823666170926150259] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/21/2017] [Indexed: 11/22/2022]
Abstract
Background Experimental studies have shown that neonatal exposure to stress, pain, opioids and anaesthetics may cause histologic and morphologic changes in the central nervous system with associated functional and behavioural changes in the long term. An important question is whether this holds true for humans also - and in particular for sick neonates who often are exposed to pain and receive anaesthetics and sedatives. Methods In this narrative review, we evaluate the effects of neonatal exposure to stress, pain, opioids and anaesthetics in infancy and childhood in animals and in preterm born and term born humans on pain sensitivity, brain morphology, cognition and behaviour later in life. Results In animals, neonatal exposure to stress, pain, opioids and early exposure to anaesthetics are associated with neurodegeneration and cognitive problems later in life. Human studies mainly focus on pain sensitivity, cognition and behaviour and find contradictory outcomes. Dramatic long-term effects found in animal studies could not be confirmed in human. Conclusion While studies in animals suggest neurotoxic effects of early exposure to stress, pain, opioids and anaesthetics, these effects seem clinically less relevant in humans. A possible reason is that the latter often receive opioids in the presence of pain and opioids and anaesthetics in balanced therapeutic dosages and with adequate monitoring of physiological parameters, in contrast to animal studies.
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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Lukoshe A, van den Bosch GE, van der Lugt A, Kushner SA, Hokken-Koelega AC, White T. Aberrant White Matter Microstructure in Children and Adolescents With the Subtype of Prader-Willi Syndrome at High Risk for Psychosis. Schizophr Bull 2017; 43:1090-1099. [PMID: 28510708 PMCID: PMC5581891 DOI: 10.1093/schbul/sbx052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Prader-Willi Syndrome (PWS) is a complex neurogenetic disorder caused by loss of the paternal 15q11.2-q13 locus, due to deletion (DEL), maternal uniparental disomy (mUPD), or imprinting center defects. Individuals with mUPD have up to 60% risk of developing psychosis in early adulthood. Given the increasing evidence for white matter abnormalities in psychotic disorders, we investigated white matter microstructure in children and adolescents with PWS, with a particular emphasis on the DEL and mUPD subtypes. Magnetic resonance diffusion weighted images were acquired in 35 directions at 3T and analyzed using fractional anisotropy (FA), mean, axial, and radial diffusivity (MD, AD, RD) values obtained by tract-based spatial statistics (TBSS) in 28 children and adolescents with PWS and 61 controls. In addition, we employed a recently developed white matter pothole approach, which does not require local FA differences to be spatially co-localized across subjects. After accounting for age and gender, individuals with PWS had significantly lower global FA and higher MD, compared with controls. Individuals with mUPD had lower FA in multiple regions including the corpus callosum, cingulate, and superior longitudinal fasciculus and larger potholes, compared with DEL and controls. The observed differences in individuals with mUPD are similar to the white matter abnormalities in individuals with psychotic disorders. Conversely, the subtle white matter abnormalities in individuals with DEL are consistent with their substantially lower risk of psychosis. Future studies to investigate the specific neurobiological mechanism underlying the differential psychosis risk between the DEL and mUPD subtypes of PWS are highly warranted.
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Affiliation(s)
- Akvile Lukoshe
- Dutch Growth Research Foundation, Rotterdam, The Netherlands;,Department of Pediatrics, Erasmus Medical Centre Rotterdam/Sophia Children’s Hospital Rotterdam, Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus Medical Centre Rotterdam, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Anita C Hokken-Koelega
- Dutch Growth Research Foundation, Rotterdam, The Netherlands;,Department of Pediatrics, Erasmus Medical Centre Rotterdam/Sophia Children’s Hospital Rotterdam, Rotterdam, The Netherlands;,These authors contributed equally to the article
| | - Tonya White
- Department of Radiology, Erasmus Medical Centre Rotterdam, Postbus 2040, 3000 CA Rotterdam, The Netherlands;,Department of Child and Adolescent Psychiatry, Erasmus Medical Centre Rotterdam—Sophia Children’s Hospital, Rotterdam, The Netherlands,These authors contributed equally to the article.,To whom correspondence should be addressed; tel: +31-0-10-703-70-72, e-mail:
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13
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Schiller RM, van den Bosch GE, Muetzel RL, Smits M, Dudink J, Tibboel D, Ijsselstijn H, White T. Neonatal critical illness and development: white matter and hippocampus alterations in school-age neonatal extracorporeal membrane oxygenation survivors. Dev Med Child Neurol 2017; 59:304-310. [PMID: 27873310 DOI: 10.1111/dmcn.13309] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 11/30/2022]
Abstract
AIM To examine the neurobiology of long-term neuropsychological deficits after neonatal extracorporeal membrane oxygenation (ECMO). METHOD This cross-sectional study assessed white matter integrity and hippocampal volume of ECMO survivors (8-15y) and healthy children (8-17y) using diffusion tensor imaging (DTI) and structural magnetic resonance imaging (MRI) respectively. Neuropsychological outcome was evaluated in ECMO survivors. Included clinical predictors of white matter integrity: age start ECMO, ECMO duration, highest oxygenation index before ECMO, highest mean airway pressure, and mechanical ventilation duration. RESULTS ECMO survivors (n=23) had lower global fractional anisotropy than healthy children (n=54) (patients=0.368; comparison group=0.381; p=0.018), but similar global mean diffusivity (p=0.410). ECMO survivors had lower fractional anisotropy in the left cingulum bundle (ECMO survivors=0.345; comparison group=0.399; p<0.001) and higher mean diffusivity in a region of the left parahippocampal cingulum (patients=0.916; comparison group=0.871; p<0.001). Higher global mean diffusivity predicted worse verbal memory in ECMO survivors (n=17) (β=-0.74, p=0.008). ECMO survivors (n=23) had smaller bilateral hippocampal volume than healthy children (n=43) (left, p<0.001; right, p<0.001) and this was related to worse verbal memory (left, β=0.65, p=0.018; right, β=0.71, p=0.006). INTERPRETATION Neonatal ECMO survivors are at risk for long-term brain alterations, which may partly explain long-term neuropsychological impairments. Neuroimaging may contribute to better risk stratification of long-term impairments.
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Affiliation(s)
- Raisa M Schiller
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ryan L Muetzel
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marion Smits
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Jeroen Dudink
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke Ijsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tonya White
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
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14
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Lukoshe A, van Dijk SE, van den Bosch GE, van der Lugt A, White T, Hokken-Koelega AC. Altered functional resting-state hypothalamic connectivity and abnormal pituitary morphology in children with Prader-Willi syndrome. J Neurodev Disord 2017; 9:12. [PMID: 28331554 PMCID: PMC5356363 DOI: 10.1186/s11689-017-9188-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 01/26/2017] [Indexed: 11/17/2022] Open
Abstract
Background Prader-Willi syndrome (PWS) is a complex neurodevelopmental disorder, characterized by endocrine problems and hyperphagia, indicating hypothalamic-pituitary dysfunction. However, few studies have explored the underlying neurobiology of the hypothalamus and its functional connectivity with other brain regions. Thus, the aim of this study was to examine the anatomical differences of the hypothalamus, mammillary bodies, and pituitary gland as well as resting state functional connectivity of the hypothalamus in children with PWS. Methods Twenty-seven children with PWS (13 DEL, 14 mUPD) and 28 typically developing children were included. Manual segmentations by a blinded investigator were performed to determine the volumes of the hypothalamus, mammillary bodies, and pituitary gland. In addition, brain-wide functional connectivity analysis was performed using the obtained masks of the hypothalamus. Results Children with PWS showed altered resting state functional connectivity between hypothalamus and right and left lateral occipital complex, compared to healthy controls. In addition, children with PWS had on average a 50% smaller pituitary volume, an irregular shape of the pituitary, and a longer pituitary stalk. Pituitary volume did not increase in volume during puberty in PWS. No volumetric differences in the hypothalamus and mammillary bodies were found. In all subjects, the posterior pituitary bright spot was observed. Conclusions We report altered functional hypothalamic connectivity with lateral occipital complexes in both hemispheres, which are implicated in response to food and reward system, and absence of connectivity might therefore at least partially contribute to the preoccupation with food in PWS.
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Affiliation(s)
- Akvile Lukoshe
- Dutch Growth Research Foundation, Postbus 23068, 3001 KB Rotterdam, The Netherlands.,Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Postbus 2060, 3000 CB Rotterdam, The Netherlands
| | - Suzanne E van Dijk
- Department of Child and Adolescent Psychiatry, Erasmus MC-Sophia Children's Hospital, Postbus 2060, 3000 CB Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Intensive Care and department of pediatric surgery, Erasmus MC-Sophia Children's Hospital, Postbus 2060, 3000 CB Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus Medical Centre-Sophia Children's Hospital, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Tonya White
- Department of Child and Adolescent Psychiatry, Erasmus MC-Sophia Children's Hospital, Postbus 2060, 3000 CB Rotterdam, The Netherlands.,Department of Radiology, Erasmus Medical Centre-Sophia Children's Hospital, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Anita C Hokken-Koelega
- Dutch Growth Research Foundation, Postbus 23068, 3001 KB Rotterdam, The Netherlands.,Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Postbus 2060, 3000 CB Rotterdam, The Netherlands
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15
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands
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16
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Valkenburg AJ, van den Bosch GE, de Graaf J, van Lingen RA, Weisglas-Kuperus N, van Rosmalen J, Groot Jebbink LJM, Tibboel D, van Dijk M. Long-Term Effects of Neonatal Morphine Infusion on Pain Sensitivity: Follow-Up of a Randomized Controlled Trial. J Pain 2015; 16:926-33. [PMID: 26120056 DOI: 10.1016/j.jpain.2015.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/29/2015] [Accepted: 06/15/2015] [Indexed: 01/02/2023]
Abstract
Short-term and long-term effects of neonatal pain and its analgesic treatment have been topics of translational research over the years. This study aimed to identify the long-term effects of continuous morphine infusion in the neonatal period on thermal pain sensitivity, the incidence of chronic pain, and neurological functioning. Eighty-nine of the 150 participants of a neonatal randomized controlled trial on continuous morphine infusion versus placebo during mechanical ventilation underwent quantitative sensory testing and neurological examination at the age of 8 or 9 years. Forty-three children from the morphine group and 46 children from the placebo group participated in this follow-up study. Thermal detection and pain thresholds were compared with data from 28 healthy controls. Multivariate analyses revealed no statistically significant differences in thermal detection thresholds and pain thresholds between the morphine and placebo groups. The incidence of chronic pain was comparable between both groups. The neurological examination was normal in 29 (76%) of the children in the morphine group and 25 (61%) of the children in the control group (P = .14). We found that neonatal continuous morphine infusion (10 μg/kg/h) has no adverse effects on thermal detection and pain thresholds, the incidence of chronic pain, or overall neurological functioning 8 to 9 years later. Perspective: This unique long-term follow-up study shows that neonatal continuous morphine infusion (10 μg/kg/h) has no long-term adverse effects on thermal detection and pain thresholds or overall neurological functioning. These findings will help clinicians to find the most adequate and safe analgesic dosing regimens for neonates and infants.
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Affiliation(s)
- Abraham J Valkenburg
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Gerbrich E van den Bosch
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joke de Graaf
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Richard A van Lingen
- Princess Amalia Department of Pediatrics, Division of Neonatology, Isala Clinics, Zwolle, The Netherlands
| | - Nynke Weisglas-Kuperus
- Department of Neonatology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Liesbeth J M Groot Jebbink
- Princess Amalia Department of Pediatrics, Division of Neonatology, Isala Clinics, Zwolle, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Neonatology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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van den Bosch GE, White T, El Marroun H, Simons SHP, van der Lugt A, van der Geest JN, Tibboel D, van Dijk M. Prematurity, Opioid Exposure and Neonatal Pain: Do They Affect the Developing Brain? Neonatology 2015; 108:8-15. [PMID: 25871803 DOI: 10.1159/000376566] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Traditionally, 10 years ago, children born preterm often routinely received morphine, especially during mechanical ventilation. Studies in neonatal rats, whose stage of brain development roughly corresponds to that of children born preterm, found negative long-term effects after pain and opioid exposure. OBJECTIVES We studied possible effects of prematurity, procedural pain and opioids in humans 10 years later. We hypothesized that these factors would negatively influence neurobiological, neuropsychological and sensory development later in life. METHODS We included 19 children born preterm who as neonates participated in an RCT on the short-term effects of morphine administration and who previously participated in our follow-up studies at ages 5 and 8/9 years. We assessed associations between brain morphology (n = 11), neuropsychological functioning (n = 19) and thermal sensitivity (n = 17) and prematurity, opioid exposure and neonatal pain. RESULTS Significant correlations (coefficients 0.60-0.85) of gestational age, number of painful procedures and morphine exposure with brain volumes were observed. Significant correlations between these factors and thermal sensitivity were not established. Neuropsychological outcome was significantly moderately correlated with morphine exposure in only two subtests, and children performed in general 'average' by Dutch norms. CONCLUSIONS Although prematurity, opioid exposure and neonatal pain were significantly associated with brain volume, no major associations with neuropsychological functioning or thermal sensitivity were detected. Our findings suggest that morphine administration during neonatal life does not affect neurocognitive performance or thermal sensitivity during childhood in children born preterm without brain damage during early life. Future studies with larger sample sizes are needed to confirm these findings.
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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18
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Abstract
We present a case study of a 10-year-old child with severe burns that were misinterpreted as inflicted burns. Because of multiple injuries since early life, the family was under suspicion of child abuse and therefore under supervision of the Child Care Board for 2 years before the boy was burned. Because the boy incurred the burns without feeling pain, we conducted a thorough medical examination and laboratory testing, evaluated detection and pain thresholds, and used MRI to study brain morphology and brain activation patterns during pain between this patient and 3 healthy age- and gender-matched controls. We found elevated detection and pain thresholds and lower brain activation during pain in the patient compared with the healthy controls and reference values. The patient received the diagnosis of hereditary sensory and autonomic neuropathy type IV on the basis of clinical findings and the laboratory testing, complemented with the altered pain and detection thresholds and MRI findings. Hereditary sensory and autonomic neuropathy IV is a very rare congenital pain insensitivity syndrome characterized by the absence of pain and temperature sensation combined with oral mutilation due to unawareness, fractures, and anhidrosis caused by abnormalities in the peripheral nerves. Health care workers should be aware of the potential presence of this disease to prevent false accusations of child abuse.
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Affiliation(s)
| | | | - Paul Vos
- Department of Pediatrics, Medical Center Haaglanden, Den Haag, Netherlands
| | - Jan Dokter
- Burn Center, Maasstad Hospital, Rotterdam, Netherlands; and
| | - Tonya White
- Child and Adolescent Psychiatry/Psychology, and Radiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Departments of Pediatric Surgery
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19
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Ceelie I, de Wildt SN, van Dijk M, van den Berg MMJ, van den Bosch GE, Duivenvoorden HJ, de Leeuw TG, Mathôt R, Knibbe CAJ, Tibboel D. Effect of intravenous paracetamol on postoperative morphine requirements in neonates and infants undergoing major noncardiac surgery: a randomized controlled trial. JAMA 2013; 309:149-54. [PMID: 23299606 DOI: 10.1001/jama.2012.148050] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Continuous morphine infusion as standard postoperative analgesic therapy in young infants is associated with unwanted adverse effects such as respiratory depression. OBJECTIVE To determine whether intravenous paracetamol (acetaminophen) would significantly (>30%) reduce morphine requirements in neonates and infants after major surgery. DESIGN, SETTING, AND PATIENTS Single-center, randomized, double-blind study conducted in a level 3 pediatric intensive care unit in Rotterdam, The Netherlands. Patients were 71 neonates or infants younger than 1 year undergoing major thoracic (noncardiac) or abdominal surgery between March 2008 and July 2010, with follow-up of 48 hours. INTERVENTIONS All patients received a loading dose of morphine 30 minutes before the end of surgery, followed by continuous morphine or intermittent intravenous paracetamol up to 48 hours postsurgery. Infants in both study groups received morphine (boluses and/or continuous infusion) as rescue medication on the guidance of the validated pain assessment instruments. MAIN OUTCOME MEASURES Primary outcome was cumulative morphine dose (study and rescue dose). Secondary outcomes were pain scores and morphine-related adverse effects. RESULTS The cumulative median morphine dose in the first 48 hours postoperatively was 121 (interquartile range, 99-264) μg/kg in the paracetamol group (n = 33) and 357 (interquartile range, 220-605) μg/kg in the morphine group (n = 38), P < .001, with a between-group difference that was 66% (95% CI, 34%-109%) lower in the paracetamol group. Pain scores and adverse effects were not significantly different between groups. CONCLUSION AND RELEVANCE Among infants undergoing major surgery, postoperative use of intermittent intravenous paracetamol compared with continuous morphine resulted in a lower cumulative morphine dose over 48 hours. TRIAL REGISTRATION trialregister.nl Identifier: NTR1438.
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Affiliation(s)
- Ilse Ceelie
- Intensive Care and Department of Pediatric Surgery, Erasmus MC–Sophia Children's Hospital, Rotterdam, The Netherlands
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20
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van den Bosch GE, El Marroun H, Schmidt MN, Tibboel D, Manoach DS, Calhoun VD, White TJH. Brain connectivity during verbal working memory in children and adolescents. Hum Brain Mapp 2012; 35:698-711. [PMID: 23233279 DOI: 10.1002/hbm.22193] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 08/09/2012] [Accepted: 08/14/2012] [Indexed: 11/06/2022] Open
Abstract
Working memory (WkM) is a fundamental cognitive process that serves as a building block for higher order cognitive functions. While studies have shown that children and adolescents utilize similar brain regions during verbal WkM, there have been few studies that evaluate the developmental differences in brain connectivity. Our goal was to study the development of brain connectivity related to verbal WkM in typically developing children and adolescents. Thirty-five healthy children and adolescents, divided into three groups: 9-12 (children), 13-16 (young adolescents), and 17-19 (older adolescents) years, were included in this functional magnetic resonance imaging (fMRI) study. The verbal WkM task involved a modified Sternberg item recognition paradigm using three different loads. Brain connectivity analysis was performed using independent component analyses and regressing the components with the design matrix to determine task-related networks. Connectivity analyses resulted in four components associated solely with encoding, four solely with recognition and two with both. Two networks demonstrated age-related differences with respect to load, (1) the left motor area and right cerebellum, and 2) the left prefrontal cortex, left parietal lobe, and right cerebellum. Post hoc analyses revealed that the first network showed significant effects of age between children and the two older groups. There was increasing connectivity with increasing load for adolescents. The second network demonstrated age-related differences between children and older adolescents. Children have higher task-related connectivity at lower loads, but they tend to equalize with the adolescents with higher loads. Finally, a non-load related network involving the orbital frontal and anterior cingulate cortices showed less connectivity in children. Hum Brain Mapp 35:698-711, 2014. © 2012 Wiley Periodicals, Inc.
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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21
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van den Bosch GE, Merkus PJFM, Buysse CMP, Boehmer ALM, Vaessen-Verberne AAPH, van Veen LN, Hop WCJ, de Hoog M. Risk factors for pediatric intensive care admission in children with acute asthma. Respir Care 2012; 57:1391-7. [PMID: 22348677 DOI: 10.4187/respcare.01325] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Severe acute asthma in children is associated with substantial morbidity and may require pediatric ICU (PICU) admission. The aim of the study was to determine risk factors for PICU admission. METHODS The study used a retrospective multicenter case-control design. The cases included children admitted to the PICU because of severe acute asthma and a history of out-patient treatment by pediatricians or pediatric pulmonologists. Controls were children with asthma without a PICU admission for severe acute asthma. The children were matched for sex, age, hospital, and time elapsed since the diagnosis of asthma. Fourteen possible risk factors were analyzed. RESULTS Sixty-six cases were matched to 164 controls. In univariate analysis, all but one of the analyzed variables were significantly associated with PICU-hospitalization. After multivariate conditional logistic regression analysis, 4 risk factors remained significant. These included active or passive smoking, allergies, earlier hospitalization for asthma, and non-sanitized home. CONCLUSIONS Physicians and parents should be aware of these risk factors, and efforts should be made to counteract them.
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Affiliation(s)
- Gerbrich E van den Bosch
- Department of Pediatric Intensive Care, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands.
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