Do We Still Hurt Newborn Babies?

Influence of Early-Life Stress on the Excitability of Dynorphin Neurons in the Adult Mouse Dorsal Horn

While early-life adversity has been associated with a higher risk of developing chronic pain in adulthood, the cellular and molecular mechanisms by which chronic stress during the neonatal period can persistently sensitize developing nociceptive circuits remain poorly understood. Here, we investigate the effects of early-life stress (ELS) on synaptic integration and intrinsic excitability in dynorphin-lineage (DYN) interneurons within the adult mouse superficial dorsal horn (SDH), which are important for inhibiting mechanical pain and itch. The administration of neonatal limited bedding between postnatal days (P)2 and P9 evoked sex-dependent effects on spontaneous glutamatergic signaling, as female SDH neurons exhibited a higher amplitude of miniature excitatory postsynaptic currents (mEPSCs) after ELS, while mEPSC frequency was reduced in DYN neurons of the male SDH. Furthermore, ELS decreased the frequency of miniature inhibitory postsynaptic currents selectively in female DYN neurons. As a result, ELS increased the balance of spontaneous excitation versus inhibition (E:I ratio) in mature DYN neurons of the female, but not male, SDH network. Nonetheless, ELS weakened the total primary afferent-evoked glutamatergic drive onto adult DYN neurons selectively in females, without modifying afferent-evoked inhibitory signaling onto the DYN population. Finally, ELS failed to significantly change the intrinsic membrane excitability of mature DYN neurons in either males or females. Collectively, these data suggest that ELS exerts a long-term influence on the properties of synaptic transmission onto DYN neurons within the adult SDH, which includes a reduction in the overall strength of sensory input onto this important subset of inhibitory interneurons. PERSPECTIVE: This study suggests that chronic stress during the neonatal period influences synaptic function within adult spinal nociceptive circuits in a sex-dependent manner. These findings yield new insight into the potential mechanisms by which early-life adversity might shape the maturation of pain pathways in the central nervous system (CNS).

Neonatal paw pricking alters adolescent behavior in a sex-dependent manner and sucrose partially remediates the effects

Neonatal exposure to noxious stimuli such as repeated heel lances can cause behavior changes. In the NICU sucrose given prior to procedures attenuates the immediate behavioral response to noxious stimuli but may not ameliorate the long-term consequences, and treatment with 24% sucrose can brain structure and behavior in adult rodents. We used a rat model to determine whether paw pricks during the neonatal period alter social interaction and/or paw withdrawal thresholds (PWT) in adolescence, and if 7% sucrose mitigates these effects. One male and one female pup per litter was assigned to each of six experimental groups (no paw prick (control), 1 paw prick (1PP), or 2PP, ± sucrose). Hind paws were pricked once or twice each day between postnatal day (P)3 and P10. Social behavior and PWT were tested in adolescence using the modified social interaction test and von Frey filaments, respectively. Social behavior was altered in the 2PP group; total time interacting was lower in 2PP rats, primarily due to less time sniffing a play partner. Sucrose did not mitigate effects of paw prick but trended to alter social behaviors in males; it decreased time in contact but increased social motivation (movement toward a play partner). PWTs were higher in 2PP animals, this was not altered by sucrose. Thus, rat pups exposed to paw pricks in the neonatal period have some altered behaviors in adolescence. The nature of the behavioral changes is sex-dependent, but sucrose did not mitigate these changes.

The effects of open and closed suctioning systems on neonatal pain and vital signs in neonatal intensive care units

BACKGROUND

Endotracheal suctioning is a procedure used by neonatal intensive care unit nurses to maximize oxygenation and clear airways of secretions, and is one of the most common painful procedures causing stress in intubated newborns.

AIM

This aim of this study is to compare the effects of open and closed endotracheal suctioning on pain, peak heart rate and oxygen saturation in neonates on mechanicalventilation.

MATERIALS AND METHODS

This experimental-design study was conducted on 30 newborns who were mechanically ventilated in the tertiary neonatal intensive care unit of a public hospital. First, closed suctioning and then open suctioning was performed on patients during the day. Pain, peak heart rate and oxygen saturation levels were evaluated before, during and 30 min after each suctioning procedure.

RESULTS

Of the newborns included in the study, 53.3 % were male and 36.6 % were admitted to intensive care unit due to a heart defect. No statistically significant differences were found in pain, peak heart rate, or oxygen saturation between the open and closed suctioning methods. However, oxygen saturation levels during suctioning were lower compared to levels before and 30 min after the procedure. Additionally, peak heart rate was lower during suctioning compared to 30 min afterward.

CONCLUSIONS

The study concludes that there is no significant difference between open and closed suctioning techniques concerning pain, peak heart rate, and oxygen saturation.

IMPLICATIONS TO PRACTICE

Given its sterility and ease of use, the closed suction method may be preferable in clinical settings.

Pain Assessment and Management Practices via Education & Reinforcement (PAMPER): A Quality Improvement Initiative

OBJECTIVES

To establish neonatal pain management practices as an essential developmental supportive measure at a tertiary care unit.

METHODS

This quality improvement initiative was conducted as per Point-of-Care-Quality-Improvement Model over 6 mo, followed by 2 y of sustenance phase at a Neonatal Intensive Care Unit (NICU) in northern India. Infants of birth weight ≤1800 g were included and assessed for pain. Pain Assessment and Management Practices via Education and Reinforcement (PAMPER) group was created by resident doctors and nursing staff. The Premature Infant Pain Profile score was used for the assessment of pain. Limiting factors were analyzed using a fishbone diagram and interventions were done in multiple Plan-Do-Study-Act cycles.

RESULTS

At the end of interventions, 100% of procedures were assessed for pain. The mean (standard deviation) documented pain score for the first seven days was reduced from 12.8 (0.3) in the baseline phase to 7 (2.5). These interventions helped to sustain the practice in >70% of infants in the next 2 y.

CONCLUSIONS

Low-cost interventions improved the pain assessment and management policy of authors' NICU with the establishment of a standard protocol. Audits and reinforcement at regular intervals helped in its long-term sustenance.

Parental impact during and after neonatal intensive care admission

Parents play a pivotal role in neurodevelopmental outcomes of their children in the neonatal intensive care unit (NICU) and beyond. Integration of parents in clinical care and research is synergistic. Engaged parents yield more comprehensive clinical care and more robust and meaningful research products. Subsequently, successful clinical and research efforts improve outcomes for children. We review strategies for parental integration into NICU clinical care and research, including parental involvement in therapeutic interventions and neurodevelopmental care, and effective communication strategies for clinicians and researchers. We discuss challenges in neonatal trials and emphasize the need for building a culture of research, collaborative partnerships with patient advocacy organizations, and ongoing support beyond the NICU. Overall, we call for recognizing and fostering the impactful role of parents as teammates with clinicians and researchers in optimizing neurodevelopmental outcomes in the NICU and beyond.

Assessment of Stress and Anxiety in Parents of Neonates Admitted in a Tertiary Care Neonatal Intensive Care Unit (NICU)

Background A newborn's admission into the Neonatal Intensive Care Unit (NICU) is one unexpected event capable of causing much stress and anxiety among parents. The current study aims to evaluate and compare parental stress and anxiety levels between mothers and fathers. Methodology This cross-sectional study was conducted in the NICU of a tertiary care center, in Uttarakhand where a total of 306 mothers and fathers were enrolled. Data was compiled using a questionnaire consisting of demographic details of parents and infants' clinical profiles, Parental Stressor Scale (PSS) NICU, and State-Trait Anxiety Inventory (STAI) scales were used to evaluate stress and anxiety, respectively. Results Mothers mean stress levels were greater and statistically significant. The most affected subscale in both parents was the change in parental role (M: 4.4/F: 3.3; p < 0.001). Parents with high trait anxiety also had high state anxiety (M: 51.3/F: 45.5; p < 0.001). Mothers were found to have higher trait and state anxiety than fathers. Conclusion Parents of newborns admitted in the NICU experience significant stress and anxiety. Mothers had higher levels of stress and anxiety; similar findings have been recorded previously in Indian and western literature.

A scoping review of the epidemiology and treatment of painful procedures in hospitalized neonates: What has changed in the past three decades?

BACKGROUND

Care of newborns hospitalized in the neonatal intensive care unit (NICU) includes multiple painful procedures/day. Epidemiologic studies have reported the frequency and nature of procedures and treatment interventions. However, evidence on the changing trends in the nature and frequency of neonatal pain procedures or treatments over time is absent or inconclusive. We aimed to determine the frequency and nature of painful procedures/neonate/day in the NICU.

DATABASES AND DATA TREATMENT

MEDLINE and Embase searches were conducted from database inception to July 2023. Studies that reported the nature and frequency of painful procedures and associated pain treatments in neonates were included. Standard inverse-variance random-effects meta-analyses were used to combine studies. Heterogeneity between studies was quantified using the I2 statistic.

RESULTS

Of 2622 unique citations, 64 full-text articles were reviewed; 23 were included. Six additional studies identified in a previous review, and six publications from reference lists were added, resulting in 35 studies. The mean number of painful procedures/neonate/day was 7.38 (95% CI 5.60, 9.17; range <2 to 17). Although the frequency of painful procedures in more recent studies was reduced, it was not statistically significant (p = 0.16). Painful procedures were more frequent during longer observation periods. Needle-related procedures were most common and did not change over time. Procedure-related treatment was suboptimal and inconsistently reported.

CONCLUSIONS

Frequency of painful procedures in the NICU has shown a clinically important decrease but has not significantly changed over time. A paradigm shift moving responsibility from providers to systems in changing pain practices in the NICU is required.

SIGNIFICANCE STATEMENT

The decrease in the daily frequency of painful procedures in hospitalized neonates might be clinically relevant but is not yet statistically significant. Pain treatment is insufficiently documented and reported. This lack of progress in neonatal care might be a result of the complexity of defining pain and stress; inconsistencies in determining the burden of procedural pain; the influence of barriers and facilitators on practice change; and the focus on an individual rather than system responsibility for pain prevention and treatment.

Developmental Outcomes after Opioid Exposure in the Fetus and Neonate

The overall prevalence of opiate use has been increasing, currently affecting approximately 0.6% of the global population and resulting in a significant proportion of infants being born with prenatal opioid exposure. Animal and human models of prenatal opioid exposure demonstrate detrimental effects on brain anatomy as well as neurodevelopment. Less is known about the neurologic sequelae of postnatal opioid exposure in hospitalized infants. In this review, we summarize our current understanding of the impact of prenatal and postnatal opioid exposure on the brain and on neurodevelopment outcomes. We also identify resources and management strategies that may help mitigate neurodevelopmental delays and deficits associated with opioid exposure in this vulnerable population.

Performance Evaluation of a Supervised Machine Learning Pain Classification Model Developed by Neonatal Nurses

BACKGROUND

Early-life pain is associated with adverse neurodevelopmental consequences; and current pain assessment practices are discontinuous, inconsistent, and highly dependent on nurses' availability. Furthermore, facial expressions in commonly used pain assessment tools are not associated with brain-based evidence of pain.

PURPOSE

To develop and validate a machine learning (ML) model to classify pain.

METHODS

In this retrospective validation study, using a human-centered design for Embedded Machine Learning Solutions approach and the Neonatal Facial Coding System (NFCS), 6 experienced neonatal intensive care unit (NICU) nurses labeled data from randomly assigned iCOPEvid (infant Classification Of Pain Expression video) sequences of 49 neonates undergoing heel lance. NFCS is the only observational pain assessment tool associated with brain-based evidence of pain. A standard 70% training and 30% testing split of the data was used to train and test several ML models. NICU nurses' interrater reliability was evaluated, and NICU nurses' area under the receiver operating characteristic curve (AUC) was compared with the ML models' AUC.

RESULTS

Nurses weighted mean interrater reliability was 68% (63%-79%) for NFCS tasks, 77.7% (74%-83%) for pain intensity, and 48.6% (15%-59%) for frame and 78.4% (64%-100%) for video pain classification, with AUC of 0.68. The best performing ML model had 97.7% precision, 98% accuracy, 98.5% recall, and AUC of 0.98.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The pain classification ML model AUC far exceeded that of NICU nurses for identifying neonatal pain. These findings will inform the development of a continuous, unbiased, brain-based, nurse-in-the-loop Pain Recognition Automated Monitoring System (PRAMS) for neonates and infants.

Human vs machine towards neonatal pain assessment: A comprehensive analysis of the facial features extracted by health professionals, parents, and convolutional neural networks

Neonates are not able to verbally communicate pain, hindering the correct identification of this phenomenon. Several clinical scales have been proposed to assess pain, mainly using the facial features of the neonate, but a better comprehension of these features is yet required, since several related works have shown the subjectivity of these scales. Meanwhile, computational methods have been implemented to automate neonatal pain assessment and, although performing accurately, these methods still lack the interpretability of the corresponding decision-making processes. To address this issue, we propose in this work a facial feature extraction framework to gather information and investigate the human and machine neonatal pain assessments, comparing the visual attention of the facial features perceived by health-professionals and parents of neonates with the most relevant ones extracted by eXplainable Artificial Intelligence (XAI) methods, considering the VGG-Face and N-CNN deep learning architectures. Our experimental results show that the information extracted by the computational methods are clinically relevant to neonatal pain assessment, but yet do not agree with the facial visual attention of health-professionals and parents, suggesting that humans and machines can learn from each other to improve their decision-making processes. We believe that these findings might advance our understanding of how humans and machines code and decode neonatal facial responses to pain, enabling further improvements in clinical scales widely used in practical situations and in face-based automatic pain assessment tools as well.

Orientin Reduces the Effects of Repeated Procedural Neonatal Pain in Adulthood: Network Pharmacology Analysis, Molecular Docking Analysis, and Experimental Validation

Background

Premature infants often undergo painful procedures and consequently experience repeated procedural neonatal pain. This can elicit hyperalgesia and cognitive impairment in adulthood. Treatments for neonatal pain are limited. Orientin is a flavonoid C-glycoside that has repeatedly been shown to have pharmacological effects in the past decades. The aim of this study was to systematically explore the effect of orientin on repeated procedural neonatal pain using network pharmacology, molecular docking analysis, and experimental validation.

Methods

Several compound-protein databases and disease-protein databases were employed to identify proteins that were both predicted targets of orientin and involved in neonatal pain. A protein-protein interaction (PPI) network was constructed, and Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed to explore the potential mechanism of action. Molecular docking analysis was employed to calculate the binding energy and visualize the interactions between orientin and potential target proteins. Finally, a mouse model of repeated procedural neonatal pain was established and orientin was administered for 6 days. The mechanical and thermal pain thresholds were assessed in neonates and adult mice. A Morris water maze was employed to investigate cognitive impairment in adult mice.

Results

A total of 286 proteins that were both predicted targets of orientin and involved in neonatal pain were identified. The hub proteins were SRC, HSP90AA1, MAPK1, RHOA, EGFR, AKT1, PTPN11, ESR1, RXRA, and HRAS. GO analysis indicated that the primary biological process (BP), molecular function (MF), and cellular component (CC) were protein phosphorylation, protein kinase activity, and vesicle lumen, respectively. KEGG analysis revealed that the mitogen-activated protein kinase (MAPK) signaling pathway may be the key to the mechanism of action. Molecular docking analysis showed the high binding affinities of orientin for MAPK1, MAPK8, and MAPK14. In mice, orientin inhibited the hyperalgesia in the pain threshold tests in neonates and adult mice and cognitive impairment in adult mice. Immunofluorescence showed that phosphorylated MAPK1 (p-ERK) protein levels in the hippocampus and spinal dorsal horn were downregulated by orientin.

Conclusion

The findings suggested that orientin alleviates neonatal pain, and the MAPK signaling pathway is involved.

Regional Anesthesia for Neonates

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Validity and Reliability of Pain and Behavioral Scales for Preterm Infants: A Systematic Review

OBJECTIVE

To systematically review the instruments used to assess behavior, stress, and/or pain in preterm newborns in the neonatal intensive care unit (NICU) and verify the validity and reliability of these instruments.

DATA SOURCES

Electronic searches were conducted in PubMed/MEDLINE, Cochrane Library, Web of Science, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature on Health Sciences (LILACS), and EBSCOhost Research Platform. 12,295 records were found.

REVIEW/ANALYSIS METHODS

37 studies met the inclusion and exclusion criteria.  The COnsensus-based Standards for selecting health Measurement INstruments (COSMIN) checklist was used to assess the quality assessment and measurement properties.

RESULTS

We identified 25 scales that assessed behavior, pain, and/or stress in preterm newborns. The Behavioral Indicators of Infant Pain (BIPP), Crying, Requires Oxygen, Increased Vital Signs, Expression, Sleeplessness (CRIES), Premature Infant Pain Profile (PIPP), and Premature Infant Pain Profile-Revised (PIPP-R) had scored "very good" in quality data. The PIPP and PIPP-R scales received the "very good" classification in validity assessment. The Evaluation Enfant Douleur (EVENDOL), Children's and Infants Postoperative Pain Scale (CHIPPS), PIPP-R, Neonatal Pain Agitation and Sedation Scale (N-PASS), Bernese Pain Scale for Neonates (BPSN), Faceless Acute Neonatal Pain Scale (FANS), BIIP, and Pain Assessment Scale for Preterm Infants (PASPI) obtained an assessment classified as excellent on reliability, both for inter-rater reliability and internal consistency, and the BPSN demonstrated a very strong value to intra-rater reliability.

CONCLUSIONS

Considering the assessments of inter-rater reliability, internal consistency, and quality of scales by COSMIN, the BIPP, and PIPP-R, were the scales considered appropriate.

A Bibliometric Analysis of Neonatal Pain Management Research From 2010 to 2022

BACKGROUND

Research related to neonatal pain management has received increasing attention in recent years. Effective pain management contributes to the maintenance of the healthy physical and mental growth of the newborn. To better understand this research topic, we analyzed the current state of development in this field over the past thirteen years by bibliometric analysis and provide directions for future research.

METHODS

Original articles were collected from the Web of Science Core Collection (WoSCC) between January 1, 2010, to December 31, 2022, the title and abstract clearly stating 'neonatal pain management' or its alternative search keywords. CiteSpace, VOSviewer, and the WoS analysis tool were used to analyze and present the data.

RESULTS

A total of 967 articles met the inclusion criteria. Significant growth of the number of publications increased roughly fourfold from 2010 to 2022. Overall, the United States and Canada were the highest contributors to neonatal pain management research. Weak cooperation was observed in international research (developing and developed countries) and cross-institutional cooperation. Neonatal pain-related research was the most common focus. Pain education and interventions for parents and medical personnel have also received increasing attention recently.

CONCLUSION

The current study revealed that research in terms of publications on neonatal pain management has rapidly increased for more than the past ten years. Developed countries, especially the United States and Canada, were more concerned with this topic than developing countries. More international research and cross-institutional cooperation are required to promote the development of neonatal pain medicine in the future.

Developmental impact of peripheral injury on neuroimmune signaling

A peripheral injury drives neuroimmune interactions at the level of the injury and throughout the neuraxis. Understanding these systems will be beneficial in the pursuit to target persistent pain that involves both neural and immune components. In this review, we discuss the impact of injury on the development of neuroimmune signaling, along with data that suggest a possible cellular immune memory. We also discuss the parallel effects of injury in the nervous system and immune related areas including bone marrow, lymph node and central nervous system-related cells. Finally, we relate these findings to patient populations and current research that evaluates human tissue.

Extended Reality Use in Paediatric Intensive Care: A Scoping Review

Background: Extended reality (XR) technology such as virtual and augmented reality is increasingly being utilised in paediatric medicine due to its role in medical education and reported positive impacts on outcomes including pain, anxiety, and sleep. To the author's knowledge, no previous reviews investigating the use of XR in paediatric intensive care have been undertaken. Objectives: To scope the use of XR in paediatric intensive care, and assess its barriers to adoption, including safety considerations, cleaning and infection control. Eligibility criteria: All articles of any methodological design discussing the use of XR within paediatric intensive and critical care were included. Sources of evidence: Four databases (EMBASE, CINAHL, PsychInfo, PubMed) and Google Scholar were searched without any limitations on publication year. Charting methods: Data was extracted into Microsoft Excel by two authors independently (AG & SF) and cross-checked for completeness. Results: One hundred and eighty-eight articles were originally identified. Following the application of eligibility criteria 16 articles utilising XR in clinical interventions (n = 7) and medical education (n = 9) were included. Articles utilised VR and AR for highly variable purposes within both medical education (eg disaster preparedness, intubation) and clinical interventions (eg decrease pain, nausea, anxiety and improve Glasgow Coma Scale). Conclusions: While research into the use of XR in paediatric intensive care is still in its infancy it has increased dramatically over the past 5 years within two key areas. Firstly, in healthcare education, to assist in the acquisition of PICU-specific knowledge and practice of skills such as intubation of difficult airways. Secondly, studies have evaluated and demonstrated that with appropriate use, VR appears to be a safe and feasible intervention to decrease pain and anxiety in PICU patients.

Sympathetic nervous system activity and pain-related response indexed by electrodermal activity during the earliest postnatal life in healthy term neonates

Sympathetic nervous system (SNS) undergoes a prolonged period of fetal and neonatal development and maturation during which is vulnerable to a variety of influences (e.g. painful experiences). Thus, we aimed to evaluate SNS activity at rest and in response to stressful stimulus (pain) within the earliest postnatal life in healthy term neonates using electrodermal activity (EDA) measures. In twenty eutrophic healthy term neonates EDA was recorded within the first two hours after birth (measurement 1 - M1) and 72 h after birth (measurement 2 - M2) at rest and in response to pain (M1 - intramuscular K vitamin administration; M2 - heel stick). Evaluated parameters were skin conductance level (SCL), non-specific skin conductance responses (NS.SCRs), skin SCL 10 s before pain stimulus (SCL_10 before pain), skin conductance response (SCR) peak after pain stimulus, SCL 10 s after pain stimulus (SCL_10 after pain), SCR magnitude, latency, SCR rise/decline time, SCR half recovery time. SCL was significantly decreased at rest during M2 compared to M1 (p=0.010). SCL_10 before pain, SCR peak after pain, and SCL_10 after pain stimulus were significantly decreased in M2 compared to M1 (p=0.014, p=0.020, p=0.011, respectively). SCL was significantly decreased and NS.SCRs were significantly higher in the recovery period after the pain stimulus during M2 compared to M1 (p=0.015, p=0.032, respectively). Our results indicate EDA parameters sensitive to detect sympathetic changes during the earliest postnatal life reflecting its potential in early diagnosis of the autonomic maturation - linked pathological states in neonates.

Paediatric palliative care in the NICU: A new era of integration

We are entering a new era of integration between neonatal medicine and paediatric palliative care, with increasing recognition that the role and skills of palliative care extend beyond care of only the terminally ill infant. This paper addresses the principles of paediatric palliative care and how they apply in the NICU, considers who provides palliative care in this setting and outlines the key components of care. We consider how the international standards of palliative care pertain to neonatal medicine and how a fully integrated approach to care may be realised across these two disciplines. Palliative care is so much more than end-of-life care, offering a proactive and holistic approach which addresses the physical, emotional, spiritual and social needs of the infant and family. This is a truly interdisciplinary endeavour, relying on a harmonisation of the skills from both the neonatal and palliative care teams to deliver high-quality coordinated care.

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..

Evidence-Based Nursing Practices for the Prevention of Newborn Procedural Pain in Neonatal Intensive Therapy-An Exploratory Study

BACKGROUND

Due to the progress in neonatology, in particular, in the past three decades, the mortality rate among patients of intensive care units has decreased. However, this is connected not only with newborns needing to stay longer in the unit, but also with the exposure of newborns to many painful procedures and stresses. Lack of or insufficient pain prevention has a negative impact on the sensory or locomotor development of newborns. Despite the presence of guidelines based on scientific evidence, the use of pharmacological and non-pharmacological pain-management methods in newborns is still insufficient.

AIM

The aim of the study was to: identify the knowledge nurses/midwives have of recommended non-pharmacological and/or pharmacological methods, in particular, in relation to medical intervention procedures; assess the interventions for pain relief applied by midwives/nurses most often in their clinical practice; examine the role of age, general work experience, education level and years of work of medical professionals on a neonatal ward, as well as the referral level of a unit, versus the application of pharmacological and non-pharmacological methods.

METHODS

A descriptive and quantitative study conducted in 2019 among Polish nurses/midwives working at neonatal intensive care units.

RESULTS

The analysis of the material reflected the deficit of knowledge and the insufficient daily use of recommended pain-relief measures among the respondents.

CONCLUSIONS

The interpretation of data indicates that despite the clear and easily available recommendations of scientific societies concerning the mode of conduct in particular medical procedures, medical personnel do not apply those recommendations in their everyday practice. It is necessary to plan and implement education strategies for nurses/midwives on standard pain-management interventions during painful medical procedures.

Enriched environment rescues neonatal pain induced cognitive deficits and the impaired hippocampal synaptic plasticity later in life

Although extensive and untreated pain that occurs during a critical developmental window may impair cognition later in life, environmental interventions at early might promote. However, the underlying mechanism is poorly understood. Our current study utilized a rat model of "repetitive needle pricks" from the day of birth (P0) to postnatal day 7 (P7) to mimic the painful experience of preterm neonates in the Neonatal intensive care unit (NICU). Enriched environment (EE) during development period (from P15 to P70) was implemented as a nonpharmacological intervention approach. Electrophysiological recording, behavioral tests and biochemical analysis were performed after the end of EE (between P71 and P80). Results showed neonatal repetitive pain resulted in a reduction in mechanical withdrawal thresholds by the von Frey test in P70 (P < 0.001). Furthermore, neonatal repetitive pain impaired spatial learning and memory (P < 0.05) and even led to dysfunction in fear memory (P < 0.01). In contrast, EE rescued neonatal pain induced cognitive deficits and normalized hippocampal long-term potentiation in rats exposed to neonatal pain (P < 0.05). The beneficial effect of EE might be the improvements in hippocampal synaptic plasticity via up-regulating neurotrophic factors and N-methyl-D-aspartate (NMDA) receptors in the hippocampus. Our findings provide evidence that early environmental intervention might be a safe strategy to overcome neurodevelopmental abnormalities in preterm infants who experienced multiple procedural painful events during the early critical period. This article is protected by copyright. All rights reserved.

The influence of skin-to-skin contact on Cortical Activity during Painful procedures in preterm infants in the neonatal intensive care unit (iCAP mini): study protocol for a randomized control trial

BACKGROUND

Strong evidence suggests that maternal-infant skin-to-skin contact (SSC) is effective in reducing behavioural responses to pain. Given the multi-sensory benefits of SSC, it is highly likely that SSC provided during pain in early life may reduce pain-induced brain activity. The aim of this study is to examine the effect of SSC compared to 24% sucrose on pain-induced activity in the preterm infant brain during a medically required heel lance. Secondary objectives include determining (a) differences between behavioural pain response and noxious-related brain activity during heel lance and (b) rate of adverse events across groups.

METHODS

We will randomly assign 126 babies (32 to 36 completed weeks gestational age) admitted to the neonatal intensive care unit, and their mothers within the first seven days of age to receive (i) SSC plus sterile water and (ii) 24% oral sucrose. Each baby will receive a medically indicated heel lance, following a no treatment baseline period. The primary outcome is noxious-related brain activity measured using an electroencephalogram (EEG) pain-specific event-related potential. Secondary outcomes include pain intensity measured using a bio-behavioural infant pain assessment tool (Premature Infant Pain Profile-Revised) and rate of adverse events.

DISCUSSION

This will be the first clinical trial to compare the effect of SSC and 24% sucrose on pain-induced brain activity in the preterm infant brain during a clinical noxious stimulus, measured using EEG. Given the negative neurodevelopmental outcomes associated with unmanaged pain, it is imperative that preterm babies receive the most effective pain-reducing treatments to improve their health outcomes. Our findings will have important implications in informing optimal pain assessment and management in preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03745963 . Registered on November 19, 2018.

Efficacy of Skin-to-Skin Care versus Swaddling for Pain Control Associated with Vitamin K Administration in Full-Term Neonates: A Randomized Controlled Trial

OBJECTIVE

The objective of the study was to assess the efficacy of immediate skin-to-skin care (SSC) versus swaddling in pain response to intramuscular injection of vitamin K at 30 min of birth in neonates.

METHODS

Healthy full-term newborns were enrolled immediately after normal vaginal delivery and randomized in two groups, SSC and swaddling. Neonatal Infant Pain Scale (NIPS) was measured before, immediately after and at 2 min after the injection.

RESULTS

Total 100 newborns were enrolled in the study (50 in each group). The mean (SD) birth weight of newborns in the SSC and swaddling group was 2668 (256) and 2730 (348) g, respectively. NIPS was comparable between the SSC and swaddling at before [1.78 (0.58) vs. 1.96 (0.83), p = 0.21], and immediately after the injection [4.82 (0.72) vs. 5.08 (0.75), p = 0.08]. NIPS at 2 min after the injection was significantly low in the SSC group compared to the swaddling group [1.38 (0.70) vs. 2.88 (1.00), p < 0.001]. At 2 min after injection, the NIPS score was significantly lower than baseline in the SSC group (p = 0.002), while it was significantly higher in the swaddling group (p < 0.001). A significantly higher proportion of newborns had a NIPS score of more than three at 2 min after injection in the swaddling group as compared to the SSC group (22% vs. 2%, p < 0.001).

CONCLUSION

Immediate SSC was more efficacious as compared to swaddling as a pain control intervention while giving vitamin K injection.

CLINICAL TRIAL REGISTRATION

The trial is registered with the Clinical Trial Registry of India with Registration number: CTRI/2020/01/022984.

The practice of procedural pain assessment and management in neonatal intensive care unit in Ethiopia: Cross-sectional study

BACKGROUND AND AIMS

Neonates in intensive care units undergo frequent painful procedures for diagnostic or care-related purposes. Untreated pain has serious short-term and long-term complications. This study aims to evaluate the frequency of painful procedures, pain assessment, and their analgesic management practice among neonates admitted to the NICU.

METHODS

The present study is a hospital-based cross-sectional study of neonates admitted at level II NICU of St. Paul hospital millennium medical college in Ethiopia between March and August 2019. Data were collected from medical charts of neonates and bedside observation using a checklist. The parameters included were demographic characteristics, types of painful procedures, pain assessment practice, and analgesic intervention provided during painful procedures. Descriptive statistics, Mann-Whitney U-test, and Kruskal-Wallis test were used to compare the number of painful procedures and influencing factors. P-value < .05 was considered statistically significant.

RESULTS

Of the 325 neonates included in this study, a median of 4 (3-7) painful procedures were performed per neonate in the first 24 hours of NICU stay. Heel lance 280 (20.7%) and Venipuncture 249 (18.41%) were the most commonly performed painful procedures. Of the 1352 painful procedures, none of the neonates received any form of analgesic intervention and none of the neonate's pain scores were documented on their medical chart. The higher number of painful procedures were associated with gestational age between 28 and 31 weeks, birth weight less than 1500 g, and use of CPAP respiratory support P-value <.001, <.001, and .0015, respectively.

CONCLUSION

Painful procedures were frequently performed in NICU without any form of analgesic intervention. Strategies to introduce neonatal pain assessment and their analgesic management for clinical practice are necessary.

Practices of Procedural Pain Management in Neonates through Continuous Quality Improvement Measures

Objective

Although the benefits of pain control measures in neonates are well known, the actual usage was not optimal in our unit. Therefore, we implemented a quality improvement project to improve pain management practices through multiple Plan-Do-Study-Act (PDSA) cycles.

Method

Our project included hemodynamically stable newborns weighing ≥1300 g. We identified four common procedures: intravenous cannulation, venous sampling, heel prick, and nasogastric tube insertion. The selected pain control measures were skin-to-skin contact, breastfeeding, expressed breast milk orally, and oral sucrose. Between April 2019 and September 2019, we intervened multiple times and reassessed shortcomings. We encouraged evidence-based practices and gave solutions for shortcomings. Data were interpreted weekly to assess the compliance to pain control interventions.

Results

Minimal pain control measures (3-4%) were utilized for identified procedures before the project began. We could improve the use of pain control measures steadily and achieve the target of 80% of procedures after seven different interventions over five months. There was a retention of the effect on reassessing twice at second and fourth months of stopping further intervention once the target got achieved.

Conclusion

Quality Improvement science can identify the shortcomings and help to improve the compliance for pain control practices in neonates, as demonstrated in this neonatal unit.

Assessment and Management of Pain in Preterm Infants: A Practice Update

Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant.

Hydromorphone Prescription for Pain in Children-What Place in Clinical Practice?

While morphine is the gold standard treatment for severe nociceptive pain in children, hydromorphone is increasingly prescribed in this population. This review aims to assess available knowledge about hydromorphone and explore the evidence for its safe and effective prescription in children. Hydromorphone is an opioid analgesic similar to morphine structurally and in its pharmacokinetic and pharmacodynamic properties but 5-7 times more potent. Pediatric pharmacokinetic and pharmacodynamic data on hydromorphone are sorely lacking; they are non-existent in children younger than 6 months of age and for oral administration. The current data do not support any advantage of hydromorphone over morphine, both in terms of efficacy and safety in children. Morphine should remain the treatment of choice for moderate and severe nociceptive pain in children and hydromorphone should be reserved as alternative treatment. Because of the important difference in potency, all strategies should be taken to avoid inadvertent administration of hydromorphone when morphine is intended.

[Pediatric Palliative Care - When the End Comes with the Beginning]

Pediatric Palliative Care - When the End Comes with the Beginning Abstract. Palliative care is not usually associated with childhood and adolescence. Nevertheless, in German-speaking Europe alone, more than 50 000 children live with life-shortening illnesses, and about 5000 children die every year. Palliative care for children and adolescents (PPC) is an attitude that must not be forced on anyone, but must be lived; and, in the case of complex-chronic diseases often over many years. A successful and sustainable implementation of PPC is therefore based on an appreciative collaboration between different teams and the affected families, true to the quadriga presented here of comprehensive symptom control with curiosity, patience, activity and humility. Necessary basics such as the care plan, interprofessional home visits and the round table, plus 24-hour accessibility, are here presented, as well as a triage technique and the advanced care management.

[Preterm birth: a risk for mental health?]

One in 12 children is born before 37 completed weeks of gestation and during the last decades survival rates and developmental outcomes of even very premature children have significantly improved. As a result, mental health sequelae of preterm birth are more frequently addressed. The manifestation of a distinct psychopathological profile with co-occurrence of symptoms associated with attention deficit/hyperactivity, autism spectrum and anxiety disorders has been recognized and discussed as "preterm behavioral phenotype", mainly affecting high-risk children with very low birth weights. Current research findings on parental psychological distress and early childhood developmental conditions after preterm birth indicate contextual factors that are of relevance, also for clinicians in psychotherapeutic practice.

Morphine or hydromorphone: which should be preferred? A systematic review

OBJECTIVE

To systematically review available paediatric literature on comparisons between morphine (Mo) and hydromorphone (Hm), to guide clinicians to rationally use these medications.

DESIGN

Systematic review within four databases for all studies published from 1963 to July 2019.

SETTING

All paediatric settings.

ELIGIBILITY

All studies comparing Mo to Hm in individuals younger than 21 years.

MAIN OUTCOME MEASURES

The primary outcome was to compare clinical efficacy and side effects of Mo and Hm. The secondary outcomes were the comparison of pharmacokinetic profiles and the description of predefined Mo to Hm conversion ratios used across the paediatric literature.

RESULTS

Among 754 abstracts reviewed, 59 full-text articles met inclusion criteria and 24 studies were included in the analysis: 4 studies compared pharmacodynamics of Mo and Hm and 20 studies reported the use of a predefined Mo to Hm conversion ratio. Most studies had a poor methodological quality. Available evidence suggests that, when given intravenously, the equianalgesic ratio of Mo to Hm is 5:1. Intravenous administration with this ratio results in a similar rate of adverse effects, including pruritus and nausea. The epidural administration with a ratio of 10:1 results in more pruritus and urinary retention with Mo than Hm. Pharmacokinetic data were reported in only one study. A wide range of pre-established ratios for different routes of administration were reported, but few were based on evidence.

CONCLUSION

Current literature does not permit a rational choice between Mo and Hm. A ratio of 5:1 seems adequate for intravenous administration and leads to a similar rate of adverse effects.

Staff awareness and bundling reduce skin breaks and blood tests in neonatal intensive care

AIM

Skin breaks (SBs) for procedures and blood sampling are common in neonatal intensive care units (NICU), contributing to pain, infection risk and anaemia. We aimed to document their prevalence, identify areas for improvement and, through staff awareness, reduce their frequency.

METHODS

Quality improvement project via prospective audit at a tertiary-level NICU in Australia was conducted. All infants admitted to the NICU for >24 h during two audit periods were included in the study. A specifically designed bedside audit tool was used to prospectively document all SB and blood tests performed on infants during a 4-week audit period (audit 1). Results were reviewed to identify areas for improvement, and disseminated to staff at unit meetings, shift handover and email. Following education and awareness, the audit was repeated (audit 2), and data were compared. Frequency of SB and blood tests performed was measured. Data were tested for normality and analysed using parametric or non-parametric tests where appropriate.

RESULTS

There were 52 NICU admissions during each audit period (104 total), with 34 (65%) and 31 (60%) having audit sheets completed, respectively. Median (interquartile range) gestational age and mean (standard deviation) birthweight were 29 (26.3-35) weeks and 1836 (1185) g for audit 1, 30 (28.5-31.5) weeks and 1523 (913) g for audit 2. The reduction in total blood tests (mean) was 36.3%, skin breaks per admitted baby day reduced by 60% and total blood volume sampled (mean) by 37.7%.

CONCLUSIONS

A quality improvement project by prospective audit and staff education was associated with reductions in frequency of skin breaks and blood tests in the NICU.

Pain Relief in Late Preterm Neonates: A Comparative Study of Kangaroo Mother Care, Oral Dextrose 50%, and Supine Nesting Position

Objective:

The objectrve is to compare the analgesic effect of Kangaroo Mother Care (KMC), oral dextrose 50% (D50) and supine nesting position in late preterm neonates (34 week to <37 week Gestation Age) while doing heel prick for blood glucose monitoring.

Materials and Methods:

Babies were randomized into three groups; KMC, D50 and supine nesting. Premature infant pain profile (PIPP) score was used to measure pain severity following heel prick. Total crying time was also compared.

Results:

Data of 149 eligible babies were analyzed; significant difference was noted in total PIPP scores (mean; SD) across groups; KMC (8.42 [1.99]), D50 (8.76 [1.84]) and nesting (13.08 [1.70]) (P < 0.001). Post hoc analysis revealed comparable scores among KMC and D50 groups (P = 0.638), significantly less than nesting group (P < 0.001). Significant difference in crying time (median; interquartile range) was also noted amongst three groups (P < 0.001).

Conclusion:

The analgesic effect of KMC and oral D50 is comparable and found to be superior to supine nesting position in reducing pain of heel prick.

What Facial Features Does the Pediatrician Look to Decide That a Newborn Is Feeling Pain?

OBJECTIVE

 The study aimed to analyze the gaze fixation of pediatricians during the decision process regarding the presence/absence of pain in pictures of newborn infants.

STUDY DESIGN

 Experimental study, involving 38 pediatricians (92% females, 34.6 ± 9.0 years, 22 neonatologists) who evaluated 20 pictures (two pictures of each newborn: one at rest and one during a painful procedure), presented in random order for each participant. The Tobii-TX300 equipment tracked eye movements in four areas of interest of each picture (AOI): mouth, eyes, forehead, and nasolabial furrow. Pediatricians evaluated the intensity of pain with a verbal analogue score from 0 to 10 (0 = no pain; 10 = maximum pain). The number of pictures in which pediatricians fixed their gaze, the number of gaze fixations, and the total and average time of gaze fixations were compared among the AOI by analysis of variance (ANOVA). The visual-tracking parameters of the pictures' evaluations were also compared by ANOVA according to the pediatricians' perception of pain presence: moderate/severe (score = 6-10), mild (score = 3-5), and absent (score = 0-2). The association between the total time of gaze fixations in the AOI and pain perception was assessed by logistic regression.

RESULTS

 In the 20 newborn pictures, the mean number of gaze fixations was greater in the mouth, eyes, and forehead than in the nasolabial furrow. Also, the average total time of gaze fixations was greater in the mouth and forehead than in the nasolabial furrow. Controlling for the time of gaze fixation in the AOI, each additional second in the time of gaze fixation in the mouth (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.08-1.46) and forehead (OR: 1.16; 95% CI: 1.02-1.33) was associated with an increase in the chance of moderate/severe pain presence in the neonatal facial picture.

CONCLUSION

 When challenged to say whether pain is present in pictures of newborn infants' faces, pediatricians fix their gaze preferably in the mouth. The longer duration of gaze fixation in the mouth and forehead is associated with an increase perception that moderate/severe pain is present.

KEY POINTS

· Neonatal pain assessment is intrinsically subjective.. · Visual tracking identifies the focus of attention of individuals.. · Adults' gaze in neonates' mouth and forehead is associated with pain perception..

Amygdalar Corticotropin-Releasing Factor Signaling Is Required for Later-Life Behavioral Dysfunction Following Neonatal Pain

Neonatal pain such as that experienced by infants in the neonatal intensive care unit is known to produce later-life dysfunction including heightened pain sensitivity and anxiety, although the mechanisms remain unclear. Both chronic pain and stress in adult organisms are known to influence the corticotropin-releasing factor (CRF) system in the Central Nucleus of the Amygdala, making this system a likely candidate for changes following neonatal trauma. To examine this, neonatal rats were subjected to daily pain, non-painful handling or left undisturbed for the first week of life. Beginning on postnatal day, 24 male and female rats were subjected to a 4-day fear conditioning and sensory testing protocol. Some subjects received intra-amygdalar administration of either Vehicle, the CRF receptor 1 (CRF₁) receptor antagonist Antalarmin, or the CRF receptor 2 (CRF₂) receptor antagonist Astressin 2B prior to fear conditioning and somatosensory testing, while others had tissue collected following fear conditioning and CRF expression in the CeA and BLA was assessed using fluorescent in situ hybridization. CRF₁ antagonism attenuated fear-induced hypersensitivity in neonatal pain and handled rats, while CRF₂ antagonism produced a general antinociception. In addition, neonatal pain and handling produced a lateralized sex-dependent decrease in CRF expression, with males showing a diminished number of CRF-expressing cells in the right CeA and females showing a similar reduction in the number of CRF-expressing cells in the left BLA compared to undisturbed controls. These data show that the amygdalar CRF system is a likely target for alleviating dysfunction produced by early life trauma and that this system continues to play a major role in the lasting effects of such trauma into the juvenile stage of development.

The Effect of 3 Positions Given to Preterm Infants During Heelstick Procedure on Pain and Durations of Crying and Procedure

The purpose of this randomized controlled study was to determine the effect of 3 positions given to preterm infant during heelstick procedure on the pain and durations of crying and procedure. The sample of the study consisted of 90 preterm infants (30 in each group). The heelstick procedure was video recorded. Data from the pain scores, durations of crying, and procedure were collected watching the video recordings. It was determined that the pain mean score of the infants in the control group (supine on the crib) (5.50 ± 2.13) was statistically significantly higher than that of the infants in the positions of upright (3.00 ± 2.17) and supine on the lap (3.20 ± 2.46) (P < .01), and there was no difference between the positions of upright and supine on the lap (P > .05). Giving the positions of upright or supine on the lap during heelstick is effective in reducing pain, shortening the duration of crying, and calming down the infant. Heelstick in the position of upright on the lap shortened the procedure duration and allowed the infants to be subjected to less painful procedure. It is recommended for nurses to take the preterm infants on their laps during heel lancing and give them the upright position, in particular.

The burden of early life stress on the nociceptive system development and pain responses

For a long time, the capacity of the newborn infant to feel pain was denied. Today it is clear that the nociceptive system, even if still immature, is functional enough in the newborn infant to elicit pain responses. Unfortunately, pain is often present in the neonatal period, in particular in the case of premature infants which are subjected to a high number of painful procedures during care. These are accompanied by a variety of environmental stressors, which could impact the maturation of the nociceptive system. Therefore, the question of the long-term consequences of early life stress is a critical question. Early stressful experience, both painful and non-painful, can imprint the nociceptive system and induce long-term alteration in brain function and nociceptive behavior, often leading to an increase sensitivity and higher susceptibility to chronic pain. Different animal models have been developed to understand the mechanisms underlying the long-term effects of different early life stressful procedures, including pain and maternal separation. This review will focus on the clinical and preclinical data about early life stress and its consequence on the nociceptive system.

Case Report: Intact Survival of a Marginally Viable Male Infant Born Weighing 268 Grams at 24 Weeks Gestation

We report the case of a preterm small for gestational age male infant born at 24 weeks of gestation with a birth weight of 268 g who was discharged from our hospital without the requirement for home oxygen therapy or tube feeding. He did not experience severe intraventricular hemorrhage, periventricular leukomalacia, hearing disability, or any other serious complications. At that time (February 2019), according to the University of Iowa's Tiniest Babies Registry, he was the tiniest male infant in the world to survive without any serious complications other than severe retinopathy of prematurity that required laser therapy. Although the survival rate of infants with extremely low birth weight is improving worldwide, a high mortality rate and incidence of severe complications remain common for infants weighing <300 g at birth, particularly in male infants. In recent years, there have been frequent discussions regarding the ethical and social issues involved in treating extremely preterm infants weighing <400 g. Despite the challenges, reports of such infants surviving are increasing. Neonatal medicine has already achieved great success in treating infants weighing 400 g or more at birth. However, lack of evidence and experience may make physicians reluctant to treat infants weighing less than this. The present case demonstrates that intact survival of a marginally viable male infant with a birth weight of <300 g is possible with minimal handling and family involvement beginning shortly after birth. Our detailed description of the clinical course of this case should provide invaluable information to physicians around the world who treat such infants. This report will aid in the progress of neonatal medicine and help to address many of the social and ethical issues surrounding their care.

Knowledge, attitudes and practices of neonatal professionals regarding pain management

Pain management is an important issue which impacts the prognosis of neonates in neonatal intensive care units. Evidence has shown that professionals' knowledge and attitudes regarding pain management can impact the quality of their practice. The purpose of this study was to evaluate the knowledge, attitudes, and practices of neonatal professionals regarding neonatal pain management. A cross-sectional study was performed involving neonatal physicians and nurses, using a research questionnaire to investigate the knowledge and attitudes of professionals as well as to assess their practice of pain management. Research found an apparent discrepancy between the knowledge levels of neonatologists and nurses regarding pain assessment and management, with nurses displaying weaker professional knowledge and more negative attitudes toward pain management than did neonatologists. Additionally, research revealed a lack of knowledge and negative attitudes among participants regarding the provision of sufficient opioid analgesics to sick infants during invasive procedures and even for dying neonates. There is an urgent need for continuing education regarding neonatal pain management with the goal of empowering neonatal professionals; further research is needed into the question of how to translate education into more reliable practice.Conclusion: This research provides useful information regarding the knowledge, attitudes, and clinical practice of neonatal pain management among neonatologists and nurses and points out some differences in the knowledge levels of these two groups. What is Known: •Neonates can perceive and respond to pain stimuli by showing their biological signals similarly to children and adults. •Untreated or insufficient pain management for high-risk neonates has short-term. negative effects and may also induce long-term negative effects. What is New: •The level of knowledge, the attitudes, and the practices regarding neonatal pain in intensive care are different among neonatal professionals. •There is an urgent need to provide interdisciplinary continuing education to improve the knowledge of neonatal professionals and encourage them to more highly prioritize neonatal pain management.

The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates

BACKGROUND

The neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates.

OBJECTIVE

The objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates.

METHODS

Neonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score.

RESULTS

Nurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the 'variation in the timing of the pain score' and the 'integration of critical thinking and judgement' used when assessing pain in neonates.

CONCLUSIONS

The clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Adult brain activation in response to pain is changed by neonatal painful stimulation according to sex: A manganese-enhanced MRI study

Although it is known that nociceptive stimulation in the first postnatal week in rats is useful to model preterm pain, resulting in activation of specific brain areas, as assessed in vivo using manganese-enhanced magnetic resonance imaging (MEMRI), little is known about its long-term effects and sex specificity. Here we aimed to investigate whether inflammatory pain induced in male and female adult rats modify the pattern of brain activation between animals subjected or not to neonatal pain. For this, Complete Freund's adjuvant (CFA) was injected into the left hind paw of rat pups on postnatal day 1 (P1) or P8 to induce inflammatory response. During adulthood, CFA-treated and control animals were injected with CFA 1 hr prior MRI. MEMRI has the ability to enhance the contrast of selective brain structures in response to a specific stimulus, as the pain. MEMRI responses were consistent with activation of nociceptive pathways and these responses were reduced in animals treated with CFA on P1, but increased in animals treated on P8, mainly in the female group. In agreement, P8 female group showed exacerbated responses in the thermal nociceptive test. Using MEMRI, we conclude that the natural ability of adult rats to recognize and react to pain exposition is modified by neonatal painful exposition, mainly among females.

Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled Trial

BACKGROUND

Premature infants hospitalized in the neonatal intensive care unit are routinely exposed to many painful procedures. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates, hence pain in infants should be reduced. Kangaroo care and oral sucrose are some of the methods that can help reduce pain.

AIM

This study aimed to compare the effects of kangaroo care and oral sucrose on pain relief in preterm infants during heel lancing.

METHODS

Our study involved 64 infants. The infants were randomly divided into two groups using a randomized block design of drawing out slips from a thick, non-transparent envelope. There were 64 slips in this envelope (32 for kangaroo care and 32 for oral sucrose). Kangaroo care was given to the preterm infants in the first group and oral sucrose to those in the second group. In both groups, heart rate and oxygen saturation were measured and pain score was evaluated by two observers using the Premature Infant Pain Profile (PIPP) before, during, and 2 minutes after blood sampling by heel lancing.

RESULTS

There was a statistically significant difference between the groups in favor of the kangaroo group in terms of change in the PIPP values after heel lancing. Kangaroo care is more effective than oral sucrose in pain relief during heel lancing in preterm infants.

CONCLUSIONS

In addition to many benefits it offers to infants, kangaroo care can be used to reduce pain during painful procedures in premature infants.

Pain Scales in Neonates Receiving Mechanical Ventilation in Neonatal Intensive Care Units - Systematic Review

INTRODUCTION

Recently, interest in the problem of proper prevention and monitoring of pain, especially acute, has been increasing in relation to various age groups. Greater awareness of the problem prompts discussion about the purpose of analgesia in newborns treated with mechanical ventilation.

AIM

The purpose of the systematic review was to analyze current research on the use of pain scales in newborns treated with mechanical ventilation in the Neonatal Intensive Care Unit.

METHODS

Medline databases: PubMed, OVID, EBSCO, Web of Science and Cochrane Library were traced using the appropriate keywords. The search was limited to studies in English. The review took into account the years 2006-2019. Considering the criteria, 12 articles were included in further analysis, to which full access was obtained.

RESULTS

The analyzed scientific research showed differences in beliefs about the validity and credibility of the scales used. Researchers indicated that staff with practical experience in using scales in their daily practice was very skeptical of the results obtained on their basis.

CONCLUSION

Based on this review, no explicit evidence can be obtained to support the use of one proper scale in pain assessment. It can be inferred that the COMFORT and N-PASS scales are effective for pain assessment and for determining the need for analgesics in mechanically ventilated neonates. These scales may be equally effective in assessing chronic pain, especially in mechanically ventilated children. On the other hand, the PIPP and CRIES scales are most commonly recommended for assessing acute and postoperative pain.

Quantification of neonatal procedural pain severity: a platform for estimating total pain burden in individual infants

There is increasing evidence that long-term outcomes for infants born prematurely are adversely affected by repeated exposure to noxious procedures. These interventions vary widely, for example, in the extent of damage caused and duration. Neonatal intensive care unit (NICU) procedures are therefore likely to each contribute differently to the overall pain burden of individual neonates, ultimately having a different impact on their development. For researchers to quantify the procedural pain burden experienced by infants on NICU, we aimed to estimate the pain severity of common NICU procedures using published pain scores. We extracted pain scores over the first minute (pain reactivity) from the literature, using 59 randomized controlled trials for 15 different procedures. Hierarchical cluster analysis of average pain scores resulted in 5 discrete severity groups; mild (n = 1), mild to moderate (n = 3), moderate (n = 7), severe (n = 3), and very severe (n = 1). The estimate of the severity of individual procedures provided new insight into infant pain reactivity which is not always directly related to the invasiveness and duration of a procedure; thus, both heel lance and skin tape removal are moderately painful procedures. This estimate of procedural pain severity, based on pain reactivity scores, provides a novel platform for retrospective quantification of an individual neonate's pain burden due to NICU procedures. The addition of measures that reflect the recovery from each procedure, such as brain activity and behavioural regulation, would further improve estimates of the pain burden of neonatal intensive care.

Methodological Issues in the Study of the Development of Pain Responsivity in Preterm Neonates: A Systematic Review

The study of the development of neonatal pain responses is of key importance, both for research and for clinical reasons, with particular regard to the population of preterm neonates, given the amount of painful procedures they are exposed to on a daily basis. The aim of this work was to systematize our knowledge about the development of pain responses in prematurely born neonates by focusing on some key methodological issues. Studies on the impact of age variables, namely gestational age (GA), postmenstrual age (PMA) and chronological age (CH), on pain responsivity in premature neonates were identified using Medline and Scopus. Studies (N = 42) were categorized based on terminological and methodological approaches towards age variables, and according to output variables considered (facial, nonfacial behavioral, physiological). Distinct multidimensional developmental patterns were found for each age-sampling strategy. Overall, each of the three age variables seems to affect pain responsivity, possibly differently across age windows. Targeted as well as integrated approaches, together with a renewed attention for methodological consistency, are needed to further our knowledge on this topic.

Neonatal Injury Evokes Persistent Deficits in Dynorphin Inhibitory Circuits within the Adult Mouse Superficial Dorsal Horn

Neonatal tissue damage induces long-term deficits in inhibitory synaptic transmission within the spinal superficial dorsal horn (SDH) that include a reduction in primary afferent-evoked, feedforward inhibition onto adult projection neurons. However, the subpopulations of mature GABAergic interneurons which are compromised by early-life injury have yet to be identified. The present research illuminates the persistent effects of neonatal surgical injury on the function of inhibitory SDH interneurons derived from the prodynorphin (DYN) lineage, a population that synapses directly onto lamina I spinoparabrachial neurons and is known to suppress mechanical pain and itch in adults. The results demonstrate that hindpaw incision at postnatal day 3 (P3) significantly decreased the strength of primary afferent-evoked glutamatergic drive onto DYN neurons within the adult mouse SDH while increasing the appearance of afferent-evoked inhibition onto the same population. Neonatal injury also dampened the intrinsic membrane excitability of mature DYN neurons, and reduced their action potential discharge in response to sensory input, compared with naive littermate controls. Furthermore, P3 incision decreased the efficacy of inhibitory DYN synapses onto adult spinoparabrachial neurons, which reflected a prolonged reduction in the probability of GABA release. Collectively, the data suggest that early-life tissue damage may persistently constrain the ability of spinal DYN interneurons to limit ascending nociceptive transmission to the adult brain. This is predicted to contribute to the loss of feedforward inhibition onto mature projection neurons, and the "priming" of nociceptive circuits in the developing spinal cord, following injuries during the neonatal period.SIGNIFICANCE STATEMENT Neonatal injury has lasting effects on pain processing in the adult CNS, including a reduction in feedforward inhibition onto ascending projection neurons in the spinal dorsal horn. While it is clear that spinal GABAergic interneurons are comprised of multiple subpopulations that play distinct roles in somatosensation, the identity of those interneurons which are compromised by tissue damage during early life remains unknown. Here we document persistent deficits in spinal inhibitory circuits involving dynorphin-lineage interneurons previously implicated in gating mechanical pain and itch. Notably, neonatal injury reduced the strength of dynorphin-lineage inhibitory synapses onto mature lamina I spinoparabrachial neurons, a major output of the spinal nociceptive network, which could contribute to the priming of pain pathways by early tissue damage.

The development of pain circuits and unique effects of neonatal injury

Pain is a necessary sensation that prevents further tissue damage, but can be debilitating and detrimental in daily life under chronic conditions. Neuronal activity strongly regulates the maturation of the somatosensory system, and aberrant sensory input caused by injury or inflammation during critical periods of early postnatal development can have prolonged, detrimental effects on pain processing. This review will outline the maturation of neuronal circuits responsible for the transmission of nociceptive signals and the generation of pain sensation-involving peripheral sensory neurons, the spinal cord dorsal horn, and brain-in addition to the influences of the neuroimmune system on somatosensation. This summary will also highlight the unique effects of neonatal tissue injury on the maturation of these systems and subsequent consequences for adult somatosensation. Ultimately, this review emphasizes the need to account for age as an independent variable in basic and clinical pain research, and importantly, to consider the distinct qualities of the pediatric population when designing novel strategies for pain management.

Factors influencing the occurrence of neonatal procedural pain

OBJECTIVES

The objective of this study was to describe the occurrence of neonatal procedural pain and explore the factors that influence the frequency of painful procedures.

DESIGN

A descriptive prospective epidemiologic study.

SETTING

NICU at a general hospital in China.

METHODS

A demographic and diagnosis or illness information questionnaire and an occurrence of procedural pain questionnaire specifically designed for this study were used to record the current status of neonatal procedural pain. The neonatal infant pain scale (NIPS) was used to measure pain intensity. A multiple linear regression model was used to explore the factors influencing the frequency of painful procedures.

RESULTS

One hundred and twenty neonates experienced a total of 16,840 painful procedures. Each neonate was exposed to a median (IQR) of 66.5(27,154.75) painful procedures during hospitalization and a median (IQR) of 13(11, 19) painful procedures. All 27 different procedures were considered painful, and 70.37% (19/27) of these procedures caused severe pain. Overall, the mean NIPS score of the 27 procedures was 5.04 ± 1.52 with a range from 0 to 7. Respiratory support, age, and length of hospital stay were factors influencing the frequency of painful procedures.

CONCLUSIONS

NICU neonates experience pain at a high frequency and intensity during hospitalization. Respiratory support, age, and length of hospital stay were factors influencing the frequency of painful procedures. Strategies are needed to bridge the gap between practice and the evidence-based guidelines.