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Gieré C, Menger Y, Illouz H, Melchior M, Lelièvre V, Poisbeau P. Towards a central origin of nociceptive hypersensitivity in adult rats after a neonatal maternal separation. Eur J Neurosci 2023; 58:4155-4165. [PMID: 37821102 DOI: 10.1111/ejn.16170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
Early life adversities influence a nervous system still in development with long-term consequences for later life. These include nociceptive circuit alterations critical to shape an adaptive pain response to protect the organism from potential damage. Adult rats with a history of neonatal maternal separation (NMS) display visceral and somatic nociceptive hypersensitivity and inefficient analgesic responses to stress. In this study, we have characterized the consequences of NMS on wide dynamic range neurons (WDR) in the spinal cord of anaesthetized adult rats during the nociceptive processing of hot and cold noxious information. We found that WDR neurons of NMS rats display an excessive coding of mechanical and thermal information applied at the rat's hindpaws. This nicely explains the hypernociceptive behaviours seen after noxious mechanical, cold and hot peripheral stimulation. A peripheral change in the expression of molecular transducers for these stimuli (i.e., TRPV1, TRPM8 and TRPA1) does not seem to account for this general hyperexcitability. Instead, a decreased chloride-mediated inhibitory tone on WDR neurons may play a role as indicated by the abnormal elevation of the type 1 Na-K-Cl cotransporter transcripts. Altogether, we propose that long-term consequences of NMS are associated with reduced spinal cord inhibition favouring the expression of pain hypersensitivity. We cannot exclude that this phenomenon is also present at supraspinal sites, as other NMS-associated symptoms include excessive anxiety and impaired sociability.
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Affiliation(s)
- Clémence Gieré
- Centre National de la recherche Scientifique, Institut des Neurosciences Cellulaires et Intégratives, Université de Strasbourg, Strasbourg, France
- Ecole Universitaire de Recherche Interdisciplinaire sur la Douleur, Université de Strasbourg, Strasbourg, France
| | - Yannick Menger
- Centre National de la recherche Scientifique, Institut des Neurosciences Cellulaires et Intégratives, Université de Strasbourg, Strasbourg, France
| | - Hannah Illouz
- Centre National de la recherche Scientifique, Institut des Neurosciences Cellulaires et Intégratives, Université de Strasbourg, Strasbourg, France
- Ecole Universitaire de Recherche Interdisciplinaire sur la Douleur, Université de Strasbourg, Strasbourg, France
| | - Meggane Melchior
- Centre National de la recherche Scientifique, Laboratoire des Neurosciences Cognitive et Adaptative, Université de Strasbourg, Strasbourg, France
| | - Vincent Lelièvre
- Centre National de la recherche Scientifique, Institut des Neurosciences Cellulaires et Intégratives, Université de Strasbourg, Strasbourg, France
| | - Pierrick Poisbeau
- Centre National de la recherche Scientifique, Institut des Neurosciences Cellulaires et Intégratives, Université de Strasbourg, Strasbourg, France
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Ilhan E, Pacey V, Brown L, Spence K, van Ganzewinkel CJ, Pillai Riddell R, Campbell-Yeo M, Stevens BJ, Eriksson M, Shah V, Anand KJS, Bellieni C, Daly M, Johnston C, Hush J. What is the definition of acute episodic and chronic pain in critically ill neonates and infants? A global, four-stage consensus and validation study. BMJ Open 2022; 12:e055255. [PMID: 35264356 PMCID: PMC8915348 DOI: 10.1136/bmjopen-2021-055255] [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: 11/17/2022] Open
Abstract
OBJECTIVES To define and validate types of pain in critically ill neonates and infants by researchers and clinicians working in the neonatal intensive care unit (NICU) and high dependency unit (HDU). DESIGN A qualitative descriptive mixed-methods design. PROCEDURE/S Each stage of the study was built on and confirmed the previous stages. Stage 1 was an expert panel to develop definitions; stage 2 was a different expert panel made up of neonatal clinicians to propose clinical characteristics associated with the definitions from stage 1; stage 3 was a focus group of neonatal clinicians to provide clinical case scenarios associated with each definition and clinical characteristics; and stage 4 was a survey administered to neonatal clinicians internationally to test the validity of the definitions using the clinical case scenarios. RESULTS In stage 1, the panel (n=10) developed consensus definitions for acute episodic pain and chronic pain in neonates and infants. In stage 2, a panel (n=8) established clinical characteristics that may be associated with each definition. In stage 3, a focus group (n=11) created clinical case scenarios of neonates and infants with acute episodic pain, chronic pain and no pain using the definitions and clinical characteristics. In stage 4, the survey (n=182) revealed that the definitions allowed an excellent level of discrimination between case scenarios that described neonates and infants with acute episodic pain and chronic pain (area under the receiver operating characteristic=0.87 and 0.89, respectively). CONCLUSIONS This four-stage study enabled the development of consensus-based and clinically valid definitions of acute episodic pain and chronic pain. There is a need to define and validate other pain types to inform a taxonomy of pain experienced by neonates and infants in the NICU and HDU.
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Affiliation(s)
- Emre Ilhan
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Laura Brown
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Kaye Spence
- Grace Centre for Newborn Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Parramatta, NSW, Australia
| | | | - Rebecca Pillai Riddell
- Department of Psychology, Faculty of Health Sciences, York University, Toronto, Ontario, Canada
| | - Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bonnie J Stevens
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Sweden, Örebro, Sweden
| | - Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Departments of Paediatrics and IHPME, University of Toronto, Toronto, Ontario, Canada
| | - Kanwaljeet J S Anand
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
| | - Carlo Bellieni
- Department of Pediatrics, University of Siena, Siena, Italy
| | - Mandy Daly
- Irish Neonatal Health Alliance, Wicklow, Ireland
| | - Celeste Johnston
- Ingram School of Nursing, McGill University, Montreal, Québec, Canada
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Julia Hush
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
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Walker SM. Developmental Mechanisms of CPSP: Clinical Observations and Translational Laboratory Evaluations. Can J Pain 2021; 6:49-60. [PMID: 35910395 PMCID: PMC9331197 DOI: 10.1080/24740527.2021.1999796] [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] [Indexed: 11/02/2022] Open
Abstract
Understanding mechanisms that underly the transition from acute to chronic pain and identifying potential targets for preventing or minimizing this progression have specific relevance for chronic postsurgical pain (CPSP). Though it is clear that multiple psychosocial, family, and environmental factors may influence CPSP, this review will focus on parallels between clinical observations and translational laboratory studies investigating the acute and long-term effects of surgical injury on nociceptive pathways. This includes data related to alterations in sensitivity at different points along nociceptive pathways from the periphery to the brain; age- and sex-dependent mechanisms underlying the transition from acute to persistent pain; potential targets for preventive interventions; and the impact of prior surgical injury. Ongoing preclinical studies evaluating age- and sex-dependent mechanisms will also inform comparative efficacy and preclinical safety assessments of potential preventive pharmacological interventions aimed at reducing the risk of CPSP. In future clinical studies, more detailed and longitudinal peri-operative phenotyping with patient- and parent-reported chronic pain core outcomes, alongside more specialized evaluations of somatosensory function, modulation, and circuitry, may enhance understanding of individual variability in postsurgical pain trajectories and improve recognition and management of CPSP.
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Affiliation(s)
- Suellen M. Walker
- Clinical Neurosciences (Pain Research), Developmental Neurosciences, UCL GOS Institute of Child Health, London, UK; Department of Paediatric Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Cobo MM, Hartley C, Gursul D, Andritsou F, van der Vaart M, Schmidt Mellado G, Baxter L, Duff EP, Buckle M, Evans Fry R, Green G, Hoskin A, Rogers R, Adams E, Moultrie F, Slater R. Quantifying noxious-evoked baseline sensitivity in neonates to optimise analgesic trials. eLife 2021; 10:e65266. [PMID: 33847561 PMCID: PMC8087440 DOI: 10.7554/elife.65266] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/17/2021] [Indexed: 01/18/2023] Open
Abstract
Despite the high burden of pain experienced by hospitalised neonates, there are few analgesics with proven efficacy. Testing analgesics in neonates is experimentally and ethically challenging and minimising the number of neonates required to demonstrate efficacy is essential. EEG (electroencephalography)-derived measures of noxious-evoked brain activity can be used to assess analgesic efficacy; however, as variability exists in neonate's responses to painful procedures, large sample sizes are often required. Here, we present an experimental paradigm to account for individual differences in noxious-evoked baseline sensitivity which can be used to improve the design of analgesic trials in neonates. The paradigm is developed and tested across four observational studies using clinical, experimental, and simulated data (92 neonates). We provide evidence of the efficacy of gentle brushing and paracetamol, substantiating the need for randomised controlled trials of these interventions. This work provides an important step towards safe, cost-effective clinical trials of analgesics in neonates.
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Affiliation(s)
- Maria M Cobo
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y AmbientalesQuitoEcuador
| | - Caroline Hartley
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Deniz Gursul
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | | | | | | | - Luke Baxter
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Eugene P Duff
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Wellcome Centre for Integrative Neuroimaging, University of OxfordOxfordUnited Kingdom
| | - Miranda Buckle
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Ria Evans Fry
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Gabrielle Green
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Amy Hoskin
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Richard Rogers
- Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
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5
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Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, Birnie KA, Anderson BJ, Chambers CT, Crombez G, Ljungman G, Jordan I, Jordan Z, Roberts C, Schechter N, Sieberg CB, Tibboel D, Walker SM, Wilkinson D, Wood C. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:47-87. [PMID: 33064998 DOI: 10.1016/s2352-4642(20)30277-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK; Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium.
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paula Forgeron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, ON, Canada
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, AB, Canada
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Christine T Chambers
- Department of Psychology and Neuroscience, and Department of Pediatrics, Dalhousie University, Halifax, NS, Canada; Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Geert Crombez
- Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium
| | - Gustaf Ljungman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Neil Schechter
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | - Christine B Sieberg
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suellen M Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Chantal Wood
- Department of Spine Surgery and Neuromodulation, Poitiers University Hospital, Poitiers, France
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André V, Durier V, Beuchée A, Roué JM, Lemasson A, Hausberger M, Sizun J, Henry S. Higher tactile sensitivity in preterm infants at term-equivalent age: A pilot study. PLoS One 2020; 15:e0229270. [PMID: 32134950 PMCID: PMC7058305 DOI: 10.1371/journal.pone.0229270] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 02/03/2020] [Indexed: 01/11/2023] Open
Abstract
Despite a growing body of research on perinatal sensory abilities, data on the extent of tactile sensitivity and more particularly passive touch (i.e. sensitivity to a stimulation imposed on the skin) are relatively limited, and the development and processing of tactile function are still thus little known. This question is particularly of high importance for infants with atypical early development such as those born prematurely who are exposed to many sensory (including tactile) stimulations (being in a hospital setting) during a critical period of brain development and those born at early term whose birth occurs at the precise time of cortical reorganization, in particular in the sensory areas. Some parents and health-care providers have for instance reported that children born prematurely exhibit atypical (e.g. higher) sensitivity to “benign” tactile stimuli. In the present study, we hypothesized that preterm and early-term infants may show altered tactile sensitivity. We compared the behavioral responses around term-equivalent age of infants born either pre-term, early-term or at term to the application of a light (0.008 grams) mechanical stimulus. We found that almost all preterm infants perceive this tactile stimulus, contrarily to the two other groups of infants. This extreme tactile sensitivity may be due to experiential, maturational or more likely both processes. We also compared the tactile sensitivity of these infants to that of adults. We found that adults were irresponsive to the light mechanical stimulus. This finding opens not only new insights in understanding development of tactile processing, but also new lines of thought about the particular sensory world of premature and early-term infants and hence about the potential impact of early care practices.
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Affiliation(s)
- Vanessa André
- Univ Rennes, Normandie Univ, CNRS, EthoS (Éthologie Animale et Humaine)-UMR 6552, Rennes, France
| | - Virginie Durier
- Univ Rennes, Normandie Univ, CNRS, EthoS (Éthologie Animale et Humaine)-UMR 6552, Rennes, France
| | - Alain Beuchée
- Unité de Soins Intensifs Néonatals, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Jean-Michel Roué
- Unité de Soins Intensifs Néonatals, Centre Hospitalier Régional et Universitaire de Brest, Brest, France
| | - Alban Lemasson
- Univ Rennes, Normandie Univ, CNRS, EthoS (Éthologie Animale et Humaine)-UMR 6552, Rennes, France
| | - Martine Hausberger
- Univ Rennes, Normandie Univ, CNRS, EthoS (Éthologie Animale et Humaine)-UMR 6552, Rennes, France
| | - Jacques Sizun
- Unité de Soins Intensifs Néonatals, Centre Hospitalier Régional et Universitaire de Brest, Brest, France
| | - Séverine Henry
- Univ Rennes, Normandie Univ, CNRS, EthoS (Éthologie Animale et Humaine)-UMR 6552, Rennes, France
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Anand KJS. Defining pain in newborns: need for a uniform taxonomy? Acta Paediatr 2017; 106:1438-1444. [PMID: 28556311 PMCID: PMC5601230 DOI: 10.1111/apa.13936] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/15/2017] [Accepted: 05/24/2017] [Indexed: 12/18/2022]
Abstract
A framework for defining pain terms such as acute, persistent, prolonged or chronic pain to newborns was derived from the scientific literature on neonatal pain assessments, previous attempts to define chronic pain and the clinical and neurophysiological features of neonatal pain. This novel framework incorporates the temporal features, localising characteristics, and secondary effects of the pain experienced, as well as the behavioural and physiological response patterns of newborns. CONCLUSION Although not evidence-based, this framework provides an initial starting point for defining commonly used neonatal pain terms. It will require future revision/refinement based on the accumulating evidence for non-acute pain.
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Abstract
To provide an updated synthesis of the current state of the evidence for the effectiveness of breast-feeding and expressed breast milk feeding in reducing procedural pain in preterm and full-term born infants. A systematic search of key electronic databases (PubMed, CINAHL, EMBASE) was completed. Of the 1032 abstracts screened, 21 were found eligible for inclusion. Fifteen studies reported on the use of breast-feeding or expressed breast milk in full-term infants and 6 reported on preterm infants. Direct breast-feeding was more effective than maternal holding, maternal skin-to-skin contact, topical anesthetics, and music therapy, and was as or more effective than sweet tasting solutions in full-term infants. Expressed breast milk was not consistently found to reduce pain response in full-term or preterm infants. Studies generally had moderate to high risk of bias. There is sufficient evidence to recommend direct breast-feeding for procedural pain management in full-term infants. Based on current evidence, expressed breast milk alone should not be considered an adequate intervention.
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10
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Schnabel A, Reichl SU, Meyer‐Frießem C, Zahn PK, Pogatzki‐Zahn E. Tramadol for postoperative pain treatment in children. Cochrane Database Syst Rev 2015; 2015:CD009574. [PMID: 25785365 PMCID: PMC6464560 DOI: 10.1002/14651858.cd009574.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND According to current recommendations a multimodal approach is believed to be the gold standard for postoperative pain treatment in children. However, several surveys in the last few years demonstrated that postoperative pain in children is still a serious problem, mainly because opioids are avoided. One of the reasons for this is the fear of severe adverse events following opioid administration. Tramadol is a weak mu-opioid agonist and inhibits reuptake of noradrenaline and serotonin (5HT). Because of a relatively wide therapeutic window and a ceiling effect with a lower risk for severe adverse events (for example respiratory depression) tramadol is a widely used opioid in children. However, the exact efficacy and occurrence of adverse events following tramadol (in comparison with placebo or other opioids) for postoperative pain treatment in children and adolescents are currently not clear. OBJECTIVES To assess the effectiveness and side effect profile of tramadol for postoperative pain relief in children and adolescents undergoing different surgical procedures. SEARCH METHODS We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 6), MEDLINE via PubMed (January 1966 to July 2014) and EMBASE via Ovid (January 1947 to July 2014). There were no restrictions regarding language or date of publication. The reference lists of all included trials were checked for additional studies. SELECTION CRITERIA All randomised controlled clinical trials investigating the perioperative administration of tramadol compared to placebo or other opioids for postoperative pain treatment in children and adolescents were included. DATA COLLECTION AND ANALYSIS Three review authors independently assessed the study eligibility, performed the data extraction and assessed the risk of bias of included trials. MAIN RESULTS Twenty randomised controlled trials involving 1170 patients were included in this systematic review. The overall risk of bias in included trials was assessed as unclear, because concealment of allocation processes and blinding of outcome assessors were poorly described. Due to inconsistent outcome reporting, data from 17 included trials could be pooled for some endpoints only. Eight trials compared tramadol administration with placebo and five trials found that the need for rescue analgesia in the postoperative care unit (PACU) was reduced in children receiving tramadol (RR 0.40; 95% CI 0.20 to 0.78; low quality evidence). Only one trial investigated the number of patients with moderate to severe pain, but a non-validated pain scale was used (very low quality evidence). Four trials compared morphine with tramadol administration. There was no clear evidence of difference in the need for rescue analgesia in the PACU (RR 1.25; 95% CI 0.83 to 1.89; low quality evidence) with tramadol compared with morphine. No trials could be pooled for the outcome 'number of patients with moderate to severe pain'. Three trials were included for the comparison of tramadol with nalbuphine. There was no clear evidence for the need for rescue analgesia in the PACU (RR 0,63; 95% CI 0.16 to 2.45; low quality evidence). Only one trial reported the number of patients with moderate to severe pain, but used a non-validated pain scale (very low quality evidence). Two out of six included trials, which compared pethidine with tramadol, reported the number of children with a need for rescue analgesia within the PACU and showed no clear evidence (RR 0.93; 95% CI 0.43 to 2.02; very low quality evidence). Two trials reported the number of patients with moderate to severe pain and showed a lower RR in patients treated with tramadol (RR 0.64; 95% CI 0.36 to 1.16; low quality evidence). Only one trial was included, which compared tramadol with fentanyl, reporting the number of patients with the need for rescue analgesia (very low quality evidence). Generally, adverse events were poorly reported. Most data could be pooled for the comparison with placebo focusing on the RR for postoperative nausea and vomiting (PONV) in the postoperative care unit and 24 h postoperation. Children treated with tramadol, compared to placebo, did not show clear evidence of benefit for PONV in the postoperative care unit (RR 0.84; 95% CI 0.28 to 2.52; moderate quality evidence) and 24 h postoperation (RR 0.78; 95% CI 0.54 to 1.12; moderate quality evidence). AUTHORS' CONCLUSIONS The overall evidence regarding tramadol for postoperative pain in children is currently low or very low and should be interpreted with caution due to small studies and methodological problems (different validated and non-validated pain scales with different pain triggers, missing sample size calculations and missing intention-to-treat analysis). Nevertheless, we demonstrated that tramadol administration might provide appropriate analgesia when compared to placebo; this is based on results showing reduced rescue analgesia in children treated with tramadol compared to placebo. In contrast, the evidence regarding the comparison with other opioids (for example morphine) was uncertain. Adverse events were only poorly reported, so an accurate risk-benefit analysis was not possible.
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Affiliation(s)
- Alexander Schnabel
- University Hospital MünsterDepartment of Anaesthesiology, Intensive Care and Pain MedicineAlbert‐Schweitzer‐Campus 1, Gebäude AMünsterGermany48149
| | - Sylvia U Reichl
- Paracelsus Medical UniversityDepartment of Anesthesiology, Perioperative and Intensive Care MedicineSalzburgAustria
| | - Christine Meyer‐Frießem
- Universitatsklinikum Bergmannsheil GmbH BochumDepartment of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain ManagementRuhr UniversityBochumGermany
| | - Peter K Zahn
- Universitatsklinikum Bergmannsheil GmbH BochumDepartment of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain ManagementRuhr UniversityBochumGermany
| | - Esther Pogatzki‐Zahn
- University Hospital MünsterDepartment of Anesthesiology, Intensive Care and Pain MedicineMünsterGermany
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Abstract
Effective management of procedural and postoperative pain in neonates is required to minimize acute physiological and behavioral distress and may also improve acute and long-term outcomes. Painful stimuli activate nociceptive pathways, from the periphery to the cortex, in neonates and behavioral responses form the basis for validated pain assessment tools. However, there is an increasing awareness of the need to not only reduce acute behavioral responses to pain in neonates, but also to protect the developing nervous system from persistent sensitization of pain pathways and potential damaging effects of altered neural activity on central nervous system development. Analgesic requirements are influenced by age-related changes in both pharmacokinetic and pharmacodynamic response, and increasing data are available to guide safe and effective dosing with opioids and paracetamol. Regional analgesic techniques provide effective perioperative analgesia, but higher complication rates in neonates emphasize the importance of monitoring and choice of the most appropriate drug and dose. There have been significant improvements in the understanding and management of neonatal pain, but additional research evidence will further reduce the need to extrapolate data from older age groups. Translation into improved clinical care will continue to depend on an integrated approach to implementation that encompasses assessment and titration against individual response, education and training, and audit and feedback.
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Affiliation(s)
- Suellen M Walker
- Correspondence Suellen Walker, Portex Unit: Pain Research; 6th Floor Cardiac Wing, UCL Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK,
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Prolonged Amelioration of Experimental Postoperative Pain by Bupivacaine Released From Microsphere-Coated Hernia Mesh. Reg Anesth Pain Med 2014; 39:97-107. [DOI: 10.1097/aap.0000000000000062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nagi SS, Mahns DA. Mechanical allodynia in human glabrous skin mediated by low-threshold cutaneous mechanoreceptors with unmyelinated fibres. Exp Brain Res 2013; 231:139-51. [PMID: 23955107 DOI: 10.1007/s00221-013-3677-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/04/2013] [Indexed: 12/21/2022]
Abstract
We recently showed that C-tactile fibres (CTs) in human hairy skin (anterior leg) mediate crossover between innocuous touch and noxious touch, i.e. mechanical allodynia. Although there is no evidence for existence of a phenotypically identical class of CTs in human glabrous skin, the 'qualia' of affective stimuli are comparable across skin types. In 42 healthy subjects, muscle pain was induced by infusing hypertonic saline (5 %) into flexor carpi ulnaris muscle. Concurrently, sinusoidal vibration (200 Hz-200 μm) was applied to glabrous skin of little finger. The neural substrate of allodynia was determined by employing conduction blocks of myelinated (ulnar nerve compression) and unmyelinated (low-dose intra-dermal anaesthesia) fibres. In order to compare the expression of allodynia across spinal segments and skin types, vibration was also applied to glabrous skin of index finger and hairy skin of dorsal forearm. In addition, high-precision brushing stimuli were applied at speeds of 1.0 and 3.0 cm s(-1) to digital glabrous skin with absent myelinated fibres. During muscle pain, vibration caused a significant and reproducible increase in pain (allodynia). This effect persisted during blockade of myelinated fibres, but was abolished by inactivation of unmyelinated cutaneous fibres. The vibration-evoked effects were found to be comparable across spinal segments and skin types. Furthermore, brushing produced a near-identical expression of C-fibre-mediated allodynia. Prior to induction and upon cessation of muscle pain, vibration and brushing were reported as non-painful. Based on these results, we postulate that a functional homologue of the CTs (hairy skin) mediates allodynia in human glabrous skin.
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Affiliation(s)
- Saad S Nagi
- Department of Integrative Physiology, School of Medicine, University of Western Sydney, Locked Bag 1797, Penrith, Sydney, NSW, 2751, Australia
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14
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Ohri R, Wang JCF, Blaskovich PD, Pham LN, Costa DS, Nichols GA, Hildebrand WP, Scarborough NL, Herman CJ, Strichartz GR. Inhibition by local bupivacaine-releasing microspheres of acute postoperative pain from hairy skin incision. Anesth Analg 2013; 117:717-730. [PMID: 23921651 DOI: 10.1213/ane.0b013e3182a00851] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acute postoperative pain causes physiological deficits and slows recovery. Reduction of such pain by local anesthetics that are delivered for several days postoperatively is a desirable clinical objective, which is approached by a new formulation and applied in animal studies reported here. METHODS We subcutaneously injected a new formulation of poly-lactic-co-glycolic acid polymer microspheres, which provides steady drug release for 96+ hours into rats at the dorsal region 2 hours before surgery. A single 1.2-cm-long skin incision was followed by blunt dissection of skin away from the underlying fascia, and closed by 2 sutures, followed by 14 days of testing. Microspheres containing 5, 10, 20, and 40 mg bupivacaine were injected locally 2 hours before surgery; bupivacaine-free microspheres were the vehicle control, and bupivacaine HCl solution (0.5%), the positive control. Mechanical sensitivity was determined by the frequency of local muscle contractions to repeated pokes with nylon monofilaments (von Frey hairs) exerting 4 and 15 g forces, testing, respectively, allodynia and hyperalgesia, and by pinprick. RESULTS Injection of bupivacaine microspheres (40 mg drug) into intact skin reduced responses to 15 g von Frey hairs for 6 hours and to pinprick for 36 hours. Respective reductions from bupivacaine HCl lasted for 3 and 2 hours. Skin incision and dissection alone caused mechanical allodynia and hyperalgesia for 14 days. Microspheres containing 20 or 40 mg bupivacaine suppressed postoperative hypersensitivity for up to 3 days, reduced integrated allodynia (area under curve of response versus time) over postoperative days 1 to 5 by 51% ± 20% (mean ± SE) and 78% ± 12%, and reduced integrated hyperalgesia by 55% ± 13% and 64% ± 11%, for the respective doses. Five and ten milligrams bupivacaine in microspheres and the 0.5% bupivacaine solution were ineffective in reducing postoperative hypersensitivity, as were 40 mg bupivacaine microspheres injected contralateral to the incision. CONCLUSIONS Significant suppression of postoperative pain by the slow-release bupivacaine preparation outlasts its anesthetic action on intact skin. These findings demonstrate preventive analgesia and indicate the importance of acute processes in the development of chronic postoperative pain.
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Affiliation(s)
- Rachit Ohri
- Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115-6110.
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15
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Long term effects of pain-related stress on neurodevelopment and pain perception of infants born very prematurely. ENFANCE 2013. [DOI: 10.4074/s0013754513001043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Grunau RE. Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. Rambam Maimonides Med J 2013; 4:e0025. [PMID: 24228168 PMCID: PMC3820298 DOI: 10.5041/rmmj.10132] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Effects of early life psychosocial adversity have received a great deal of attention, such as maternal separation in experimental animal models and abuse/neglect in young humans. More recently, long-term effects of the physical stress of repetitive procedural pain have begun to be addressed in infants hospitalized in neonatal intensive care. Preterm infants are more sensitive to pain and stress, which cannot be distinguished in neonates. The focus of this review is clinical studies of long-term effects of repeated procedural pain-related stress in the neonatal intensive care unit (NICU) in relation to brain development, neurodevelopment, programming of stress systems, and later pain sensitivity in infants born very preterm (24-32 weeks' gestational age). Neonatal pain exposure has been quantified as the number of invasive and/or skin-breaking procedures during hospitalization in the NICU. Emerging studies provide convincing clinical evidence for an adverse impact of neonatal pain/stress in infants at a time of physiological immaturity, rapidly developing brain microstructure and networks, as well as programming of the hypothalamic-pituitary-adrenal axis. Currently it appears that early pain/stress may influence the developing brain and thereby neurodevelopment and stress-sensitive behaviors, particularly in the most immature neonates. However, there is no evidence for greater prevalence of pain syndromes compared to children and adults born healthy at full term. In addressing associations between pain/stress and outcomes, careful consideration of confounding clinical factors related to prematurity is essential. The need for pain management for humanitarian care is widely advocated. Non-pharmacological interventions to help parents reduce their infant's stress may be brain-protective.
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Affiliation(s)
- Ruth Eckstein Grunau
- Department of Pediatrics, University of British Columbia and Child & Family Research Institute, Vancouver, Canada; and School of Nursing and Midwifery, Queen's University Belfast, UK
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17
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Early life adversity as a risk factor for fibromyalgia in later life. PAIN RESEARCH AND TREATMENT 2011; 2012:140832. [PMID: 22110940 PMCID: PMC3196867 DOI: 10.1155/2012/140832] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 07/25/2011] [Indexed: 12/03/2022]
Abstract
The impact of early life events is increasingly becoming apparent, as studies investigate how early childhood can shape long-term physiology and behaviour. Fibromyalgia (FM), which is characterised by increased pain sensitivity and a number of affective co-morbidities, has an unclear etiology. This paper discusses risk factors from early life that may increase the occurrence or severity of FM in later life: pain experience during neonatal life causes long-lasting changes in nociceptive circuitry and increases pain sensitivity in the older organism; premature birth and related stressor exposure cause lasting changes in stress responsivity; maternal deprivation affects anxiety-like behaviours that may be partially mediated by epigenetic modulation of the genome—all these adult phenotypes are strikingly similar to symptoms displayed by FM sufferers. In addition, childhood trauma and exposure to substances of abuse may cause lasting changes in developing neurotransmitter and endocrine circuits that are linked to anxiety and stress responses.
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Werner MU, Rotbøll-Nielsen P, Ellehuus-Hilmersson C. Humidity affects the performance of von Frey monofilaments. Acta Anaesthesiol Scand 2011; 55:577-82. [PMID: 21827443 DOI: 10.1111/j.1399-6576.2011.02426.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Assessment of tactile and nociceptive thresholds of the skin with calibrated polyamide monofilaments is an established testing method both in animal and in human research. It is known that changes in relative humidity may affect the physical properties of the monofilaments. As this effect has only been studied in very small diameter monofilaments, used in neonatal research, we therefore studied complete sets of polyamide monofilaments. METHODS The effects were studied in a controlled climate chamber during six incremental changes in relative humidity from 20% to 79% (22-24°C). Following 24 h of equilibration at each humidity level, calibration with a precision scale was performed. RESULTS A highly significant linear correlation between the natural logarithm (In) of the bending force and the von Frey number was observed at all humidity levels (r(2)>0.99, P<0.0001). An inverse linear relationship between relative humidity and In of the bending force for each monofilament was found (r(2)=0.95, P<0.0001). One percent increase in relative humidity corresponded to a 1-4% relative decrease in numerical bending force, depending on the diameter of the monofilament. A significant linear relationship was observed between the coefficient of variation and the relative humidity (r(2)=0.87, P<0.001). CONCLUSIONS The data indicate that the hygroscopic properties of polyamide monofilaments must be taken into account for their reliable use in quantitative sensory testing.
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Affiliation(s)
- M U Werner
- Multidisciplinary Pain Center, Rigshospitalet, Copenhagen University Hospitals, Blegdamsvej, Denmark.
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LaPrairie JL, Murphy AZ. Long-term impact of neonatal injury in male and female rats: Sex differences, mechanisms and clinical implications. Front Neuroendocrinol 2010; 31:193-202. [PMID: 20144647 PMCID: PMC2849925 DOI: 10.1016/j.yfrne.2010.02.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/01/2010] [Accepted: 02/03/2010] [Indexed: 02/07/2023]
Abstract
Over the last several decades, the relative contribution of early life events to individual disease susceptibility has been explored extensively. Only fairly recently, however, has it become evident that abnormal or excessive nociceptive activity experienced during the perinatal period may permanently alter the normal development of the CNS and influence future responses to somatosensory input. Given the significant rise in the number of premature infants receiving high-technology intensive care over the last 20 years, ex-preterm neonates may be exceedingly vulnerable to the long-term effects of repeated invasive interventions. The present review summarizes available clinical and laboratory findings on the lasting impact of exposure to noxious stimulation during early development, with a focus on the structural and functional alterations in nociceptive circuits, and its sexually dimorphic impact.
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Affiliation(s)
- Jamie L LaPrairie
- Neuroscience Institute, Georgia State University, 38 Peachtree Center Ave, 806 GCB, Atlanta, GA 30303, USA
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20
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Fitzgerald M, Walker SM. Infant pain management: a developmental neurobiological approach. ACTA ACUST UNITED AC 2009; 5:35-50. [DOI: 10.1038/ncpneuro0984] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 10/31/2008] [Indexed: 12/21/2022]
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Abstract
The concept of fetal pain is becoming more and more relevant since the possibilities for invasive intrauterine treatment are increasing. However, there is much debate as to whether the fetus is mature enough to be able to perceive pain. But what is ‘pain’? One cannot determine whether a fetus feels pain unless one has a conception of what pain is. There is a difference in opinion about what pain really is and that is also the difficulty in studies on fetal pain: we cannot simply ask the fetus whether or not it feels pain. We can only give indirect evidence of possible harmful effects of stressful stimuli on the developing fetus. In this review we will first explore the meaning of ‘pain’. We will then discuss fetal anatomic, neurophysiologic and behavioural development and the responses which are thought to be required to experience pain. Finally, we discuss some ethical considerations and suggestions on fetal anaesthesia.
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22
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Abstract
Significant advances in the assessment and management of acute pain in children have been made, and are supported by an increase in the availability and accessibility of evidence-based data. However, methodological and practical issues in the design and performance of clinical paediatric trials limit the quantity, and may influence the quality, of current data, which lags behind that available for adult practice. Collaborations within research networks, which incorporate both preclinical and clinical studies, may increase the feasibility and specificity of future trials. In early life, the developing nervous system responds differently to pain, analgesia, and injury, resulting in effects not seen in later life and which may have long-term consequences. Translational laboratory studies further our understanding of developmental changes in nociceptor pathway structure and function, analgesic pharmacodynamics, and the impact of different forms of injury. Chronic pain in children has a negative impact on quality of life, resulting in social and emotional consequences for both the child and the family. Despite age-related differences in many chronic pain conditions, such as neuropathic pain, management in children is often empirically based on data from studies in adults. There is a major need for further clinical research, training of health-care providers, and increased resources, to improve management and outcomes for children with chronic pain.
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Affiliation(s)
- S M Walker
- Portex Department of Anaesthesia, UCL Institute of Child Health and Great Ormond Street Hospital NHS Trust, 30 Guilford Street, London WC1N 1EH, UK.
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23
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Abdulkader HM, Freer Y, Fleetwood-Walker SM, McIntosh N. Bodily progression of motor responses to increasing mechanical force stimulation in the newborn infant and the effect of heel prick. Neonatology 2008; 94:38-44. [PMID: 18182827 DOI: 10.1159/000112948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 10/01/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND The newborn infant's response to stimulation with von Frey filaments has previously been examined only at the spinal level as the flexion withdrawal response or abdominal reflex. The threshold for the spinal responses has been shown to be lower following skin damage and visceral pathology. Higher forces of mechanical stimulation elicit other body responses, which are likely to arise from higher levels in the nervous system: these have not been investigated before. OBJECTIVE To investigate the newborn infants' responses to increasing forces of mechanical (von Frey filament) stimulation and whether their progression is affected by repeated heel prick. SUBJECTS AND METHODS The study was performed in 31 full term and 77 preterm infants. Graded mechanical forces (using von Frey filaments) were applied to the heels and the abdominal skin. The thresholds for the flexion withdrawal reflex or abdominal reflex and other body responses were recorded. RESULTS The thresholds for the flexion withdrawal reflex and other body movements to graded mechanical force on the heel were significantly lower in preterm infants compared to full term infants. The threshold for the abdominal reflex and other body responses from graded mechanical stimulation of the abdomen was also significantly lower in preterm infants. In all infants thresholds were further reduced following sensitisation from previous heel pricks. The progression of the responses is independent of gestation or prior sensitisation. CONCLUSION Both preterm and full term newborn infants respond to graded mechanical stimuli by a series of body responses, which progress in response to increasing force from a simple spinal withdrawal reflex to more complex responses involving higher levels of the central nervous system.
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Affiliation(s)
- Huda M Abdulkader
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
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24
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Abstract
Although over 40 methods of pain assessment in infants are available for use in clinical practice, unrecognized and under-treated pain remains one of the most commonly reported problems within the Neonatal Intensive Care Units. A number of factors have been found to account for differences in the robustness of the pain response in neonates of varying gestational ages. Discrepancies between behavioral and physiological pain indicators have also been reported. With newer technologies, there is an opportunity not only to verify infant pain perception, but these tools may allow an identification of which of the observed indicators are most sensitive in particular clinical situations. The current controversies regarding pain assessment in preterm and term infants are reviewed to define the most important issues and to develop a dialogue for future directions.
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Affiliation(s)
- Manon Ranger
- McGill University, School of Nursing, Montreal, Canada.
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25
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Affiliation(s)
- K J S Anand
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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26
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Primary and secondary hyperalgesia can be differentiated by postnatal age and ERK activation in the spinal dorsal horn of the rat pup. Pain 2007; 128:157-68. [DOI: 10.1016/j.pain.2006.09.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Revised: 08/27/2006] [Accepted: 09/11/2006] [Indexed: 12/22/2022]
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27
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Santos CF, Calvo AM, Sakai VT, Dionísio TJ, Lauris JRP, Carvalho RM, Trindade AS. The changing pattern of analgesic and anti-inflammatory drug use in cleft lip and palate repair. ACTA ACUST UNITED AC 2006; 102:e16-20. [PMID: 16997088 DOI: 10.1016/j.tripleo.2005.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 11/09/2005] [Accepted: 12/09/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This work aimed at performing a retrospective and comparative investigation of pharmacological therapeutic approach for pain and inflammation control for cleft lip and/or palate repair. STUDY DESIGN Medical charts from 2000 patients who underwent surgical procedures at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC-USP), Brazil, were assessed to obtain information regarding type of cleft, surgical procedure, and analgesic and anti-inflammatory drugs prescribed. The first 1000 consecutive surgeries performed in 1992 and 2002 were assessed. RESULTS Different analgesic and anti-inflammatory agents-nonsteroidal anti-inflammatory drugs (NSAIDS), steroids, and opioids-were given to patients perioperatively and postoperatively. NSAIDS were given to almost all patients (97.03% in 1992 and 99.88% in 2002, P > .05). Steroid administration increased in 2002 (8.66% versus 17.71%, P < .05). Opioids were administered only in 2002 (50.31%, P < .05). CONCLUSION NSAIDS, steroids, and opioids were used for pain and inflammation control in cleft lip and palate repair at HRAC-USP. A change in the pattern of analgesic and anti-inflammatory drug use was observed when comparing 1992 and 2002. More potent compounds, such as opioids, were used in 2002 in a significant percentage of all the surgical procedures.
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Affiliation(s)
- Carlos F Santos
- Discipline of Pharmacology, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil.
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28
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Miranda A, Peles S, Shaker R, Rudolph C, Sengupta JN. Neonatal nociceptive somatic stimulation differentially modifies the activity of spinal neurons in rats and results in altered somatic and visceral sensation. J Physiol 2006; 572:775-87. [PMID: 16513666 PMCID: PMC1779998 DOI: 10.1113/jphysiol.2006.108258] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The role ofintramuscular, low pH saline injections during the neonatal period in the development and maintenance of visceral hyperalgesia has not been systematically studied. We aimed to investigate alterations in visceral sensation and neural circuitry that result from noxious stimuli in early life. Neonatal male Sprague-Dawley rats received sterile saline injections of pH 4.0 or 7.4 in the gastrocnemius muscle starting at postnatal day 8. Injections were given unilaterally every other day for 12 days ending on postnatal day 20. A third group received needle prick only on the same shedule as the second group, while a fourth group was left naïve. At 2 months of age, rats underwent assessment of cutaneous and deep somatic sensitivity using von Frey filaments and gastrocnemius muscle pinch, respectively. A visceromotor response (VMR) to graded colorectal distension (CRD; 10-80 mmHg for 30 s with 180 s interstimulus intervals) was recorded. Extracellular single-unit recordings from the thoracolumbar spinal neurons (T13-L1) were performed in adult pH 4.0 injected and naïve controls. There was no difference in the threshold for response to mechanical stimulation of the paw in rats injected with pH 4.0 saline compared to all other groups. Conversely, rats treated with pH 4.0 saline showed a significant bilateral reduction in withdrawal threshold to muscle pinch as adults (P < 0.05). At colorectal distensions > or = 20 mmHg, an increase in the VMR was observed in the pH 4.0 injected group compared to all other groups (P < 0.05). Spinal neurons were classified as short latency abrupt (SL-A) or short latency sustained (SL-S). Spontaneous firing of SL-S (20.6 +/- 2.2 impulses s(-1)), but not SL-A neurons (5.3 +/- 0.9 impulses s(-1)) in the pH 4.0 treated rats was significantly higher than in control rats (SL-S, 2.6 +/- 0.8 impulses s(-1); SL-A, 3.1 +/- 0.7 impulses s(-1)). The response of SL-S neurons to CRD in the pH 4.0 group was significantly higher at distension pressures > or = 20 mmHg. Nociceptive somatic stimulation in neonatal rats results in chronic deep somatic and visceral hyperalgesia in adulthood. Colorectal distension-sensitive SL-S neurons are primarily sensitized to neonatal somatic stimulation.
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Affiliation(s)
- Adrian Miranda
- Division of Gastroenterology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
The low tactile threshold in preterm infants when they are in the neonatal intensive care unit (NICU), while their physiological systems are unstable and immature, potentially renders them more vulnerable to the effects of repeated invasive procedures. There is a small but growing literature on pain and tactile responsivity following procedural pain in the NICU, or early surgery. Long-term effects of repeated pain in the neonatal period on neurodevelopment await further research. However, there are multiple sources of stress in the NICU, which contribute to inducing high overall 'allostatic load', therefore determining specific effects of neonatal pain in human infants is challenging.
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Affiliation(s)
- Ruth E Grunau
- Centre for Community Child Health Research, Child and Family Research Institute, Vancouver, Canada.
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30
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Anand KJS, Aranda JV, Berde CB, Buckman S, Capparelli EV, Carlo W, Hummel P, Johnston CC, Lantos J, Tutag-Lehr V, Lynn AM, Maxwell LG, Oberlander TF, Raju TNK, Soriano SG, Taddio A, Walco GA. Summary proceedings from the neonatal pain-control group. Pediatrics 2006; 117:S9-S22. [PMID: 16777824 DOI: 10.1542/peds.2005-0620c] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recent advances in neurobiology and clinical medicine have established that the fetus and newborn may experience acute, established, and chronic pain. They respond to such noxious stimuli by a series of complex biochemical, physiologic, and behavioral alterations. Studies have concluded that controlling pain experience is beneficial with respect to short-term and perhaps long-term outcomes. Yet, pain-control measures are adopted infrequently because of unresolved scientific issues and lack of appreciation for the need for control of pain and its long-term sequelae during the critical phases of neurologic maturation in the preterm and term newborn. The neonatal pain-control group, as part of the Newborn Drug Development Initiative (NDDI) Workshop I, addressed these concerns. The specific issues addressed were (1) management of pain associated with invasive procedures, (2) provision of sedation and analgesia during mechanical ventilation, and (3) mitigation of pain and stress responses during and after surgery in the newborn infant. The cross-cutting themes addressed within each category included (1) clinical-trial designs, (2) drug prioritization, (3) ethical constraints, (4) gaps in our knowledge, and (5) future research needs. This article provides a summary of the discussions and deliberations. Full-length articles on procedural pain, sedation and analgesia for ventilated infants, perioperative pain, and study designs for neonatal pain research were published in Clinical Therapeutics (June 2005).
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Affiliation(s)
- Kanwaljeet J S Anand
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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Blom JMC, Benatti C, Alboni S, Capone G, Ferraguti C, Brunello N, Tascedda F. Early postnatal chronic inflammation produces long-term changes in pain behavior and N-methyl-D-aspartate receptor subtype gene expression in the central nervous system of adult mice. J Neurosci Res 2006; 84:1789-98. [PMID: 17016858 DOI: 10.1002/jnr.21077] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The objective of this study was to test whether postnatal chronic inflammation resulted in altered reactivity to pain later in life when reexposed to the same inflammatory agent and whether this alteration correlated with brain-region-specific patterns of N-methyl-D-aspartate (NMDA) receptor subtype gene expression. Neonatal mouse pups received a single injection of complete Freund's adjuvant (CFA) or saline into the left hind paw on postnatal day 1 or 14. At 12 weeks of age, both neonatal CFA- and saline-treated animals received a unilateral injection of CFA in the left hind paw. Adult behavioral responsiveness of the left paw to a radiant heat source was determined in mice treated neonatally with saline or CFA before and after receiving CFA as adults. Twenty-four hours later, brains were dissected and NMDA receptor subunit gene expression was determined in four different brain areas by using an RNase protection assay. The results indicated that NMDA receptor subtype gene expression in adult mice exposed to persistent neonatal peripheral inflammation was brain region specific and that NMDA gene expression and pain reactivity differed according to the day of neonatal CFA exposure. Similarly, adult behavioral responsiveness to a noxious radiant heat source differed according to the age of neonatal exposure to CFA. The data suggest a possible molecular basis for the hypothesis that chronic persistent inflammation experienced early during development may permanently alter the future behavior and the sensitivity to pain later in life, especially in response to subsequent or recurrent inflammatory events.
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Affiliation(s)
- Joan M C Blom
- Department of Pediatrics, University Hospital of Modena, Modena, Italy.
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32
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Anand KJS, Aranda JV, Berde CB, Buckman S, Capparelli EV, Carlo WA, Hummel P, Lantos J, Johnston CC, Lehr VT, Lynn AM, Maxwell LG, Oberlander TF, Raju TNK, Soriano SG, Taddio A, Walco GA. Analgesia and anesthesia for neonates: Study design and ethical issues. Clin Ther 2005; 27:814-43. [PMID: 16117988 DOI: 10.1016/j.clinthera.2005.06.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this article is to summarize the clinical, methodologic, and ethical considerations for researchers interested in designing future trials in neonatal analgesia and anesthesia, hopefully stimulating additional research in this field. METHODS The MEDLINE, PubMed, EMBASE, and Cochrane register databases were searched using subject headings related to infant, newborn, neonate, analgesia, anesthesia, ethics, and study design. Cross-references and personal files were searched manually. Studies reporting original data or review articles related to these topics were assessed and critically evaluated by experts for each topical area. Data on population demographics, study characteristics, and cognitive and behavioral outcomes were abstracted and synthesized in a systematic manner and refined by group members. Data synthesis and results were reviewed by a panel of independent experts and presented to a wider audience including clinicians, scientists, regulatory personnel, and industry representatives at the Newborn Drug Development Initiative workshop. Recommendations were revised after extensive discussions at the workshop and between committee members. RESULTS Designing clinical trials to investigate novel or currently available approaches for analgesia and anesthesia in neonates requires consideration of salient study designs and ethical issues. Conditions requiring treatment include pain/stress resulting from invasive procedures, surgical operations, inflammatory conditions, and routine neonatal intensive care. Study design considerations must define the inclusion and exclusion criteria, a rationale for stratification, the confounding effects of comorbid conditions, and other clinical factors. Significant ethical issues include the constraints of studying neonates, obtaining informed consent, making risk-benefit assessments, defining compensation or rewards for participation, safety considerations, the use of placebo controls, and the variability among institutional review boards in interpreting federal guidelines on human research. For optimal study design, investigators must formulate well-defined study questions, choose appropriate trial designs, estimate drug efficacy, calculate sample size, determine the duration of the studies, identify pharmacokinetic and pharmacodynamic parameters, and avoid drug-drug interactions. Specific outcome measures may include scoring on pain assessment scales, various biomarkers and their patterns of response, process outcomes (eg, length of stay, time to extubation), intermediate or long-term outcomes, and safety parameters. CONCLUSIONS Much more research is needed in this field to formulate a scientifically sound, evidence-based, and clinically useful framework for management of anesthesia and analgesia in neonates. Newer study designs and additional ethical dilemmas may be defined with accumulating data in this field.
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Affiliation(s)
- K J S Anand
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.
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Abstract
It is not known if the fetus can actually feel pain, but noxious stimulation during fetal life does cause detectable stress responses. These responses cause both short and long-term changes in the central nervous system, which can affect subsequent pain behaviour. Reducing the stress response is known to be beneficial in children and adults and recent evidence suggests this is also true for the fetus. However, the optimal amount of suppression required and the best method of achieving this (opioid or regional anaesthesia techniques) remain unknown. Prevention and treatment of pain is a basic human right, regardless of age, and if the technique of fetal surgery is to progress then a greater understanding of nociception and the stress response is required.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Bristol School of Anaesthesia, Southmead Hospital, Southmead Road, Bristol BS10 5NB, UK
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Bibliography Current World Literature. Curr Opin Anaesthesiol 2003. [DOI: 10.1097/01.aco.0000084472.59960.ce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Andrews KA, Desai D, Dhillon HK, Wilcox DT, Fitzgerald M. Abdominal sensitivity in the first year of life: comparison of infants with and without prenatally diagnosed unilateral hydronephrosis. Pain 2002; 100:35-46. [PMID: 12435457 DOI: 10.1016/s0304-3959(02)00288-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There are few studies on visceral pain in infants, despite its clinical importance. We have used the abdominal skin reflex (ASR) to measure changes in abdominal sensitivity in the presence of visceral pathology in infants. The reflex was elicited by applying calibrated von Frey hairs to each side of the abdomen and the mechanical threshold and the degree of reflex radiation as denoted by hip flexion were measured. The developmental progression of ASR properties during the first year of life was studied in a cross-sectional sample of healthy infants ranging from 30 to 95 weeks postconceptional age (PCA). These properties were compared to those in infants with unilateral hydronephrosis (UH) using a blinded protocol. Infants with UH were studied at their first outpatient appointment after birth, and postoperatively following surgery if this was indicated. The investigators were blinded to laterality and severity of hydronephrosis until data were analysed, or until surgery. A total of 30 patients with UH and 77 healthy infants were included in the study. In 21 (70%) patients, the side of hydronephrosis had a significantly lower ASR threshold than the contralateral side of the abdomen. There was a significant increase in reflex threshold and decrease in reflex radiation with increasing PCA in control infants. However, in UH infants, this relationship did not exist, even on the unaffected side of the abdomen.Our results show that infants with prenatally diagnosed UH demonstrate increased abdominal sensitivity compared with control infants. Using the ASR, we have provided the first evidence of referred visceral hypersensitivity in infants.
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Affiliation(s)
- K A Andrews
- Children Nationwide Paediatric Pain Research Centre, Department of Anatomy, University College London, Gower Street, London WC1E 6BT, UK.
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