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Ing MC, Keane OA, Lakshmanan A, Kim E, Lee HC, Kelley-Quon LI. Opioid equipotency conversions for hospitalized infants: a systematic review. J Perinatol 2024:10.1038/s41372-024-02121-z. [PMID: 39304731 DOI: 10.1038/s41372-024-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 09/05/2024] [Accepted: 09/13/2024] [Indexed: 09/22/2024]
Abstract
Hospitalized infants commonly receive opioids to reduce pain and minimize distress during invasive procedures. However, infant neurodevelopment is significantly impacted by cumulative and prolonged opioid exposures. While opioid conversion has been studied extensively in adults, no standardized equipotency opioid conversions exist for hospitalized infants and opioid stewardship efforts are inconsistent. We performed a systematic review to identify opioid dosing conversions commonly used in hospitalized infants <1 year of age, finding fourteen articles which documented or cited a calculation of cumulative opioid exposure. Morphine milligram equivalents (MME) conversion factors varied widely, with nine studies citing conversion equivalent equations commonly used in adults. Efforts to expand safe opioid stewardship to hospitalized infants will require evidence-based consensus for opioid equipotency dose conversions which acknowledge the unique physiology of infants.
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Affiliation(s)
- Madeleine C Ing
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Henry C Lee
- Division of Neonatology, University of California San Diego, La Jolla, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA.
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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2
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Sharma M, Bowman E, Zheng F, Spencer HJ, Shukri SA, Gates K, Williams M, Peeples S, Hall RW, Schootman M, Landes SJ, Curran GM. Reducing Iatrogenic Blood Losses in Premature Infants. Pediatrics 2024:e2024065921. [PMID: 39290188 DOI: 10.1542/peds.2024-065921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 06/28/2024] [Accepted: 07/02/2024] [Indexed: 09/19/2024] Open
Abstract
OBJECTIVE Iatrogenic blood losses from repetitive laboratory testing are a leading cause of anemia of prematurity and blood transfusions. We used an implementation science approach to decrease iatrogenic blood losses during the first 3 postnatal weeks among very low birth weight infants. METHODS We performed qualitative interviews of key stakeholders to assess implementation determinants (ie, barriers and facilitators to reducing iatrogenic blood losses), guided by the Consolidated Framework for Implementation Research. Next, we selected implementation strategies matched to these implementation determinants to de-implement excess laboratory tests. The number of laboratory tests, amount of blood taken (ml/kg), and laboratory charges were compared before and after implementation using quasi-Poisson and multi-variable regression models. RESULTS Qualitative interviews with 14 clinicians revealed implementation-related themes, including provider-specific factors, recurring orders, awareness of blood loss and cost, and balance between over- and under-testing. Implementation strategies deployed included resident education, revised order sets, blood loss and cost awareness, audit and feedback, and the documentation of blood out. There were 184 and 170 infants in the pre- and postimplementation cohorts, respectively. There was an 18.5% reduction in laboratory tests (median 54 [36 - 80] versus 44 [29 - 74], P = .01) in the first 3 postnatal weeks, a 17% decrease in blood taken (mean 18.1 [16.4 - 20.1] versus 15 [13.4 - 16.8], P = .01), and an overall reduction of $290 328 in laboratory charges. No difference was noted in the number of blood transfusions. Postimplementation interviews showed no adverse events attributable to implementation strategies. CONCLUSIONS An implementation science approach combining qualitative and quantitative methods reduced laboratory tests, blood loss, and charges.
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Affiliation(s)
- Megha Sharma
- Department of Pediatrics, Division of Neonatology
| | | | - Feng Zheng
- Department of Pediatrics, Division of Neonatology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | | | - Kim Gates
- Department of Biomedical Informatics
| | | | - Sara Peeples
- Department of Pediatrics, Division of Neonatology
| | | | - Mario Schootman
- Department of Internal Medicine, Division of Community Health and Research, University of Arkansas for Medical Sciences, Springdale, Arkansas
| | - Sara J Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences and Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Geoffrey M Curran
- Departments of Pharmacy Practice & Psychiatry, Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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3
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Mueller ME, Graz MB, Truttmann AC, Schneider J, Duerden EG. Neonatal amygdala volumes, procedural pain and the association with social-emotional development in children born very preterm. Brain Struct Funct 2024:10.1007/s00429-024-02845-w. [PMID: 39103553 DOI: 10.1007/s00429-024-02845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/19/2024] [Indexed: 08/07/2024]
Abstract
Very preterm birth (< 32 weeks' gestational age) is associated with later social and emotional impairments, which may result from enhanced vulnerability of the limbic system during this period of heightened vulnerability. Evidence suggests that early procedural pain may be a key moderator of early brain networks. In a prospective cohort study, neonates born very preterm (< 30 weeks' gestation) underwent MRI scanning at term-equivalent age (TEA) and clinical data were collected (mechanical ventilation, analgesics, sedatives). Procedural pain was operationalized as the number of skin breaking procedures. Amygdala volumes were automatically extracted. The Strengths and Difficulties questionnaire was used to assess social-emotional outcomes at 5 years of age (mean age 67.5 months). General linear models were employed to examine the association between neonatal amygdala volumes and social-emotional outcomes and the timing and amount of procedural pain exposure (early within the first weeks of life to TEA) as a moderator, adjusting for biological sex, gestational age, 5-year assessment age, days of mechanical ventilation and total cerebral volumes. A total of 42 preterm infants participated. Right amygdala volumes at TEA were associated with prosocial behaviour at age 5 (B = -0.010, p = 0.005). Procedural pain was found to moderate the relationship between right amygdala volumes in the neonatal period and conduct problems at 5 years, such that early skin breaking procedures experienced within the first few weeks of life strengthened the association between right amygdala volumes and conduct problems (B = 0.005, p = 0.047). Late skin breaking procedures, experienced near TEA, also strengthened the association between right amygdala volumes and conduct problems (B = 0.004, p = 0.048).
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Affiliation(s)
- Megan E Mueller
- Applied Psychology, Faculty of Education, Western University, 1137 Western Rd, London, ON, N6G 1G7, Canada
| | - Myriam Bickle Graz
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Anita C Truttmann
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Juliane Schneider
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Emma G Duerden
- Applied Psychology, Faculty of Education, Western University, 1137 Western Rd, London, ON, N6G 1G7, Canada.
- Departments of Pediatrics & Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Canada.
- Children's Health Research Institute, London, Canada.
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4
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Selvanathan T, Miller SP. Effects of pain, sedation and analgesia on neonatal brain injury and brain development. Semin Perinatol 2024; 48:151928. [PMID: 38937163 DOI: 10.1016/j.semperi.2024.151928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Critically ill newborns experience numerous painful procedures as part of lifesaving care in the Neonatal Intensive Care Unit. However, painful exposures in the neonatal period have been associated with alterations in brain maturation and poorer neurodevelopmental outcomes in childhood. The most frequently used medications for pain and sedation in the NICU are opioids, benzodiazepines and sucrose; these have also been associated with abnormalities in brain maturation and neurodevelopment making it challenging to know what the best approach is to treat neonatal pain. This article provides clinicians with an overview of how neonatal exposure to pain as well as analgesic and sedative medications impact brain maturation and neurodevelopmental outcomes in critically ill infants. We also highlight areas in need of future research to develop standardized neonatal pain monitoring and management strategies.
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Affiliation(s)
- Thiviya Selvanathan
- Pediatrics, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC, Canada; Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Steven P Miller
- Pediatrics, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC, Canada; Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
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5
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Breton-Piette A, De Clifford-Faugère G, Aita M. Prolonged pain in premature neonates hospitalised in neonatal intensive care units: A scoping review. Int J Nurs Stud 2024; 155:104773. [PMID: 38718692 DOI: 10.1016/j.ijnurstu.2024.104773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Exposure to repetitive pain during the neonatal period has been shown to have important short and long-term effects on the neurodevelopment of the premature neonate and can contribute to experienced prolonged pain. A uniform taxonomy of neonatal prolonged pain is still lacking to this day which contributes to suboptimal prolonged pain management in neonatal intensive care units. Accordingly, a scoping review exploring the state of knowledge about prolonged pain in preterm neonates hospitalised in the neonatal intensive care unit will contribute to the developing field of neonatal prolonged pain and provide recommendations for clinical prolonged pain management. OBJECTIVE To determine the scope, extent, and nature of the available literature on prolonged pain in premature neonates hospitalised in neonatal intensive care units. DESIGN Scoping review. METHODS An electronic search was conducted from inception to November 2023 in the databases of CINAHL, PubMed, Medline, Web of Science, GeryLit.org and Grey Source Index. Included studies discussed concepts related to neonatal prolonged pain such as definitions of prolonged pain, indicators of prolonged pain, contexts that result in prolonged pain, prolonged pain evaluation tools, consequences of prolonged pain and interventions for prolonged pain management. RESULTS Key concepts of neonatal prolonged pain were identified in the 86 included articles of this scoping review such as definitions (n = 26), indicators (n = 39), contexts (n = 49), scales (n = 56), consequences of prolonged pain (n = 30) and possible interventions for prolonged pain management (n = 22). Whilst a consensus on a definition has yet to be achieved, no proximate event was shown to cause prolonged pain and a time criterion was identified by authors as being relevant in defining prolonged pain. Interestingly, the context of hospitalisation was identified as being the most indicative of prolonged pain in premature neonates and should guide its evaluation and management, whilst only limited pain management interventions and consequences were discussed. CONCLUSION The findings of this scoping review contribute to the foundation of growing knowledge in neonatal prolonged pain and shed light on the ambiguity that currently exists on this topic in the scientific literature. This review summarises knowledge of key concepts necessary for a better understanding of prolonged pain and stresses the importance of considering contexts of hospitalisation for prolonged pain evaluation and management in neonatal intensive care units, with the objective of improving developmental outcomes of premature neonates. TWEETABLE ABSTRACT A scoping review reveals that the contexts of prolonged pain in premature neonates hospitalised in the neonatal intensive care unit are essential in guiding its evaluation and management.
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Affiliation(s)
- Alexandra Breton-Piette
- Faculty of Nursing, Université de Montréal, Canada; Research Centre, CHU Sainte-Justine, Canada.
| | | | - Marilyn Aita
- Faculty of Nursing, Université de Montréal, Canada; Research Centre, CHU Sainte-Justine, Canada; Quebec Network on Nursing Intervention Research (RRISIQ), Canada
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6
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Bueno M, Rao M, Aujla P, Victor C, Stevens B. A scoping review of the epidemiology and treatment of painful procedures in hospitalized neonates: What has changed in the past three decades? Eur J Pain 2024. [PMID: 38873730 DOI: 10.1002/ejp.2294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
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.
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Affiliation(s)
- Mariana Bueno
- Peter Gilgan Centre for Research and Learning (PGCRL), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Megha Rao
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | | | | | - Bonnie Stevens
- Peter Gilgan Centre for Research and Learning (PGCRL), The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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7
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De Souza E, Parvathinathan G, Anderson TA. Pain Prevalence and Treatment in Hospitalized Children and Adolescents at a US Tertiary Pediatric Hospital. Clin Pediatr (Phila) 2024; 63:805-814. [PMID: 37671731 DOI: 10.1177/00099228231196473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Poorly controlled acute pain is associated with worsened patient outcomes. Prior studies suggest that acute pain is a common complaint among hospitalized pediatric patients, but recent studies with substantial numbers of patients from US hospitals are lacking. We retrospectively reviewed inpatients at a single academic children's hospital during twelve 24-hour periods in 2021. Outcomes were assessed for patients on non-intensive care unit (ICU) inpatient floors and in ICUs. The primary outcome was any presence of moderate to severe pain. Of 1355 patients on a non-ICU inpatient floor and 485 patients in the ICU, 23.5% and 58.6%, respectively, had ≥1 moderate to severe pain score during the 24-hour analysis period. While the mean pain score was low for the majority of patients, moderate to severe pain is frequent in hospitalized children. Future studies may focus on identification of variables associated with pediatric inpatients at risk of moderate to severe pain as well as improved pain prevention and reduction strategies.
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Affiliation(s)
- Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - T Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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8
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Fong J, Lewis J, Lam M, Kesavan K. Developmental Outcomes after Opioid Exposure in the Fetus and Neonate. Neoreviews 2024; 25:e325-e337. [PMID: 38821910 DOI: 10.1542/neo.25-6-e325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/05/2023] [Accepted: 12/06/2023] [Indexed: 06/02/2024]
Abstract
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.
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Affiliation(s)
- Jeanette Fong
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Juanita Lewis
- Department of Pediatrics, Olive View UCLA Medical Center, Sylmar, CA
| | - Melanie Lam
- Department of Pediatrics, University of California, Los Angeles, CA
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9
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Selvanathan T, Miller SP. Brain health in preterm infants: importance of early-life pain and analgesia exposure. Pediatr Res 2024:10.1038/s41390-024-03245-w. [PMID: 38806664 DOI: 10.1038/s41390-024-03245-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/23/2024] [Indexed: 05/30/2024]
Abstract
"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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10
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Pavlyshyn H, Sarapuk I, Kozak K. The relationship between neonatal stress in preterm infants and developmental outcomes at the corrected age of 24-30 months. Front Psychol 2024; 15:1415054. [PMID: 38840740 PMCID: PMC11150848 DOI: 10.3389/fpsyg.2024.1415054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/10/2024] [Indexed: 06/07/2024] Open
Abstract
Aim The aim of research was to study the relationship between the stress experienced by preterm infants in the neonatal intensive care unit (NICU) and developmental status in the follow up, and to establish factors, associated with their neurodevelopment. Methods The first stage of research involved measuring stress markers (cortisol, melatonin) in infants (n = 56) during their NICU stay; the second phase assessed the developmental status at the corrected age of 24-30 months. Results The total ASQ-3 score, communication, problem solving, and personal-social skills scores at the corrected age of 24-30 months were positively correlated with melatonin level determined in the neonatal period (r = 0.31, p = 0.026; r = 0.36, p = 0.009; r = 0.30, p = 0.033, and r = 0.32; p = 0.022 respectively). In the same time, ASQ-3 communication and personal-social scores were negatively correlated with cortisol level (r = -0.31, p = 0.043; r = -0.35, p = 0.022). The ROC-curve analysis revealed that a decrease of melatonin below 3.44 ng/mL and 3.71 ng/mL during the neonatal period could predict communication and problem-solving delay, respectively. An increase in cortisol above 0.64 mcg/dl is predictive in personal-social delay. Negative correlation was identified between the NICU and total hospital stay duration and ASQ-3 communication scores in the follow-up (r = -0.27; p = 0.049 and r = -0.41; p = 0.002, respectively). The duration of mechanical ventilation was negatively correlated with gross motor scores (r = -0.46; p = 0.043). Apgar score was positively correlated with ASQ-3 communication (r = 0.29; p = 0.032) and personal-social scores (r = 0.28; p = 0.034); maternal age-with ASQ-3 total (r = 0.29; p = 0.034), communication (r = 0.37; p = 0.006), and personal-social scores (r = 0.29; p = 0.041). Positive correlations were observed between gestational age and communication scores (r = 0.28; p = 0.033). Infants who suffered neonatal sepsis had significantly often delay of communication (p = 0.014) and gross motor skills (p = 0.016). Children who required mechanical ventilation were more likely to have communication delay (p = 0.034). Conclusion Developmental outcomes in preterm infants at the corrected age of 24-30 months were associated with neonatal stress. Correlations between the communication, problem-solving and personal-social development in the follow up and cortisol and melatonin levels determined in the neonatal period supported this evidence. Factors as low gestational age, duration of hospital and NICU stay, mechanical ventilation, and sepsis were associated with more frequent delays in communication, gross motor and problems-solving skills.
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Affiliation(s)
- Halyna Pavlyshyn
- Department of Pediatrics, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
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11
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Uberos J, Campos-Martinez A, Ruiz-López A, Fernandez-Marín E, García-Serrano JL. Sensitivity and Specificity of the Newborn Infant Parasympathetic Evaluation Index in Pain Assessment of Very Low Birth Weight Infants. Am J Perinatol 2024; 41:e430-e434. [PMID: 36451626 DOI: 10.1055/s-0042-1755464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE This article describes the results of a study investigating the sensitivity and specificity of the Newborn Infant Parasympathetic Evaluation (NIPE) index for detecting the physiological changes resulting from nociception in painful procedures in very low birth weight (VLBW) infants. STUDY DESIGN A prospective observational study was carried on of 44 newborns at 23 to 32 weeks' gestational age. The sensitivity and specificity of the NIPE index are analyzed using a receiver operating characteristic curve. Most of the painful procedures performed were skin-lancing and venipunctures. Nonpainful procedures consist of no intervention, with an interval of at least 1 hour with painful procedures in each newborn. RESULTS The accuracy of the NIPE index to diagnose mild nociceptive stimulation in VLBW newborns is 73.2%. CONCLUSION The NIPE index is a useful technique for assessing nociceptive stimulation in newborns, presenting less observer-dependent variability than other pain assessment scales. KEY POINTS · The NIPE index offers an objective assessment of pain.. · Moderate-high sensitivity of the NIPE index in the evaluation of pain in premature newborns.. · Painful procedures in VLBW newborns are reflected as a decrease in the NIPE score..
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Affiliation(s)
- Jose Uberos
- Neonatal Intensive Care Unit, San Cecilio Clinical Hospital, Granada, Spain
| | | | - Aida Ruiz-López
- Neonatal Intensive Care Unit, San Cecilio Clinical Hospital, Granada, Spain
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12
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Jang YH, Ham J, Kasani PH, Kim H, Lee JY, Lee GY, Han TH, Kim BN, Lee HJ. Predicting 2-year neurodevelopmental outcomes in preterm infants using multimodal structural brain magnetic resonance imaging with local connectivity. Sci Rep 2024; 14:9331. [PMID: 38653988 DOI: 10.1038/s41598-024-58682-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024] Open
Abstract
The neurodevelopmental outcomes of preterm infants can be stratified based on the level of prematurity. We explored brain structural networks in extremely preterm (EP; < 28 weeks of gestation) and very-to-late (V-LP; ≥ 28 and < 37 weeks of gestation) preterm infants at term-equivalent age to predict 2-year neurodevelopmental outcomes. Using MRI and diffusion MRI on 62 EP and 131 V-LP infants, we built a multimodal feature set for volumetric and structural network analysis. We employed linear and nonlinear machine learning models to predict the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) scores, assessing predictive accuracy and feature importance. Our findings revealed that models incorporating local connectivity features demonstrated high predictive performance for BSID-III subsets in preterm infants. Specifically, for cognitive scores in preterm (variance explained, 17%) and V-LP infants (variance explained, 17%), and for motor scores in EP infants (variance explained, 15%), models with local connectivity features outperformed others. Additionally, a model using only local connectivity features effectively predicted language scores in preterm infants (variance explained, 15%). This study underscores the value of multimodal feature sets, particularly local connectivity, in predicting neurodevelopmental outcomes, highlighting the utility of machine learning in understanding microstructural changes and their implications for early intervention.
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Affiliation(s)
- Yong Hun Jang
- Department of Translational Medicine, Hanyang University Graduate School of Biomedical Science and Engineering, Seoul, Republic of Korea
| | - Jusung Ham
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, IA, 52242, USA
| | - Payam Hosseinzadeh Kasani
- Department of Pediatrics, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Hyuna Kim
- Department of Translational Medicine, Hanyang University Graduate School of Biomedical Science and Engineering, Seoul, Republic of Korea
| | - Joo Young Lee
- Department of Translational Medicine, Hanyang University Graduate School of Biomedical Science and Engineering, Seoul, Republic of Korea
| | - Gang Yi Lee
- Department of Translational Medicine, Hanyang University Graduate School of Biomedical Science and Engineering, Seoul, Republic of Korea
| | - Tae Hwan Han
- Division of Neurology, Department of Pediatrics, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Bung-Nyun Kim
- Division of Children and Adolescent Psychiatry, Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun Ju Lee
- Department of Pediatrics, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
- Hanyang Institute of Bioscience and Biotechnology, Hanyang University, Seoul, Republic of Korea.
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13
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Zafar A, Hall M. Types of home respiratory support in children with bronchopulmonary dysplasia and factors determining its duration: A scoping review. Pediatr Pulmonol 2024; 59:834-844. [PMID: 38197530 DOI: 10.1002/ppul.26848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/13/2023] [Accepted: 12/23/2023] [Indexed: 01/11/2024]
Abstract
Bronchopulmonary dysplasia also known as chronic lung disease of prematurity has changed as a disease entity over the last five decades and children with "new bronchopulmonary dysplasia (BPD)" have better survival rates. This necessitates strategies to prevent severe BPD and provide organized home support. Home respiratory support in these children varies from home oxygen to noninvasive ventilation and tracheostomy ventilation. This review was conducted utilizing Joanna Briggs Institute publications on evidence synthesis and presentation of results for a scoping review. The Preferred Reporting Items for Systematic Review and Meta-Analyses were used to report the results. The risk of bias assessment was done using "The Cochrane Handbook for Systematic Reviews tool for interventional studies." After screening for the duplication of results and applying inclusion and exclusion criteria, twenty-seven studies were assessed by reading the full texts. Out of these, eleven were finally included in this systematic review. The total sample size from all studies was 4794, including 2705 males. The 4/11 studies home oxygen, one study reported continuous positive airway pressure/bilevel positive airway pressure and seven studies used tracheostomy or tracheostomy ventilation. The median duration of post-natal invasive ventilation was higher in those discharged on home oxygen compared to those who did not need oxygen at discharge. There is a significant proportion of children who are tracheostomy ventilated (8.65%) at home. In the absence of established guidelines, these children are vulnerable when it comes to care at home and the timing of decannulation. For home oxygen alone, guidelines by ERS, ATS and BTS have streamlined weaning protocols and the need for having a multi-disciplinary team to care for these children.
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Affiliation(s)
- Adnan Zafar
- Pediatric Pulmonology, John Hopkins Aramco Healthcare, Saudi Arabia
| | - Michael Hall
- Neonatology, University of Southampton, Southampton, UK
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Li Y, Huang X, Hu Y, Yang L, Zhang X, Chen Q. Alleviating Neonatal Intensive Care Unit Stress: A Chinese Medicine Approach in Neonatal Rats. BIOMED RESEARCH INTERNATIONAL 2024; 2024:2733884. [PMID: 38464682 PMCID: PMC10924680 DOI: 10.1155/2024/2733884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/03/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024]
Abstract
Background Premature infants are exposed to numerous stressors in neonatal intensive care unit (NICU) during a crucial period for brain development; this period exerts long-term influences on cognitive and behavioral development. Aims To evaluate the effect of NICU-related stress on neonatal rat pups and explore the effect of Chinese medicine treatment (CMT). Methods Sixty male rat pups were randomly assigned to three groups: the control group, the NICU group (NICU-related stress), and the CMT group (NICU-related stress plus CMT). All stressors and interventions were administered from 0 to 7 days after birth. Body weight, serum corticosterone levels, and behavior in the open field (OF) test, elevated plus maze (EPM) test, sucrose preference test, and Morris water maze (MWM) test were recorded, and blood samples were collected at five different time points (T0, T1, T2, T3, and T4). Results The body weights of rats in the CMT and control groups were heavier than those in the NICU group in both early life and adulthood (P < 0.05). Serum corticosterone levels significantly differed with time (except T0 vs. T1 and T3 vs. T4) but did not significantly differ among the three groups (F = 0.441, P = 0.894). Regardless of age, spatial memory and anxiety-like and depression-like behavior did not differ among the three groups. Conclusion NICU-related stress exerted a long-term effect on rat growth and development but did not affect spatial memory, anxiety-like behavior, depression-like behavior, or serum corticosterone levels. CMT alleviated the impact of NICU-related stress on rats and promoted the growth and development of neonatal rats.
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Affiliation(s)
- Yingxin Li
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
| | - Xi Huang
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
| | - Yanlin Hu
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
| | - Liming Yang
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
| | - Xiujuan Zhang
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
| | - Qiong Chen
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
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Calandrino A, Montobbio C, Bonato I, Cipresso G, Vinci F, Caruggi S, Battaglini M, Andreato C, Mongelli F, Massirio P, Brigati G, Minghetti D, Ramenghi LA. Optimizing haemoglobin measurements in VLBW newborns: Insights from a comparative retrospective study. Early Hum Dev 2024; 190:105949. [PMID: 38290276 DOI: 10.1016/j.earlhumdev.2024.105949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Haemoglobin levels assessment is a crucial part of neonatal intensive care practice, the painful experience of repeated heel pricks and venepunctures blood sampling may negatively affect neonatal clinical course. To date the reliability of haemoglobin levels obtained by point-of-care testing (POCT) analysis if compared to standard blood cell count remains controversial. MATERIALS AND METHODS Retrospective study conducted on all inborn premature infants (gestational age < 32 weeks) admitted to NICU of the IRCCS Giannina Gaslini Institute during the period May 2021-April 2023. We considered blood samplings occurred within the first 28 days of life recording the laboratory haemoglobin levels (Hblab) (reference method), the point-of-care haemoglobin levels (HbPOCT) (alternative method) and the type of puncture (arterial, venous and capillary). A Bland-Altman analysis was performed to evaluate the Hb agreement, it determines the bias (mean difference between the reference and alternative methods) and limits of agreement (LOA; lower, l-LOA; upper, u-LOA) of measures. An acceptable limit of agreement was 1 g/dl according to the existing literature. RESULTS We considered 845 blood samplings from 189 enrolled patients. The comparison between the reference and the alternative method showed a good agreement for the capillary sampling technique with l-LOA of -0.717 (-0.776; -0.659) and u-LOA of 0.549 (0.490; 0.607), these results were not achievable with the other techniques, with LOAs over ±1 g/dl threshold (venous CONCLUSIONS The reliability of capillary POCT measured haemoglobin levels may reduce clinical-related costs and the number of painful experiences, with obvious positive effects on the daily neonatal life in the NICU and on the developing brain structures.
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Affiliation(s)
- Andrea Calandrino
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Carolina Montobbio
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy.
| | - Irene Bonato
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Gaia Cipresso
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Francesco Vinci
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Samuele Caruggi
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Marcella Battaglini
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Chiara Andreato
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Federica Mongelli
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Paolo Massirio
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Giorgia Brigati
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Diego Minghetti
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
| | - Luca Antonio Ramenghi
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
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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. FRONTIERS IN PAIN RESEARCH 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] [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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Roberts SD, Sananes R, Wojtowicz M, Seed M, Miller SP, Chau V, Au-Young SH, Guo T, Ly L, Kazazian V, Grunau RE, Williams TS. Neurodevelopmental outcomes at 18 months of children diagnosed with CHD compared to children born very preterm. Cardiol Young 2024:1-7. [PMID: 38163986 DOI: 10.1017/s1047951123004316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To compare neurodevelopmental outcomes and parent behaviour ratings of children born term with CHD to children born very preterm. METHODS A clinical research sample of 181 children (CHD [n = 81]; very preterm [≤32 weeks; n = 100]) was assessed at 18 months. RESULTS Children with CHD and born very preterm did not differ on Bayley-III cognitive, language, or motor composite scores, or on expressive or receptive language, or on fine motor scaled scores. Children with CHD had lower ross motor scaled scores compared to children born very preterm (p = 0.047). More children with CHD had impaired scores (<70 SS) on language composite (17%), expressive language (16%), and gross motor (14%) indices compared to children born very preterm (6%; 7%; 3%; ps < 0.05). No group differences were found on behaviours rated by parents on the Child Behaviour Checklist (1.5-5 years) or the proportion of children with scores above the clinical cutoff. English as a first language was associated with higher cognitive (p = 0.004) and language composite scores (p < 0.001). Lower median household income and English as a second language were associated with higher total behaviour problems (ps < 0.05). CONCLUSIONS Children with CHD were more likely to display language and motor impairment compared to children born very preterm at 18 months. Outcomes were associated with language spoken in the home and household income.
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Affiliation(s)
- Samantha D Roberts
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | - Renee Sananes
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | | - Michael Seed
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Division of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Vann Chau
- Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie H Au-Young
- Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ting Guo
- Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Linh Ly
- Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vanna Kazazian
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ruth E Grunau
- Division of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Tricia S Williams
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Zaffino JV, Shiff I, Stern AP, Flanders D, Weinberg E, Savlov D, Garfield H, Pillai Riddell R. Caregiver Ratings of Toddler Pain: The Role of Caregiver Psychological Predictors. J Pediatr Psychol 2023; 48:870-878. [PMID: 37776143 DOI: 10.1093/jpepsy/jsad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION/AIM Young children's limited ability to self-report pain necessitates an understanding of the factors that influence pain ratings. The current paper examines the relative prediction of caregiver psychological factors and toddler pain behaviors on caregiver pain ratings post-vaccination. METHODS One hundred fifty-six parent-toddler dyads were video recorded during pediatric vaccinations. Child pain behaviors were coded before, during, and after the needle using the Face, Legs, Activity, Cry, Consolability Scale and the Neonatal Facial Coding System). Caregivers rated their child's pain after the needle, reported pre- and post-needle worry during the visit, and completed rating scales assessing other areas of psychological functioning within 2 weeks after the appointment. Regression models were estimated to examine the relative contribution of child and caregiver factors to the prediction of caregiver pain ratings. RESULTS The regression model predicting caregiver pain ratings from the toddlers' pain-related distress (facial activity immediately after the needle, overall pain-related behavior immediately after, 1-min and 2-min post-needle) and caregiver worry were significant (adjusted R-square = 0.21), with caregiver pre- and post-needle worry being the only significant predictors of caregiver pain ratings. CONCLUSIONS This study outlines that although child distress behavior remains a significant influence on pain ratings during toddlerhood, when caregiver worry (pre- and post-needle) was entered into the model, they were the only significant predictors of caregiver pain ratings.
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Affiliation(s)
- Jessica V Zaffino
- Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Ilana Shiff
- Department of Psychology, York University, Toronto, ON, Canada
| | - Amy P Stern
- Department of Psychology, York University, Toronto, ON, Canada
| | | | | | | | - Hartley Garfield
- University of Toronto, Toronto, ON, Canada
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Rebecca Pillai Riddell
- Department of Psychology, York University, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- The Hospital for Sick Children, Toronto, ON, Canada
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Ferzli GTE, Jebbia M, Miller AN, Nelin LD, Shepherd EG. Respiratory management of established severe bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151816. [PMID: 37758578 DOI: 10.1016/j.semperi.2023.151816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Respiratory management of infants with established severe BPD is difficult and there is little evidence upon which to base decisions. Nonetheless, the physiology of severe BPD is well described with a predominantly obstructive pattern. This pulmonary dysfunction results in prolonged exhalatory time constants and thus ventilator management must be focused on maintaining adequate oxygenation and ventilation through achieving full exhalation. This approach is often difficult to maintain in acute care settings and a culture of chronic care focused on slow change and steady progress is imperative. Once respiratory stability is achieved, the focus should shift to growth and development and avoidance of care practices and medications that impair neurodevelopment.
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Affiliation(s)
- George T El- Ferzli
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Maria Jebbia
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Audrey N Miller
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Leif D Nelin
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Edward G Shepherd
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States.
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Miller AN, Shepherd EG, Manning A, Shamim H, Chiang T, El-Ferzli G, Nelin LD. Tracheostomy in Severe Bronchopulmonary Dysplasia-How to Decide in the Absence of Evidence. Biomedicines 2023; 11:2572. [PMID: 37761012 PMCID: PMC10526913 DOI: 10.3390/biomedicines11092572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Infants with the most severe forms of bronchopulmonary dysplasia (BPD) may require long-term invasive positive pressure ventilation for survival, therefore necessitating tracheostomy. Although life-saving, tracheostomy has also been associated with high mortality, postoperative complications, high readmission rates, neurodevelopmental impairment, and significant caregiver burden, making it a highly complex and challenging decision. However, for some infants tracheostomy may be necessary for survival and the only way to facilitate a timely and safe transition home. The specific indications for tracheostomy and the timing of the procedure in infants with severe BPD are currently unknown. Hence, centers and clinicians display broad variations in practice with regard to tracheostomy, which presents barriers to designing evidence-generating studies and establishing a consensus approach. As the incidence of severe BPD continues to rise, the question remains, how do we decide on tracheostomy to provide optimal outcomes for these patients?
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Affiliation(s)
- Audrey N. Miller
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
| | - Edward G. Shepherd
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
| | - Amy Manning
- Department of Otolaryngology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.M.); (H.S.); (T.C.)
| | - Humra Shamim
- Department of Otolaryngology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.M.); (H.S.); (T.C.)
| | - Tendy Chiang
- Department of Otolaryngology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.M.); (H.S.); (T.C.)
| | - George El-Ferzli
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
| | - Leif D. Nelin
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
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Kara N, Arman D, Seymen Z, Gül A, Cömert S. Effects of fentanyl and sucrose on pain in retinopathy examinations with pain scale, near-infrared spectroscopy, and ultrasonography: a randomized trial. World J Pediatr 2023; 19:873-882. [PMID: 36976515 DOI: 10.1007/s12519-023-00705-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/12/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy of intravenous, intranasal fentanyl and oral sucrose in reducing the pain response during retinopathy of prematurity examinations using premature infant pain profile (PIPP) scores. METHOD The study included 42 infants who underwent retinopathy screening examinations. The infants were divided into three groups: oral sucrose, intranasal fentanyl, and intravenous fentanyl. Vital signs (heart rate, arterial oxygen saturation, and mean arterial pressure) were recorded. The PIPP was used to determine pain severity. Cerebral oxygenation and middle cerebral artery blood flow were evaluated using near-infrared spectroscopy and Doppler ultrasonography, respectively. The data obtained were compared between groups. RESULTS There was no significant difference between the three groups regarding postconceptional and postnatal ages or birth weights and weight at the time of examination. All babies had moderate pain during the examination. No correlation was observed between analgesia method and pain scores (P = 0.159). In all three groups, heart rate and mean arterial pressure increased, whereas oxygen saturation decreased during the exam compared with pre-examination values. However, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation (sPO2) values did not differ between groups (HR, P = 0.150; MAP, P = 0.245; sPO2, P = 0.140). The cerebral oxygenation (rSO2) values between the three groups were found to be similar [rSO2: P = 0.545, P = 0.247, P = 0.803; fractional tissue oxygen extraction (FTOE): P = 0.553, P = 0.278]. Regarding cerebral blood flow values, we also did not find any difference between the three groups [mean blood flow velocity (Vmean): P = 0.569, P = 0.975; maximum flow velocity (Vmax): P = 0.820, P = 0.997]. CONCLUSIONS Intravenous and intranasal fentanyl and oral sucrose were not superior to each other in preventing pain during the examination for retinopathy of prematurity (ROP). Sucrose may be a good alternative for pain control during ROP examination. Our findings suggest that ROP exam may not affect cerebral oxygenation or cerebral blood flow. Larger scale studies are needed to determine the best pharmacological option to reduce pain during ROP exams and evaluate the effects of this procedure on cerebral oxygenation and blood flow.
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Affiliation(s)
- Nursu Kara
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey.
| | - Didem Arman
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Zeynep Seymen
- Department of Opthalmology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Adem Gül
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
| | - Serdar Cömert
- Department of Pediatrics, Division of Neonatology, University of Health Sciences Istanbul Research and Training Hospital, Istanbul, Turkey
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22
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Deptola S, Hemmann B, Hemmelgarn T, DiPaola K, Cortezzo DE. Propofol Sedation Washouts in Critically Ill Infants: A Case Series. J Pediatr Pharmacol Ther 2023; 28:354-364. [PMID: 37795284 PMCID: PMC10547045 DOI: 10.5863/1551-6776-28.4.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/29/2022] [Indexed: 10/06/2023]
Abstract
Medically complex infants are experiencing longer hospital stays, more invasive procedures, and increasingly involved therapeutic interventions that often require long-term analgesia and sedation. This is most commonly achieved with continuous intravenous infusions of opioids and benzodiazepines. There are times when patients develop a tolerance for these medications or the clinical scenario necessitates a rapid wean of them. A rapid wean of either class of medication can lead to increased signs of pain and agitation or withdrawal symptoms. As a result, when a rapid wean is needed or there has been a failure to control symptoms with conventional measures, alternative therapies are considered. Propofol, a sedative hypnotic typically used for general anesthesia and procedural sedation, is one such medication. It has effectively been used for short-term sedation in adults and children to facilitate weaning benzodiazepines and opioids. There is a paucity of data on the use of propofol in infants for this purpose. Here we describe the use of propofol to rapidly wean high-dose sedation and analgesia medications, a propofol sedation washout, in 3 infants. The washouts proved to be safe and efficacious. Based on institutional experience and a literature review, considerations and recommendations are made for propofol sedation washouts in infants.
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Affiliation(s)
- Stephen Deptola
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Brianna Hemmann
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Trina Hemmelgarn
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kyle DiPaola
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - DonnaMaria E. Cortezzo
- Division of Neonatology and Pulmonary Biology (DEC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Pain and Palliative Medicine (DEC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics (DEC), University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Anesthesiology (DEC), University of Cincinnati College of Medicine, Cincinnati, Ohio
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23
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Giordano V, Deindl P, Gal E, Unterasinger L, Fuiko R, Steinbauer P, Weninger M, Berger A, Olischar M. Pain and neurodevelopmental outcomes of infants born very preterm. Dev Med Child Neurol 2023; 65:1043-1052. [PMID: 36647629 DOI: 10.1111/dmcn.15505] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 01/18/2023]
Abstract
AIM To investigate the impact of the level of pain experienced by infants born preterm on neurodevelopmental outcomes during their stay in a neonatal intensive care unit. METHOD In this retrospective data analysis we included all surviving infants born preterm with a gestational age between 23 and 32 weeks from 2011 to 2015, who were assessed using the Neonatal Pain, Agitation, and Sedation Scale and examined at 1 year of age using the Bayley Scales of Infant Development. We excluded all infants who had suffered severe neurological morbidities and undergone surgical interventions. RESULTS A total of 196 infants born preterm were included in the analyses: 105 in the 'no pain group' and 91 in the 'pain group'. Significant differences between the groups were detected for both mental and motor development (p = 0.003, 95% confidence interval [CI] 2.23-10.92; p = 0.025, 95% CI 0.64-9.78). The results remained significant after controlling for other important medical conditions (p = 0.001, 95% CI -19.65 to -5.40; p = 0.010, 95% CI -16.18 to -2.29). INTERPRETATION Neonatal pain exposure was associated with altered neurodevelopmental outcomes of infants born very preterm at a corrected age of 12 months. This observation highlights the importance of adequate pain management to reduce the risk of poor neurodevelopmental outcomes in these vulnerable patients.
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Affiliation(s)
- Vito Giordano
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Philipp Deindl
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elisabeth Gal
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Lukas Unterasinger
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Renate Fuiko
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Philipp Steinbauer
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Manfred Weninger
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Monika Olischar
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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24
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Duerden EG, McPherson C. Editorial: Pain in infants: pain management practices and the association with outcome. FRONTIERS IN PAIN RESEARCH 2023; 4:1216764. [PMID: 37383880 PMCID: PMC10295128 DOI: 10.3389/fpain.2023.1216764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 06/30/2023] Open
Affiliation(s)
- Emma G. Duerden
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Applied Psychology, Faculty of Education, & Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Christopher McPherson
- Department of Pharmacy, St. Louis Children’s Hospital, St. Louis, MO, United States
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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25
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Li W, Zhang H, Huang X, Ye R, Lin Y. Effects of routine procedures on salivary cortisol in mechanically ventilated neonates. Sci Rep 2023; 13:4622. [PMID: 36944698 PMCID: PMC10030645 DOI: 10.1038/s41598-023-29913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/13/2023] [Indexed: 03/23/2023] Open
Abstract
Even though the stress secondary to invasive procedures has been investigated, less attention has been paid to the stimulation or pain caused by routine procedures on neonates. The changes in salivary cortisol concentration in mechanically ventilated NICU patients during routine procedures were monitored to provide reference and guidance for pain management. 80 mechanically ventilated neonates in the hospital from Sep 2021 to Mar 2022 were selected. The salivary cortisol levels of the neonates were monitored during nursing procedures and were categorized by their risk levels to the following groups: high-risk (endotracheal suctioning and arterial blood sampling), moderate-risk (gastric tube insertion, venipuncture), and low-risk (bedside bathing and diaper changes). The changes in heart rate were also recorded and compared. The concentration of cortisol in the saliva of the neonates was 1.5 ± 0.8 nmol/L during the sleeping state, 6.2 ± 1.3 nmol/L during endotracheal suctioning, 6.4 ± 1.4 nmol/L during arterial blood sampling, 6.1 ± 1.2 nmol/L during venipuncture, 4.4 ± 1.1 nmol/L during gastric tube insertion, 3.5 ± 0.8 nmol/L during bedside bathing, and 3.3 ± 0.9 nmol/L during a diaper change. The results revealed a statistically significant effect between routine procedures on salivary cortisol levels. Compared with the neonates in the control sleep state, there was a significant (P < 0.05) change in salivary cortisol concentration of infants undergoing high and moderate-risk nursing procedures. There was a small but significant (P < 0.05) change in salivary cortisol levels in infants who underwent low-risk procedures compared to infants in the control sleep state. Further, the fluctuation of salivary cortisol levels in routine procedures was more frequent compared with routine handling at night. The fluctuations of salivary cortisol concentration in high-risk procedures were larger than that of infants who underwent low-risk procedures, with the difference being statistically significant (P < 0.05). It was also determined that the top four influencing factors on the infants' heart rate were arterial blood sampling venipuncture, intubation, endotracheal suctioning, and gastric tube insertion (P < 0.05). Monitoring the saliva cortisol concentration index and heart rates can reflect the impact of different routine procedures on newborns and can be used to manage neonatal pain in the future.
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Affiliation(s)
- Wanting Li
- Fujian Provincial key Laboratory of Neonatal Diseases, Xiamen, China
- Xiamen Children's Hospital, Xiamen, China
| | | | - Xianghui Huang
- Fujian Provincial key Laboratory of Neonatal Diseases, Xiamen, China.
- Xiamen Children's Hospital, Xiamen, China.
| | - Ruming Ye
- Xiamen Children's Hospital, Xiamen, China
| | - Ying Lin
- Fujian Provincial key Laboratory of Neonatal Diseases, Xiamen, China
- Xiamen Children's Hospital, Xiamen, China
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26
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Dersch-Mills D, Howlett A, Lind J, Marchuk A, Mohammad K. Impact of dexmedetomidine in conjunction with a weaning protocol on post-surgical opioid use in a neonatal intensive care unit. Pharmacotherapy 2023. [PMID: 36862038 DOI: 10.1002/phar.2787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/23/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023]
Abstract
STUDY OBJECTIVE To describe the impact of protocol-driven dexmedetomidine (and clonidine) use on opioid exposure in post-surgical neonates. DESIGN Retrospective chart review. SETTING A Level III, surgical NICU. PATIENTS Surgical neonates who received clonidine or dexmedetomidine concomitantly with an opioid for sedation and/or analgesia post-operatively. INTERVENTION Implementation of a standardized sedation/analgesia weaning protocol. MEASUREMENTS AND MAIN RESULTS There were clinically, although not statistically, significant reductions in opioid wean duration (240 vs. 227 h, p = 0.82), total opioid duration (604 vs. 435 h, p = 0.23), and total opioid exposure (91 vs. 51 mg ME/kg, p = 0.13), and limited impact on NICU outcomes or pain/withdrawal scores with use of the protocol. Increases in use of medications in alignment with the protocol (e.g., scheduled acetaminophen and opioids weaned first) were noted. CONCLUSIONS We have been unable to demonstrate a reduction in opioid exposure with use of alpha-2 agonists alone; addition of a weaning protocol showed a reduction in opioid duration and exposure (although not statistically significant). At this point, dexmedetomidine and clonidine should not be introduced outside standardized protocols with scheduled acetaminophen post-operatively.
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Affiliation(s)
- Deonne Dersch-Mills
- Alberta Health Services, Pharmacy Services, Calgary, Alberta, Canada.,Alberta Children's Hospital, Neonatal Intensive Care Unit, Calgary, Alberta, Canada
| | - Alixe Howlett
- Alberta Children's Hospital, Neonatal Intensive Care Unit, Calgary, Alberta, Canada.,Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jan Lind
- Alberta Children's Hospital, Neonatal Intensive Care Unit, Calgary, Alberta, Canada
| | - Allison Marchuk
- Neonatal Nursing Extension Program, Mount Royal University, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Alberta Children's Hospital, Neonatal Intensive Care Unit, Calgary, Alberta, Canada.,Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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27
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Naik V, Jin J, Tinsay A, Pricco N, Madhok M. Medication Use in the Diagnostic Pediatric Lumbar Puncture. Clin Pediatr (Phila) 2023; 62:227-233. [PMID: 36028950 DOI: 10.1177/00099228221120687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The lumbar puncture (LP) is a common procedure in the pediatric emergency department. A retrospective review was conducted of patients who had LPs from 2012 to 2016 at 2 children's hospitals to (1) characterize medication use during the pediatric LP and (2) test the hypothesis that varied medication use influences LP outcome. Outcomes were defined as unsuccessful if the LP was documented as unsuccessful, had a cerebrospinal fluid (CSF) red blood cell (RBC) count >400 cells/µL, or if a second LP was performed within 24 hours. In total, 8463 patients were reviewed and 2806 (33%) were included in the study. We noted significant variation in LP medication use. When adjusted for patient demographics, location, weight, position, and provider experience, our regression model revealed that the use of fentanyl, ketamine, nitrous oxide, and propofol were best associated with LP success. These data suggest the need for a standardized LP medication protocol as provider choice in medication significantly influences LP outcome.
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Affiliation(s)
- Vishal Naik
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jing Jin
- Children's Minnesota, Minneapolis, MN, USA
| | - Andrea Tinsay
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Nicholas Pricco
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Manu Madhok
- University of Minnesota Medical School, Minneapolis, MN, USA
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28
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Selvanathan T, Zaki P, McLean MA, Au-Young SH, Chau CMY, Chau V, Synnes AR, Ly LG, Kelly E, Grunau RE, Miller SP. Early-life exposure to analgesia and 18-month neurodevelopmental outcomes in very preterm infants. Pediatr Res 2023:10.1038/s41390-023-02536-y. [PMID: 36859445 DOI: 10.1038/s41390-023-02536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND We assessed variability of analgesic use across three tertiary neonatal intensive care units (NICUs) accounting for early-life pain, quantified as number of invasive procedures. We also determined whether analgesia exposure modifies associations between early-life pain and neurodevelopment. METHODS Multicenter prospective study of 276 very preterm infants (born <24-32 weeks' gestational age [GA]). Detailed data of number of invasive procedures and duration of analgesia exposure were collected in initial weeks after birth. Eighteen-month neurodevelopmental assessments were completed in 215 children with Bayley Scales for Infant Development-Third edition. RESULTS Multivariable linear regressions revealed significant differences in morphine use across sites, for a given exposure to early-life pain (interaction p < 0.001). Associations between early-life pain and motor scores differed by duration of morphine exposure (interaction p = 0.01); greater early-life pain was associated with poorer motor scores in infants with no or long (>7 days) exposure, but not short exposure (≤7 days). CONCLUSIONS Striking cross-site differences in morphine exposure in very preterm infants are observed even when accounting for early-life pain. Negative associations between greater early-life pain and adverse motor outcomes were attenuated in infants with short morphine exposure. These findings emphasize the need for further studies of optimal analgesic approaches in preterm infants. IMPACT In very preterm neonates, both early-life exposure to pain and analgesia are associated with adverse neurodevelopment and altered brain maturation, with no clear guidelines for neonatal pain management in this population. We found significant cross-site variability in morphine use across three tertiary neonatal intensive care units in Canada. Morphine use modified associations between early-life pain and motor outcomes. In infants with no or long durations of morphine exposure, greater early-life pain was associated with lower motor scores, this relationship was attenuated in those with short morphine exposure. Further trials of optimal treatment approaches with morphine in preterm infants are warranted.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Pearl Zaki
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Mia A McLean
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Stephanie H Au-Young
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Cecil M Y Chau
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Vann Chau
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Anne R Synnes
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Linh G Ly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Edmond Kelly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada.,BC Women's Hospital, Vancouver, BC, Canada
| | - Steven P Miller
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada. .,Department of Pediatrics, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC, Canada.
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29
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Current pain management practices for preterm infants with necrotizing enterocolitis: a European survey. Pediatr Res 2023:10.1038/s41390-023-02508-2. [PMID: 36828969 PMCID: PMC10382315 DOI: 10.1038/s41390-023-02508-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a highly painful intestinal complication in preterm infants that requires adequate pain management to prevent short- and long-term effects of neonatal pain. There is a lack of international guidelines for pain management in NEC patients. Therefore, this study aims to describe current pain management for NEC patients in European neonatal intensive care units (NICUs). METHODS An online survey was designed and conducted to assess current practices in pain management for NEC patients in European NICUs. The survey was distributed via neonatal societies, digital platforms, and professional contacts. RESULTS Out of the 259 responding unique European NICUs from 36 countries, 61% had a standard protocol for analgesic therapy, 73% assessed pain during NEC, and 92% treated NEC patients with intravenous analgosedatives. There was strong heterogeneity in the used pain scales and initial analgesic therapy, which mainly included acetaminophen (70%), fentanyl (56%), and/or morphine (49%). A third of NICU representatives considered their pain assessment adequate, and half considered their analgesic therapy adequate for NEC patients. CONCLUSIONS Various pain scales and analgesics are used to treat NEC patients in European NICUs. Our results provide the first step towards an international guideline to improve pain management for NEC patients. IMPACT This study provides an overview of current pain management practices for infants with necrotizing enterocolitis (NEC) in European neonatal intensive care units. Choice of pain assessment tools, analgosedatives, and dosages vary considerably among NICUs and countries. A third of NICU representatives were satisfied with their current pain assessment practices and half of NICU representatives with their analgesic therapy practices in NEC patients in their NICU. The results of this survey may provide a first step towards developing a European pain management consensus guideline for patients with NEC.
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30
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Li N, Chen B, Jia G, Xu R, Xia Y, Lai C, Li G, Li W, Han Y. Reduced BDNF expression in the auditory cortex contributed to neonatal pain-induced hearing impairment and dendritic pruning deficiency in mice. Reg Anesth Pain Med 2023; 48:85-92. [PMID: 36384877 PMCID: PMC9811087 DOI: 10.1136/rapm-2022-103621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/23/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Procedural pain in neonates is associated with impaired neurodevelopment. Whether hearing development is impaired, however, remains unknown. This study examined potential cause-and-effect relationship between neonatal pain and subsequent hearing loss in mice. METHODS Male C57BL/6J mouse pups received an intra-plantar injection of complete Freund's adjuvant on postnatal day 7 or repetitive needle prick stimuli from postnatal days 0-7. Mechanical and thermal pain thresholds were tested between postnatal days 14 and 49. The auditory brainstem response test was used to determine hearing thresholds. The inner ear structures and dendritic morphology in auditory cortex were assessed using immunofluorescence and Golgi-staining. The effects of oxycodone, tropomyosin receptor kinase B agonists and antagonists were tested. RESULTS Neonatal pain resulted in impaired hearing in adulthood of both pain models No damage or synapse loss was found in the cochlea but increased dendritic spine density and reduced brain-derived neurotrophic factor level were found in auditory cortex in neonatal pain group. Oxycodone attenuated hearing loss and the associated changes in dendritic spine density and brain-derived neurotrophic factor changes in auditory cortex. A tropomyosin receptor kinase B agonist reversed neonatal pain-induced hearing impairment and decreased caspase 3 expression in auditory cortex. Administration of tropomyosin receptor kinase B antagonist in naïve mouse pups impaired hearing development suppressed phosphorylated-AKT, and increased caspase 3 expression. CONCLUSION Chronic pain during the neonatal period resulted in impaired hearing in adulthood in mice, possibly via the brain-derived neurotrophic factor signaling pathway and dendritic spine pruning deficiency in auditory cortex.
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Affiliation(s)
- Nanqi Li
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, China
| | - Bing Chen
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, China,Department of Anesthesiology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Gaogan Jia
- NHC Key Laboratory of Hearing Medicine, ENT Hospital of Fudan University, Shanghai, China
| | - Rui Xu
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, China
| | - Ying Xia
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, China
| | - Chuijin Lai
- NHC Key Laboratory of Hearing Medicine, ENT Hospital of Fudan University, Shanghai, China
| | - Gang Li
- Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Wenxian Li
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, China
| | - Yuan Han
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, China
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31
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Nakhleh-Philippe P, Zores C, Stern-Delfils A, Escande B, Astruc D, Severac F, Kuhn P. Adequacy of sedation analgesia to support the comfort of neonates undergoing therapeutic hypothermia and its impact on short-term neonatal outcomes. Front Pediatr 2023; 11:1057724. [PMID: 36969279 PMCID: PMC10034099 DOI: 10.3389/fped.2023.1057724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives We aimed to evaluate (1) whether sedation analgesia (SA) used during therapeutic hypothermia (TH) was efficient to support the wellbeing of neonates with hypoxic-ischemic encephalopathy, (2) the SA level and its adjustment to clinical pain scores, and (3) the impact of inadequate SA on short-term neonatal outcomes evaluated at discharge. Methods This was an observational retrospective study performed between 2011 and 2018 in two level III centers in Alsace, France. We analyzed the wellbeing of infants by using the COMFORT-Behavior (COMFORT-B) clinical score and SA level during TH, according to which we classified infants into four groups: those with excess SA, adequate SA, lack of SA, and variability of SA. We analyzed the variations in doses of SA and their justification. We also determined the impact of inadequate SA on neonatal outcomes at discharge by multivariate analyses with multinomial regression, with adequate SA as the reference. Results A total of 110 patients were included, 89 from Strasbourg university hospital and 21 from Mulhouse hospital. The COMFORT-B score was assessed 95.5% of the time. Lack of SA was mainly found on the first day of TH (15/110, 14%). In all, 62 of 110 (57%) infants were in excess of SA over the entire duration of TH. Most dose variations were related to clinical pain scores. Inadequate SA was associated with negative short-term consequences. Infants with excess of SA had a longer duration of mechanical ventilation [mean ratio 1.46, 95% confidence interval (CI), 1.13-1.89, p = 0.005] and higher incidence of abnormal neurological examination at discharge (odds ratio 2.61, 95% CI, 1.10-6.18, p = 0.029) than infants with adequate SA. Discussion Adequate SA was not easy to achieve during TH. Close and regular monitoring of SA level may help achieve adequate SA. Excess of SA can be harmful for newborns with hypoxic-ischemic encephalopathy who are undergoing TH.
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Affiliation(s)
- Pauline Nakhleh-Philippe
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Department of Neonatology, Hospital of Mulhouse, Mulhouse, France
| | - Claire Zores
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | | | - Benoît Escande
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - Dominique Astruc
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - François Severac
- Department of Public Health and Epidemiology, University Hospital of Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Correspondence: Kuhn Pierre
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32
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Ohishi A, Ueno D, Fujita T, Segawa Y, Yamamoto T, Fujisawa Y, Iijima S. Safety and accuracy of neonatal continuous glucose monitoring. Pediatr Int 2023; 65:e15616. [PMID: 37795844 DOI: 10.1111/ped.15616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Hypoglycemia is a significant problem for all neonates and requires minimally invasive and reliable monitoring. The primary objective of this study was to verify the safety and accuracy of the continuous glucose monitoring (CGM) of full-term neonates using Freestyle Libre, a flash glucose monitoring (FGM) device. METHODS The study was conducted on 20 neonates. Shortly after birth, we placed the FGM sensor on the outside of the neonates' thighs. We scanned the CGM values at 60, 120, 180, and 360 min after birth and simultaneously obtained blood glucose values with plantar capillaries by heel puncture. The neonates wore the sensors for up to 6 h and then they were removed. RESULTS Of the 75 data points to be measured, 65 points (86.7%) were obtained by scan. There was no change in the sensor attachment site in 12 of 18 completed cases in this study but we observed slight induration in four cases (22.2%) and slight redness in one case (5.5%) at the sensor puncture site. A moderate correlation was observed between the CGM and blood glucose values. The CGM values tended to be low at 120, 180, and 360 min after birth, and tended to be high only at 60 min after birth. CONCLUSIONS The CGM device was safe to wear on the neonate and the CGM data correlated well with blood glucose levels. There was dissociation between CGM data and blood glucose levels in the acute period soon after birth when the blood glucose levels changed rapidly.
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Affiliation(s)
- Akira Ohishi
- Maternal-Fetal and Neonatal Care Center, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Daizo Ueno
- Department of Regional Neonatal and Perinatal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoka Fujita
- Maternal-Fetal and Neonatal Care Center, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuki Segawa
- Maternal-Fetal and Neonatal Care Center, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takuya Yamamoto
- Maternal-Fetal and Neonatal Care Center, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yasuko Fujisawa
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shigeo Iijima
- Department of Regional Neonatal and Perinatal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Budh HP, Nimbalkar S. Surfactant Replacement Therapy: What’s the New Future? JOURNAL OF NEONATOLOGY 2022; 36:331-347. [DOI: 10.1177/09732179221136963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Surfactant replacement therapy (SRT) can be lifesaving for preterm babies with respiratory distress because of surfactant deficiency. Attempts have been made over the last two decades to make surfactant administration as smooth and as nontraumatic as possible. Lesser invasive techniques, such as less invasive surfactant administration, minimally invasive surfactant therapy, intrapartum pharyngeal surfactant therapy, and the laryngeal mask airway, are preferred over invasive techniques like intubate surfactant extubation to reduce trauma and peridosing adverse effects. However, at present, aerosolized surfactant (AS) via nebulization remains the only truly noninvasive method of SRT. Many animal and human studies have shown promising results with the use of AS with similar clinical effects to an instilled surfactant with greater safety potential. But still AS has not been adapted to routine neonatal care. There is still scope for studies to further strengthen the role of AS. Also, SRT is a constantly changing field with new innovations revolutionizing and replacing old techniques.
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Affiliation(s)
- Hetal Pramod Budh
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
| | - Somashekhar Nimbalkar
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
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Zhao T, Griffith T, Zhang Y, Li H, Hussain N, Lester B, Cong X. Early-life factors associated with neurobehavioral outcomes in preterm infants during NICU hospitalization. Pediatr Res 2022; 92:1695-1704. [PMID: 35338349 PMCID: PMC9509490 DOI: 10.1038/s41390-022-02021-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study was to investigate the influence of early-life pain/stress and medical characteristics on neurobehavioral outcomes in preterm infants. METHODS A prospective cohort study was conducted with 92 preterm infants (28-32 weeks gestational age [GA]). Early-life pain/stress was measured via the Neonatal Infant Stressor Scale (NISS) during the first 28 days of NICU hospitalization. Neurobehavioral outcomes were evaluated using the NICU Network Neurobehavioral Scale at 36-38 weeks post-menstrual age. Functional regression and machine learning models were performed to investigate the predictors of neurobehavioral outcomes. RESULTS Infants experienced daily acute pain/stress (24.99 ± 7.13 frequencies) and chronic events (41.13 ± 17.81 h). Up to 12 days after birth, both higher acute and chronic NISS scores were associated with higher stress scores; and higher chronic NISS scores were also related to lower self-regulation and quality of movement. Younger GA predicted worse neurobehavioral outcomes; GA < 31.57 weeks predicted worse stress/abstinence, self-regulation, and excitability; GA < 30.57 weeks predicted poor quality of movement. A higher proportion of maternal breastmilk intake predicted better self-regulation, excitability, and quality of movement in older GA infants. CONCLUSIONS Preterm infants are vulnerable to the impact of early-life pain/stress. Neurobehavioral outcomes are positively associated with increased GA and higher maternal breastmilk intake. IMPACT During the first 12 days of life, preterm infant neurobehavioral outcomes were vulnerable to the negative impact of acute and chronic pain/stress. Future research is warranted to investigate the long-term effects of early-life pain/stress on neurobehavioral outcomes. Gestational age remains one of the critical factors to predict neurobehavioral outcomes in preterm infants; older gestational age significantly predicted better neurobehavioral outcomes. Feeding with a higher proportion of maternal breastmilk predicted better neurobehavioral outcomes. Future research is warranted to investigate how maternal breastmilk may buffer the negative effects of early-life pain/stress on neurobehavioral outcomes.
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Affiliation(s)
- Tingting Zhao
- School of Nursing, University of Connecticut, Storrs, CT, USA
| | - Thao Griffith
- Department of Family and Community Health Nursing, Marcella Niehoff School of Nursing, Loyola University Chicago, Maywood, IL, USA
| | - Yiming Zhang
- Department of Statistics, University of Connecticut, Storrs, CT, USA
| | - Hongfei Li
- Department of Statistics, University of Connecticut, Storrs, CT, USA
| | - Naveed Hussain
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
- Division of Neonatology, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Barry Lester
- Brown Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Xiaomei Cong
- School of Nursing, University of Connecticut, Storrs, CT, USA.
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.
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Lo E, Kalish BT. Neurodevelopmental outcomes after neonatal surgery. Pediatr Surg Int 2022; 39:22. [PMID: 36449183 DOI: 10.1007/s00383-022-05285-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 12/05/2022]
Abstract
Children who require surgery in the newborn period are at risk for long-term neurodevelopmental impairment (NDI). There is growing evidence that surgery during this critical window of neurodevelopment gives rise to an increased risk of brain injury, predisposing to neurodevelopmental challenges including motor delays, learning disabilities, executive function impairments, and behavioral disorders. These impairments can have a significant impact on the quality of life of these children and their families. This review explores the current literature surrounding the effect of neonatal surgery on neurodevelopment, as well as the spectrum of proposed mechanisms that may impact neurodevelopmental outcomes. The goal is to identify modifiable risk factors and patients who may benefit from close neurodevelopmental follow-up and early referral to therapy.
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Affiliation(s)
- Emily Lo
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian T Kalish
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Molecular Genetics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Vulnerability of the Neonatal Connectome following Postnatal Stress. J Neurosci 2022; 42:8948-8959. [PMID: 36376077 PMCID: PMC9732827 DOI: 10.1523/jneurosci.0176-22.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
Stress following preterm birth can disrupt the emerging foundation of the neonatal brain. The current study examined how structural brain development is affected by a stressful early environment and whether changes in topological architecture at term-equivalent age could explain the increased vulnerability for behavioral symptoms during early childhood. Longitudinal changes in structural brain connectivity were quantified using diffusion-weighted imaging (DWI) and tractography in preterm born infants (gestational age <28 weeks), imaged at 30 and/or 40 weeks of gestation (N = 145, 43.5% female). A global index of postnatal stress was determined based on the number of invasive procedures during hospitalization (e.g., heel lance). Higher stress levels impaired structural connectivity growth in a subnetwork of 48 connections (p = 0.003), including the amygdala, insula, hippocampus, and posterior cingulate cortex. Findings were replicated in an independent validation sample (N = 123, 39.8% female, n = 91 with follow-up). Classifying infants into vulnerable and resilient based on having more or less internalizing symptoms at two to five years of age (n = 71) revealed lower connectivity in the hippocampus and amygdala for vulnerable relative to resilient infants (p < 0.001). Our findings suggest that higher stress exposure during hospital admission is associated with slower growth of structural connectivity. The preservation of global connectivity of the amygdala and hippocampus might reflect a stress-buffering or resilience-enhancing factor against a stressful early environment and early-childhood internalizing symptoms.SIGNIFICANCE STATEMENT The preterm brain is exposed to various external stimuli following birth. The effects of early chronic stress on neonatal brain networks and the remarkable degree of resilience are not well understood. The current study aims to provide an increased understanding of the impact of postnatal stress on third-trimester brain development and describe the topological architecture of a resilient brain. We observed a sparser neonatal brain network in infants exposed to higher postnatal stress. Limbic regulatory regions, including the hippocampus and amygdala, may play a key role as crucial convergence sites of protective factors. Understanding how stress-induced alterations in early brain development might lead to brain (re)organization may provide essential insights into resilient functioning.
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Gomaa N, Konwar C, Gladish N, Au-Young SH, Guo T, Sheng M, Merrill SM, Kelly E, Chau V, Branson HM, Ly LG, Duerden EG, Grunau RE, Kobor MS, Miller SP. Association of Pediatric Buccal Epigenetic Age Acceleration With Adverse Neonatal Brain Growth and Neurodevelopmental Outcomes Among Children Born Very Preterm With a Neonatal Infection. JAMA Netw Open 2022; 5:e2239796. [PMID: 36322087 PMCID: PMC9631102 DOI: 10.1001/jamanetworkopen.2022.39796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Very preterm neonates (24-32 weeks' gestation) remain at a higher risk of morbidity and neurodevelopmental adversity throughout their lifespan. Because the extent of prematurity alone does not fully explain the risk of adverse neonatal brain growth or neurodevelopmental outcomes, there is a need for neonatal biomarkers to help estimate these risks in this population. OBJECTIVES To characterize the pediatric buccal epigenetic (PedBE) clock-a recently developed tool to measure biological aging-among very preterm neonates and to assess its association with the extent of prematurity, neonatal comorbidities, neonatal brain growth, and neurodevelopmental outcomes at 18 months of age. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted in 2 neonatal intensive care units of 2 hospitals in Toronto, Ontario, Canada. A total of 35 very preterm neonates (24-32 weeks' gestation) were recruited in 2017 and 2018, and neuroimaging was performed and buccal swab samples were acquired at 2 time points: the first in early life (median postmenstrual age, 32.9 weeks [IQR, 32.0-35.0 weeks]) and the second at term-equivalent age (TEA) at a median postmenstrual age of 43.0 weeks (IQR, 41.0-46.0 weeks). Follow-ups for neurodevelopmental assessments were completed in 2019 and 2020. All neonates in this cohort had at least 1 infection because they were originally enrolled to assess the association of neonatal infection with neurodevelopment. Neonates with congenital malformations, genetic syndromes, or congenital TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes and other agents) infection were excluded. EXPOSURES The extent of prematurity was measured by gestational age at birth and PedBE age difference. PedBE age was computed using DNA methylation obtained from 94 age-informative CpG (cytosine-phosphate-guanosine) sites. PedBE age difference (weeks) was calculated by subtracting PedBE age at each time point from the corresponding postmenstrual age. MAIN OUTCOMES AND MEASURES Total cerebral volumes and cerebral growth during the neonatal intensive care unit period were obtained from magnetic resonance imaging scans at 2 time points: approximately the first 2 weeks of life and at TEA. Bayley Scales of Infant and Toddler Development, Third Edition, were used to assess neurodevelopmental outcomes at 18 months. RESULTS Among 35 very preterm neonates (21 boys [60.0%]; median gestational age, 27.0 weeks [IQR, 25.9-29.9 weeks]; 23 [65.7%] born extremely preterm [<28 weeks' gestation]), extremely preterm neonates had an accelerated PedBE age compared with neonates born at a later gestational age (β = 9.0; 95% CI, 2.7-15.3; P = .01). An accelerated PedBE age was also associated with smaller cerebral volumes (β = -5356.8; 95% CI, -6899.3 to -2961.7; P = .01) and slower cerebral growth (β = -2651.5; 95% CI, -5301.2 to -1164.1; P = .04); these associations remained significant after adjusting for clinical neonatal factors. These findings were significant at TEA but not earlier in life. Similarly, an accelerated PedBE age at TEA was associated with lower cognitive (β = -0.4; 95% CI, -0.8 to -0.03; P = .04) and language (β = -0.6; 95% CI, -1.1 to -0.06; P = .02) scores at 18 months. CONCLUSIONS AND RELEVANCE This cohort study of very preterm neonates suggests that biological aging may be associated with impaired brain growth and neurodevelopmental outcomes. The associations between epigenetic aging and adverse neonatal brain health warrant further attention.
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Affiliation(s)
- Noha Gomaa
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chaini Konwar
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole Gladish
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie H. Au-Young
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ting Guo
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Min Sheng
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah M. Merrill
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Edmond Kelly
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Vann Chau
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Helen M. Branson
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Linh G. Ly
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emma G. Duerden
- Faculty of Education, Western University, London, Ontario, Canada
| | - Ruth E. Grunau
- Division of Neonatology, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Michael S. Kobor
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven P. Miller
- Neuroscience and Mental Health Program, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
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Sanatkar M, Dastjani Farahani A, Bazvand F. Ketamine Analgesia as an Alternative to General Anesthesia During Laser Treatment for Retinopathy of Prematurity. J Pediatr Ophthalmol Strabismus 2022; 59:416-421. [PMID: 35446192 DOI: 10.3928/01913913-20220225-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the safety and efficacy of ketamine analgesia as an alternative to general anesthesia during laser treatment for retinopathy of prematurity (ROP). METHODS Eighteen premature neonates with ROP underwent laser treatment. The procedure was performed in the operating room, and the neonates were admitted to the neonatal intensive care unit (NICU) after the procedure. An initial dose of 1 mg/kg of ketamine was administered. If the neonate exhibited movement or distress during the procedure, incremental doses of ketamine were administered. Perioperative ventilation status, severity of pain during the procedure, surgeon satisfaction, and perioperative events were recorded. RESULTS Eighteen premature neonates underwent ketamine analgesia during laser treatment for ROP. The procedure was performed in 16 patients with good tolerance and without events. The Premature Infant Pain Profile (PIPP) scores during the procedure were 5 or less in 12 neonates (44.4%), 5 to 10 in 4 neonates (22.2%), and greater than 10 in 2 (11.1%) neonates. Three neonates had perioperative events, which resolved completely with minimal intervention. None of the neonates needed intubation perioperatively, and hemodynamic instability, hypotension, and bradycardia were not recorded in any of the neonates during or after the procedure. CONCLUSIONS The ROP laser treatment under ketamine sedation could be performed in premature neonates with few perioperative complications and provide satisfactory operative conditions. [J Pediatr Ophthalmol Strabismus. 2022;59(6):416-421.].
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Brain Development and Maternal Behavior in Relation to Cognitive and Language Outcomes in Preterm-Born Children. Biol Psychiatry 2022; 92:663-673. [PMID: 35599181 DOI: 10.1016/j.biopsych.2022.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Children born very preterm (≤32 weeks gestational age) show poorer cognitive and language development compared with their term-born peers. The importance of supportive maternal responses to the child's cues for promoting neurodevelopment is well established. However, little is known about whether supportive maternal behavior can buffer the association of early brain dysmaturation with cognitive and language performance. METHODS Infants born very preterm (N = 226) were recruited from the neonatal intensive care unit for a prospective, observational cohort study. Chart review (e.g., size at birth, postnatal infection) was conducted from birth to discharge. Magnetic resonance imaging, including diffusion tensor imaging, was acquired at approximately 32 weeks postmenstrual age and again at term-equivalent age. Fractional anisotropy, a quantitative measure of brain maturation, was obtained from 11 bilateral regions of interest in the cortical gray matter. At 3 years (n = 187), neurodevelopmental testing (Bayley Scales of Infant and Toddler Development-III) was administered, and parent-child interaction was filmed. Maternal behavior was scored using the Emotional Availability Scale-IV. A total of 146 infants with neonatal brain imaging and follow-up data were included for analysis. Generalized estimating equations were used to examine whether maternal support interacted with mean fractional anisotropy values to predict Cognitive and Language scores at 3 years, accounting for confounding neonatal and maternal factors. RESULTS Higher maternal support significantly moderated cortical fractional anisotropy values at term-equivalent age to predict higher Cognitive (interaction term β = 2.01, p = .05) and Language (interaction term β = 1.85, p = .04) scores. CONCLUSIONS Findings suggest that supportive maternal behavior following early brain dysmaturation may provide an opportunity to promote optimal neurodevelopment in children born very preterm.
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Liu J, Fang S, Wang Y, Gao L, Xin T, Liu Y. The effectiveness of massage interventions on procedural pain in neonates: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e30939. [PMID: 36254036 PMCID: PMC9575769 DOI: 10.1097/md.0000000000030939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The painful procedures experienced by neonates during hospitalization have short-term or long-term effects on neonates. While the limitations of previous interventions make it imperative to explore effective interventions that are readily available. This systematic review and meta-analysis was conducted to evaluate the safety and effectiveness of massage for pain management in neonates. METHODS This systematic review was registered in PROSPER. PubMed, Embase, Cochrane Library, and the Clinical Trials Registry were searched to December 2021. Two reviewers independently carried out study selection, data extraction, bias risk assessment. Continuous data were analyzed by mean differences (MD). Dichotomous data were reported using relative risk. If at least two studies reported identical results by the same pain assessment tool, a meta-analysis was conducted using random effect model and inverse variance. RESULTS Total 11 included studies involving 755 neonates investigated the effects of massage on neonatal pain response compared to standard care. The meta-analysis showed that massage could effectively improve pain response in neonates compared to standard care no matter whether neonatal infant pain scale (NIPS) or premature infant pain profile (PIPP) was used as an assessment tool. Besides, massage was also effective for crying duration, blood oxygen saturation both during and after the procedure, but non-effective for the variation of respiratory rate after the procedure, and heart rate both during and after the procedure. CONCLUSIONS Massage may have a positive effect on pain relief of neonate, and rigorous trials are needed in the future to determine the most effective massage method.
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Affiliation(s)
- Jiang Liu
- School of Nursing, Weifang Medical University, Weifang, China
| | - Shirong Fang
- Weifang People’s Hospital, Weifang Medical University, Weifang, China
| | - Yuxia Wang
- Weifang Maternal and Child Health Hospital, Weifang, China
| | - Lunan Gao
- School of Nursing, Weifang Medical University, Weifang, China
| | - Tingting Xin
- School of Nursing, Weifang Medical University, Weifang, China
| | - Yuxiu Liu
- School of Nursing, Weifang Medical University, Weifang, China
- *Correspondence: Yuxiu Liu, School of Nursing, Weifang Medical University, No. 7166 Baotong Western Street, Weifang, China (e-mail: )
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McLean MA, Scoten OC, Chau CMY, Synnes A, Miller SP, Grunau RE. Association of Neonatal Pain-Related Stress and Parent Interaction With Internalizing Behaviors Across 1.5, 3.0, 4.5, and 8.0 Years in Children Born Very Preterm. JAMA Netw Open 2022; 5:e2238088. [PMID: 36269352 PMCID: PMC9587482 DOI: 10.1001/jamanetworkopen.2022.38088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Internalizing (anxiety and/or depressive) behaviors are prevalent in children born very preterm (24-32 weeks' gestation). Procedural pain-related stress in the neonatal intensive care unit (NICU) is associated with long-term internalizing problems in this population; however, whether positive parenting during toddlerhood attenuates development of internalizing behaviors across childhood is unknown. OBJECTIVE To investigate whether neonatal pain-related stress is associated with trajectories of internalizing behaviors across 1.5, 3.0, 4.5, and 8.0 years, and whether supportive parenting behaviors and lower parenting stress at 1.5 and 3.0 years attenuate this association. DESIGN, SETTING, AND PARTICIPANTS In this prospective longitudinal cohort study, preterm neonates (born at 24-32 weeks' gestation) were recruited from August 16, 2006, to September 9, 2013, with follow-up visits at ages 1.5, 3.0, 4.5, and 8.0 years. The study was conducted at BC Women's Hospital, Vancouver, Canada, with recruitment from a level III neonatal intensive care unit and sequential developmental assessments performed in a Neonatal Follow-up Program. Data analysis was performed from August to December 2021. MAIN OUTCOMES AND MEASURES Parental report of child internalizing behaviors on the Child Behavior Checklist at 1.5, 3.0, 4.5, and 8.0 years. RESULTS A total of 234 neonates were recruited, and 186 children (101 boys [54%]) were included in the current study across ages 1.5 (159 children), 3.0 (169 children), 4.5 (162 children), and 8.0 (153 children) years. After accounting for clinical factors associated with prematurity, greater neonatal pain-related stress was associated with more internalizing behaviors across ages (B = 4.95; 95% CI, 0.76 to 9.14). Higher parenting stress at age 1.5 years (B = 0.17; 95% CI, 0.11 to 0.23) and a less supportive parent environment (less sensitivity, structure, nonintrusiveness, nonhostility, and higher parenting stress; B = -5.47; 95% CI, -9.44 to -1.51) at 3.0 years were associated with greater internalizing problems across development to age 8.0 years. CONCLUSIONS AND RELEVANCE In this cohort study of children born very preterm, exposure to repetitive neonatal pain-related stress was associated with persistent internalizing behavior problems across toddlerhood to age 8.0 years. Supportive parenting behaviors during early childhood were associated with better long-term behavioral outcomes, whereas elevated parenting stress was associated with more child anxiety and/or depressive behaviors in this population. These findings reinforce the need to prevent pain in preterm neonates and inform future development of targeted parent-led behavioral interventions.
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Affiliation(s)
- Mia A. McLean
- BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olivia C. Scoten
- BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Cecil M. Y. Chau
- BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne Synnes
- BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Women’s Hospital, Vancouver, British Columbia, Canada
| | - Steven P. Miller
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ruth E. Grunau
- BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Women’s Hospital, Vancouver, British Columbia, Canada
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Sympathetic skin response as an objective tool to estimate stimulus-associated arousal in a human model of hyperalgesia. Neurophysiol Clin 2022; 52:436-445. [DOI: 10.1016/j.neucli.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
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Visoiu M. Evolving approaches in neonatal postoperative pain management. Semin Pediatr Surg 2022; 31:151203. [PMID: 36038217 DOI: 10.1016/j.sempedsurg.2022.151203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Neonates experience significant moderate and severe postoperative pain. Effective postoperative pain management in neonates is required to minimize acute and long-term effects of neonatal pain. Protecting the developing nervous system from persistent sensitization of pain pathways and developing primary hyperalgesia is essential. Opioids and acetaminophen are commonly analgesics used for pain control. Regional anesthesia provides adequate intraoperative and postoperative analgesia in neonates. It decreases exposure to opioids, reduces adverse drug effects, and facilitates early extubation. It suppresses the stress response and can prevent long-term behavioral responses to pain. The most common blocks performed in neonates are neuraxial blocks. Using ultrasound increased the number of peripheral nerve blocks performed in neonates. Recently, various peripheral nerve blocks (paravertebral, transverse abdominis plane, rectus sheath, quadratus lumborum, erector spinae plane blocks) were safely used. Many studies support analgesic efficacy but highlight neonates' unpredictability and variability of fascial blocks.
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Affiliation(s)
- Mihaela Visoiu
- Associate Professor of Anesthesiology and Perioperative Medicine, Department of Anesthesiology and Perioperative Medicine; UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA, United States of America.
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Duerden EG, Mclean MA, Chau C, Guo T, Mackay M, Chau V, Synnes A, Miller SP, Grunau RE. Neonatal pain, thalamic development and sensory processing behaviour in children born very preterm. Early Hum Dev 2022; 170:105617. [PMID: 35760006 DOI: 10.1016/j.earlhumdev.2022.105617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Altered sensory processing is commonly reported in children born very preterm (≤32 weeks' gestational age [GA]). The immature nervous system, particularly the development of connections from the thalamus to the cortex, may show enhanced vulnerability to excessive sensory stimulation, and may contribute to altered sensory processing. Our objective was to determine whether sensory processing assessed at preschool-aged in children born very preterm was predicted by neonatal procedural pain and thalamic development. METHODS In a prospective longitudinal cohort study, N = 140 very preterm infants (median GA at birth 28 weeks) underwent MRI early-in-life and again at term-equivalent age. Children returned for assessment at 4.5 years. Parents reported on child sensory processing behaviors on the Short Sensory Profile. General linear models were used to assess factors associated with sensory processing behaviors, adjusting for clinical and demographic factors. RESULTS Among extremely preterm neonates (born 24-28 weeks' GA), but not very-preterm neonates (29-32 weeks' GA), more invasive procedures were associated with poorer sensory processing (B = -0.09, 95%CI [-0.17, -0.01] p = 0.03). In the overall cohort, fewer sensory processing problems were associated with greater thalamic growth between birth and term-equivalent age (B = 0.3, 95%CI [0.11, 0.42], p < 0.001). Extremely preterm neonates exposed to a high number of skin-breaking procedures who exhibited slower neonatal thalamic growth displayed the highest sensory processing problems (B = -26.2, 95%CI [-45.96, -6.38], p = 0.01). CONCLUSION Early exposure to pain and related alterations in the developing thalamus may be a key factor underlying later sensory problems in children born extremely preterm.
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Affiliation(s)
- Emma G Duerden
- Applied Psychology, Faculty of Education, Western University, London, Canada
| | - Mia A Mclean
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Cecil Chau
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Ting Guo
- Department of Paediatrics, the Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | | | - Vann Chau
- Department of Paediatrics, the Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, Canada; BC Women's Hospital, Vancouver, Canada; BC Children's Hospital Research Institute, Vancouver, Canada
| | - Steven P Miller
- Department of Paediatrics, the Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, Vancouver, Canada; BC Women's Hospital, Vancouver, Canada; BC Children's Hospital Research Institute, Vancouver, Canada.
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45
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Velumula PK, Elbakoush F, Tabb C, Farooqi A, Lulic-Botica M, Jani S, Natarajan G, Bajaj M. Breast milk vs 24% sucrose for procedural pain relief in preterm neonates: a non-inferiority randomized controlled trial. J Perinatol 2022; 42:914-919. [PMID: 35197549 DOI: 10.1038/s41372-022-01352-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To compare the pain scores between the two groups, breast milk (BM) and 24% sucrose, in preterm neonates undergoing automated heel lance for the blood draw. METHODS The study is designed as a randomized, single-blinded, non-inferiority trial. Infants born between 30 1/7weeks and 36 6/7 weeks of gestation were randomly assigned to receive either 24% sucrose or expressed BM. The Premature Infant Pain Profile-Revised (PIPP-R) was utilized to provide pain scores. RESULTS No differences were noted in the baseline characteristics between the two groups. The quantile regression estimates for PIPP-R scores during the procedure were statistically non-significant at all percentile levels of distribution (50%ile coefficient 0, 95% CI -0.49 to 0.49). CONCLUSION We conclude that BM is not inferior to 24% sucrose in providing analgesia during heel lance in moderate and late preterm infants. TRIAL REGISTRATION This trial was registered at www. CLINICALTRIALS gov (identifier NCT04898881).
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Affiliation(s)
| | - Faesal Elbakoush
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA
| | - Carl Tabb
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA
| | | | - Mirjana Lulic-Botica
- Hutzel Women's Hospital, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - Sanket Jani
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Girija Natarajan
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Monika Bajaj
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
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Lammertink F, van den Heuvel MP, Hermans EJ, Dudink J, Tataranno ML, Benders MJNL, Vinkers CH. Early-life stress exposure and large-scale covariance brain networks in extremely preterm-born infants. Transl Psychiatry 2022; 12:256. [PMID: 35717524 PMCID: PMC9206645 DOI: 10.1038/s41398-022-02019-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
The stressful extrauterine environment following premature birth likely has far-reaching and persistent adverse consequences. The effects of early "third-trimester" ex utero stress on large-scale brain networks' covariance patterns may provide a potential avenue to understand how early-life stress following premature birth increases risk or resilience. We evaluated the impact of early-life stress exposure (e.g., quantification of invasive procedures) on maturational covariance networks (MCNs) between 30 and 40 weeks of gestational age in 180 extremely preterm-born infants (<28 weeks of gestation; 43.3% female). We constructed MCNs using covariance of gray matter volumes between key nodes of three large-scale brain networks: the default mode network (DMN), executive control network (ECN), and salience network (SN). Maturational coupling was quantified by summating the number of within- and between-network connections. Infants exposed to high stress showed significantly higher SN but lower DMN maturational coupling, accompanied by DMN-SN decoupling. Within the SN, the insula, amygdala, and subthalamic nucleus all showed higher maturational covariance at the nodal level. In contrast, within the DMN, the hippocampus, parahippocampal gyrus, and fusiform showed lower coupling following stress. The decoupling between DMN-SN was observed between the insula/anterior cingulate cortex and posterior parahippocampal gyrus. Early-life stress showed longitudinal network-specific maturational covariance patterns, leading to a reprioritization of developmental trajectories of the SN at the cost of the DMN. These alterations may enhance the ability to cope with adverse stimuli in the short term but simultaneously render preterm-born individuals at a higher risk for stress-related psychopathology later in life.
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Affiliation(s)
- Femke Lammertink
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martijn P van den Heuvel
- Department of Complex Trait Genetics, Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, Vrije University Amsterdam, Amsterdam, The Netherlands
- Department of Child Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Amsterdam, The Netherlands
| | - Erno J Hermans
- Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen Dudink
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maria L Tataranno
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Christiaan H Vinkers
- Department of Anatomy & Neurosciences, Amsterdam UMC (location Vrije University Amsterdam), Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam UMC (location Vrije University Amsterdam), Amsterdam, The Netherlands
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Cristoforo T, Gonzalez D, Bender M, Uy G, Papa L, Ben Khallouq BA, Clark M, Carr B, Cramm K. A Pilot Study Testing Intranasal Ketamine for the Treatment of Procedural Anxiety in Children Undergoing Laceration Repair. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2022; 15:479-486. [PMID: 35600518 PMCID: PMC9120296 DOI: 10.1007/s40653-021-00402-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 06/03/2023]
Abstract
Identifying non-invasive methods for anxiolysis is becoming increasingly important in the pediatric emergency department (ED). Few studies have examined the use of intranasal (IN) ketamine for procedural anxiolysis. We aim to evaluate if IN ketamine provides satisfactory anxiolysis for patients undergoing laceration repair based on anxiety and sedation scoring. We also evaluated the feasibility of using IN ketamine in future trials based on its tolerability and side-effects. A pilot study evaluating IN ketamine in the treatment of procedural anxiety for patients, 2 years and older, weighing 40 kg or less, presenting to the pediatric ED with lacerations. The need for anxiolysis was defined by an elevated modified-Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) score. Patients received 5 mg/kg of IN ketamine in addition to topical anesthesia, mYPAS-SF scoring before and during the procedure, sedation scoring, adverse events, vital signs, age, weight, laceration size and location, and satisfaction surveys were recorded. Twenty-five patients were enrolled, with mean age of 61 ± 29.2 months and mean weight of 21 ± 6.4 kg. Lacerations were located on the face, extremities, and groin with mean size of 2.1 cm. A decrease in anxiety levels was observed, from median m-YPAS-SF score of 66.7 (62.50-80.2) to 33.3 (27.09-52.00), p < 0.001. Among the patients, 92% (n = 23) were less anxious during the procedure. IN ketamine appears to be safe and well-tolerated with a positive impact on procedural anxiety. A dosage of 5 mg/kg is a reasonable starting point, as 80% of patients had appropriate anxiolysis.
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Affiliation(s)
- Thomas Cristoforo
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
| | - Dulce Gonzalez
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
| | - Mark Bender
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
- Emergency Department, Orlando Regional Medical Center, Orlando Health, Orlando, FL USA
| | - Geraldine Uy
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
- Emergency Department, Orlando Regional Medical Center, Orlando Health, Orlando, FL USA
| | - Linda Papa
- Emergency Department, Orlando Regional Medical Center, Orlando Health, Orlando, FL USA
| | - Bertha A. Ben Khallouq
- Research Department, Arnold Palmer Hospital for Children, Orlando Health, Orlando, FL USA
| | - Mark Clark
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
- Emergency Department, Orlando Regional Medical Center, Orlando Health, Orlando, FL USA
| | - Brandon Carr
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
| | - Kelly Cramm
- Pediatric Emergency Department, Arnold Palmer Hospital for Children, Orlando Health, 92 W. Miller Street, Orlando, FL USA
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Steinbauer P, Monje FJ, Kothgassner O, Goreis A, Eva C, Wildner B, Schned H, Deindl P, Seki D, Berger A, Olischar M, Giordano V. The consequences of neonatal pain, stress and opiate administration in animal models: An extensive meta-analysis concerning neuronal cell death, motor and behavioral outcomes. Neurosci Biobehav Rev 2022; 137:104661. [PMID: 35427643 DOI: 10.1016/j.neubiorev.2022.104661] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 01/21/2023]
Abstract
This systematic review and meta-analysis aimed to investigate the association of neonatal exposure to pain, stress, opiate administration alone, as well as opiate administration prior to a painful procedure on neuronal cell death, motor, and behavioral outcomes in rodents. In total, 36 studies investigating the effect of pain (n = 18), stress (n = 15), opiate administration (n = 13), as well as opiate administration prior to a painful event (n = 7) in rodents were included in our meta-analysis. The results showed a large effect of pain (g = 1.37, 95% CI 1.00-1.74, p < .001) on neuronal cell death. Moreover, higher number of neonatal pain events were significantly associated with increased neuronal cell death, increased anxiety (b = -1.18, SE = 0.43, p = .006), and depressant-like behavior (b = 1.74, SE = 0.51, p = .027) in rodents. Both opiates and pain had no impact on motor function (g = 0.26, 95% CI 0.18-0.70, p = .248).
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Affiliation(s)
- Philipp Steinbauer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Francisco J Monje
- Department of Neurophysiology and Neuropharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Oswald Kothgassner
- Department of Child and Adolescent Psychiatry, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andreas Goreis
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria; Outpatient Unit for Research, Teaching and Practice, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Chwala Eva
- Information Retrieval Office, University Library of the Medical University of Vienna, Vienna, Austria
| | - Brigitte Wildner
- Information Retrieval Office, University Library of the Medical University of Vienna, Vienna, Austria
| | - Hannah Schned
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Philipp Deindl
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children's Hospital, University Medical Center Hamburg, Eppendorf, Germany
| | - David Seki
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria; Department of Microbiology and Ecosystem Science Division of Microbial Ecology, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Monika Olischar
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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49
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Abstract
Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.
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50
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Butkevich IP, Mikhailenko VA, Vershinina EA. Sexual Dimorphism in the Effect of Neonatal Inflammatory Pain on Stress Reactivity of Hormonal Response and Cognitive Functions in Adult Rats. J EVOL BIOCHEM PHYS+ 2022; 58:353-363. [PMID: 35599637 PMCID: PMC9109674 DOI: 10.1134/s0022093022020053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022]
Abstract
The effect of moderate neonatal stress induced by inflammatory
pain in rat pups of both sexes on the hormonal response and cognitive
processes in adult animals was studied in the Morris water maze.
No significant differences in spatial learning and memory were found
in experimental rats exposed to neonatal inflammatory pain vs. control
animals. However, experimental rats exhibited sex differences in
long-term spatial memory whose efficiency was higher in males vs.
females. After long-term memory testing, stress responsiveness of
the hypothalamic-pituitary-adrenocortical axis, as assessed by the
plasma corticosterone level in the formalin test, was higher in
experimental males vs. females. Only experimental females exhibited
differences between short-term and long-term memory, with the efficiency
being higher in the former. Thus, sexual dimorphism was found in
the effect of neonatal nociceptive stress on long-term spatial memory
in adult rats: experimental males vs. females demonstrated more
effective long-term memory combined with a higher stress reactivity
of the hormonal response.
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Affiliation(s)
- I. P. Butkevich
- Pavlov Institute of Physiology,
Russian Academy of Sciences, St. Petersburg, Russia
| | - V. A. Mikhailenko
- Pavlov Institute of Physiology,
Russian Academy of Sciences, St. Petersburg, Russia
| | - E. A. Vershinina
- Pavlov Institute of Physiology,
Russian Academy of Sciences, St. Petersburg, Russia
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