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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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Selvanathan T, Miller SP. Factors affecting brain maturation trajectories in early childhood. Lancet Neurol 2024; 23:456-458. [PMID: 38631757 DOI: 10.1016/s1474-4422(24)00089-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC V6H 3V4, Canada; Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Department of Pediatrics, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC V6H 3V4, Canada; Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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Selvanathan T, Guo T, Ufkes S, Chau V, Branson H, Synnes A, Ly LG, Kelly EN, Grunau RE, Miller SP. Size and Location of Preterm Brain Injury and Associations With Neurodevelopmental Outcomes. Neurology 2024; 102:e209264. [PMID: 38527245 DOI: 10.1212/wnl.0000000000209264] [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: 08/23/2023] [Accepted: 02/05/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES We examined associations of white matter injury (WMI) and periventricular hemorrhagic infarction (PVHI) volume and location with 18-month neurodevelopment in very preterm infants. METHODS A total of 254 infants born <32 weeks' gestational age were prospectively recruited across 3 tertiary neonatal intensive care units (NICUs). Infants underwent early-life (median 33.1 weeks) and/or term-equivalent-age (median 41.9 weeks) MRI. WMI and PVHI were manually segmented for quantification in 92 infants. Highest maternal education level was included as a marker of socioeconomic status and was defined as group 1 = primary/secondary school; group 2 = undergraduate degree; and group 3 = postgraduate degree. Eighteen-month neurodevelopmental assessments were completed with Bayley Scales of Infant and Toddler Development, Third Edition. Adverse outcomes were defined as a score of less than 85 points. Multivariable linear regression models were used to examine associations of brain injury (WMI and PVHI) volume with neurodevelopmental outcomes. Voxel-wise lesion symptom maps were developed to assess relationships between brain injury location and neurodevelopmental outcomes. RESULTS Greater brain injury volume was associated with lower 18-month Motor scores (β = -5.7, 95% CI -9.2 to -2.2, p = 0.002) while higher maternal education level was significantly associated with higher Cognitive scores (group 3 compared 1: β = 14.5, 95% CI -2.1 to 26.9, p = 0.03). In voxel-wise lesion symptom maps, brain injury involving the central and parietal white matter was associated with an increased risk of poorer motor outcomes. DISCUSSION We found that brain injury volume and location were significant predictors of motor, but not cognitive outcomes, suggesting that different pathways may mediate outcomes across domains of neurodevelopment in preterm infants. Specifically, assessing lesion size and location may allow for more accurate identification of infants with brain injury at highest risk of poorer motor outcomes. These data also highlight the importance of socioeconomic status in cognitive outcomes, even in preterm infants with brain injury.
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Affiliation(s)
- Thiviya Selvanathan
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Ting Guo
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Steven Ufkes
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Vann Chau
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Helen Branson
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Anne Synnes
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Linh G Ly
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Edmond N Kelly
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Ruth E Grunau
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
| | - Steven P Miller
- From Pediatrics (T.S., S.U., R.E.G., S.P.M.), BC Children's Hospital Research Institute and the University of British Columbia, Vancouver; Pediatrics (T.S., T.G., V.C., L.G.L., S.P.M.), The Hospital for Sick Children and University of Toronto; Diagnostic Imaging (H.B.), The Hospital for Sick Children and the University of Toronto, Ontario; Pediatrics (A.S., R.E.G.), BC Women's Hospital and the University of British Columbia, Vancouver; and Pediatrics (E.N.K.), Mount Sinai Hospital, The Hospital for Sick Children and the University of Toronto, Ontario, Canada
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Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res 2024; 95:1224-1236. [PMID: 38114609 PMCID: PMC11035150 DOI: 10.1038/s41390-023-02895-6] [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] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.
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Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.
- Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Manon Bender
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California, San Francisco, California, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yvonne Wu
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mike Cotton
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
| | - Sidhartha Tan
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pia Wintermark
- Division of Neonatology, Montreal Children's Hospital, Montreal, Quebec, Canada
- McGill University Health Centre - Research Institute, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Selvanathan T, Ufkes S, Guo T, Chau V, Branson HM, Ibrahim GM, Ly LG, Kelly EN, Grunau RE, Miller SP. Pain Exposure and Brain Connectivity in Preterm Infants. JAMA Netw Open 2024; 7:e242551. [PMID: 38488791 PMCID: PMC10943417 DOI: 10.1001/jamanetworkopen.2024.2551] [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] [Received: 10/04/2023] [Accepted: 01/24/2024] [Indexed: 03/18/2024] Open
Abstract
Importance Early-life exposure to painful procedures has been associated with altered brain maturation and neurodevelopmental outcomes in preterm infants, although sex-specific differences are largely unknown. Objective To examine sex-specific associations among early-life pain exposure, alterations in neonatal structural connectivity, and 18-month neurodevelopment in preterm infants. Design, Setting, and Participants This prospective cohort study recruited 193 very preterm infants from April 1, 2015, to April 1, 2019, across 2 tertiary neonatal intensive care units in Toronto, Canada. Structural connectivity data were available for 150 infants; neurodevelopmental outcomes were available for 123 infants. Data were analyzed from January 1, 2022, to December 31, 2023. Exposure Pain was quantified in the initial weeks after birth as the total number of invasive procedures. Main Outcome and Measure Infants underwent early-life and/or term-equivalent-age magnetic resonance imaging with diffusion tensor imaging to quantify structural connectivity using graph theory measures and regional connection strength. Eighteen-month neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition. Stratifying by sex, generalized estimating equations were used to assess whether pain exposure modified the maturation of structural connectivity using an interaction term (early-life pain exposure × postmenstrual age [PMA] at scan). Generalized estimating equations were used to assess associations between structural connectivity and neurodevelopmental outcomes, adjusting for extreme prematurity and maternal education. Results A total of 150 infants (80 [53%] male; median [IQR] gestational age at birth, 27.1 [25.4-29.0] weeks) with structural connectivity data were analyzed. Sex-specific associations were found between early-life pain and neonatal brain connectivity in female infants only, with greater early-life pain exposure associated with slower maturation in global efficiency (pain × PMA at scan interaction P = .002) and local efficiency (pain × PMA at scan interaction P = .005). In the full cohort, greater pain exposure was associated with lower global efficiency (coefficient, -0.46; 95% CI, -0.78, to -0.15; P = .004) and local efficiency (coefficient, -0.57; 95% CI, -1.04 to -0.10; P = .02) and regional connection strength. Local efficiency (coefficient, 0.003; 95% CI, 0.001-0.004; P = .005) and regional connection strength in the striatum were associated with cognitive outcomes. Conclusions and Relevance In this cohort study of very preterm infants, greater exposure to early-life pain was associated with altered maturation of neonatal structural connectivity, particularly in female infants. Alterations in structural connectivity were associated with neurodevelopmental outcomes, with potential regional specificities.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Steven Ufkes
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Computational Medicine, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ting Guo
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Vann Chau
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Helen M. Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - George M. Ibrahim
- Department of Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Linh G. Ly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Edmond N. Kelly
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ruth E. Grunau
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven P. Miller
- Department of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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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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Coviello C, Lori S, Bertini G, Montano S, Gabbanini S, Bastianelli M, Cossu C, Cavaliere S, Lunardi C, Dani C. Morphine exposure and prematurity affect flash visual evoked potentials in preterm infants. Clin Neurophysiol Pract 2024; 9:85-93. [PMID: 38371463 PMCID: PMC10869246 DOI: 10.1016/j.cnp.2023.12.005] [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: 05/02/2023] [Revised: 11/14/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Objective The present study aimed to explore first the impact of perinatal risk factors on flash-VEP waves and morphology in a group of preterm infants studied at term equivalent age (TEA). Second, to correlate VEP morphology with neurological outcome at 2 years corrected age (CA). Methods Infants with a gestational age (GA) at birth <32 weeks, without major brain injury, were enrolled. Multivariate regression analyses were performed, and the models were run separately for each dependent variable N2, P2, N3 latencies and P2 amplitude. Logistic regression was applied to study N4 component (present/absent) and VEP morphology (regular/irregular). The predictors were GA, bronchopulmonary dysplasia (BPD), postmenstrual age at VEP registration, cumulative morphine and fentanyl dose, and painful procedures. Lastly, linear regression models were performed to assess the relation between the Bayley-III cognitive and motor scores at 2 years CA and VEP morphology, in relation to GA, BPD, painful procedures and cumulative morphine dose. Results Eighty infants were enrolled. Morphine was the predictor of N2 (R2 = 0.09, p = 0.006), P2 (R2 = 0.11, p = 0.002), and N3 (R2 = 0.13, p = 0.003) latencies. Younger GA was associated with lower amplitude (R2 = 0.05, p = 0.029). None of the independent variables predicted the presence of N4 component, nor VEP morphology in the logistic analysis. VEP morphology was not associated with cognitive and motor scores at 2 years. Conclusions Morphine treatment and prematurity were risk factors for altered VEPs parameters at TEA. In our cohort VEP morphology did not predict neurological outcome. Significance Morphine administration should be evaluated according to potential risks and benefits, and dosage individually accustomed, according to pain and comfort scores, considering the possible risk for neurodevelopmental impairment.
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Affiliation(s)
- Caterina Coviello
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Silvia Lori
- Neurophysiology Unit, Neuro-Musculo-Skeletal Department, Careggi University Hospital, Florence, Italy
| | - Giovanna Bertini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Simona Montano
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Simonetta Gabbanini
- Neurophysiology Unit, Neuro-Musculo-Skeletal Department, Careggi University Hospital, Florence, Italy
| | - Maria Bastianelli
- Neurophysiology Unit, Neuro-Musculo-Skeletal Department, Careggi University Hospital, Florence, Italy
| | - Cesarina Cossu
- Neurophysiology Unit, Neuro-Musculo-Skeletal Department, Careggi University Hospital, Florence, Italy
| | - Sara Cavaliere
- Neurophysiology Unit, Neuro-Musculo-Skeletal Department, Careggi University Hospital, Florence, Italy
| | - Clara Lunardi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital of Florence, Florence, Italy
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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9
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Cook KM, De Asis-Cruz J, Kim JH, Basu SK, Andescavage N, Murnick J, Spoehr E, Liggett M, du Plessis AJ, Limperopoulos C. Experience of early-life pain in premature infants is associated with atypical cerebellar development and later neurodevelopmental deficits. BMC Med 2023; 21:435. [PMID: 37957651 PMCID: PMC10644599 DOI: 10.1186/s12916-023-03141-w] [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: 06/27/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Infants born very and extremely premature (V/EPT) are at a significantly elevated risk for neurodevelopmental disorders and delays even in the absence of structural brain injuries. These risks may be due to earlier-than-typical exposure to the extrauterine environment, and its bright lights, loud noises, and exposures to painful procedures. Given the relative underdeveloped pain modulatory responses in these infants, frequent pain exposures may confer risk for later deficits. METHODS Resting-state fMRI scans were collected at term equivalent age from 148 (45% male) infants born V/EPT and 99 infants (56% male) born at term age. Functional connectivity analyses were performed between functional regions correlating connectivity to the number of painful skin break procedures in the NICU, including heel lances, venipunctures, and IV placements. Subsequently, preterm infants returned at 18 months, for neurodevelopmental follow-up and completed assessments for autism risk and general neurodevelopment. RESULTS We observed that V/EPT infants exhibit pronounced hyperconnectivity within the cerebellum and between the cerebellum and both limbic and paralimbic regions correlating with the number of skin break procedures. Moreover, skin breaks were strongly associated with autism risk, motor, and language scores at 18 months. Subsample analyses revealed that the same cerebellar connections strongly correlating with breaks at term age were associated with language dysfunction at 18 months. CONCLUSIONS These results have significant implications for the clinical care of preterm infants undergoing painful exposures during routine NICU care, which typically occurs without anesthesia. Repeated pain exposures appear to have an increasingly detrimental effect on brain development during a critical period, and effects continue to be seen even 18 months later.
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Affiliation(s)
- Kevin M Cook
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Josepheen De Asis-Cruz
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Jung-Hoon Kim
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Sudeepta K Basu
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Nickie Andescavage
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Jonathan Murnick
- Dept. of Diagnostic Imaging & Radiology, Children's National Hospital, 111 Michigan Ave. NW, Washington, D.C, 20010, USA
| | - Emma Spoehr
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Melissa Liggett
- Division of Psychology, Children's National Hospital, 111 Michigan Ave. NW, Washington, DC, 20010, USA
| | - Adré J du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Catherine Limperopoulos
- Developing Brain Institute, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
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Luzzati M, Coviello C, De Veye HS, Dudink J, Lammertink F, Dani C, Koopmans C, Benders M, Tataranno ML. Morphine exposure and neurodevelopmental outcome in infants born extremely preterm. Dev Med Child Neurol 2023; 65:1053-1060. [PMID: 36649164 DOI: 10.1111/dmcn.15510] [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] [Received: 05/27/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 01/18/2023]
Abstract
AIM To investigate the association between morphine exposure in the neonatal period and neurodevelopment at 2 and 5 years of age while controlling for potential confounders. METHOD We performed a retrospective, single-centre cohort study on 106 infants (60 males, 46 females; mean gestational age 26 weeks [SD 1]) born extremely preterm (gestational age < 28 weeks). Morphine administration was expressed as cumulative dose (mg/kg) until term-equivalent age. Neurodevelopmental outcome was assessed at 2 years with the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version and at 5 years with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition, Dutch version. Multiple linear regression analysis was used to assess the association between morphine exposure and outcome. RESULTS Sixty-four out of 106 (60.4%) infants included in the study received morphine. Morphine exposure was not associated with poorer motor, cognitive, and language subscores of the Bayley Scales of Infant and Toddler Development, Third Edition, Dutch version at 2 years. Morphine exposure was associated with lower Full-Scale IQ scores (p = 0.008, B = -9.3, 95% confidence interval [CI] = -15.6 to -3.1) and Performance IQ scores (p = 0.005, B = -17.5, 95% CI = -27.9 to -7) at 5 years of age. INTERPRETATION Morphine exposure in infants born preterm is associated with poorer Full-Scale IQ and Performance IQ at 5 years. Individualized morphine administration is advised in infants born extremely preterm.
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Affiliation(s)
- Michele Luzzati
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
- Division of Neonatology, University of Florence, Florence, Italy
| | | | - Henriette Swarenburg De Veye
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Femke Lammertink
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
- Division of Neonatology, University of Florence, Florence, Italy
| | - Corine Koopmans
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Manon Benders
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maria Luisa Tataranno
- Department of Neonatology, Division of Perinatology and Gynecology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
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11
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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: 1] [Impact Index Per Article: 1.0] [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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12
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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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13
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McNair C, Chirinian N, Uleryk E, Stevens B, McAllister M, Franck LS, Taddio A, Shah V. Effectiveness of parental education about pain in the neonatal period on knowledge, attitudes, and practices: A systematic review and meta-analysis. Paediatr Child Health 2022; 27:454-463. [PMID: 36583071 PMCID: PMC9792286 DOI: 10.1093/pch/pxac050] [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: 04/21/2021] [Accepted: 05/20/2022] [Indexed: 01/01/2023] Open
Abstract
Background Despite the availability of effective, safe, and feasible pain management strategies, infant pain remains undertreated. Parents can play a key role in advocating for or delivering pain management strategies if they are educated. To date, a quantitative synthesis of the effectiveness of parental education about pain management in the neonatal period has not been performed. Objective To systematically review the effectiveness of parental education during the neonatal period on pain management in infancy. Methods MEDLINE, EMBASE, PsycInfo, CINAHL, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) and non-randomized trials (NRTs) that evaluated parental education with respect to pain management during the neonatal period in any setting from inception to February 2021. Screening of article titles and abstracts and data extraction were performed in duplicate. The risk of bias was assessed using the Cochrane Risk Bias Tool 2.0 and the Risk of Bias in Non-randomized Studies of Interventions for RCTs and NRTs, respectively. As per the GRADE methodology, critically important and important outcomes were identified. Critically important outcomes included utilization of pain management strategies and infant pain. Important outcomes included parental knowledge about pain mitigation strategies, parental attitudes, compliance with painful procedures, procedure outcomes, and safety. Data were combined and presented as relative risk (RR) or mean or standardized mean difference (MD or SMD) with 95% confidence interval (CI). Results Of the six studies eligible for inclusion, four studies were RCTs and two studies were NRTs. Written information and/or video were used to deliver parental education during the neonatal period in hospital settings in all studies. Four studies (two RCTs and two NRTs) reported on critically important outcomes. The risk of bias was low for the two RCTs and moderate to serious for the two NRTs. Utilization of pain management strategies was assessed for heel lance in the first 48 hours of life in two studies and for vaccine injection at 2 to 6 months of life in two studies. Higher utilization rate for pain management strategies was reported in the pain education group in three studies (RR 1.15, 95% CI 1.04, 1.26; N=2712). There was no difference in the mean number of pain management strategies used in one NRT tracking utilization tracking utilization as continuous data (MD 0.20, 95% CI -0.01, 0.41; N=178). Parent-reported infant pain scores were lower in the pain education group in one RCT (MD -0.16, 95% CI -0.27, -0.06; N=1615). The quality of evidence for the outcome of utilization of pain management strategies was very low while for the outcome of infant pain the quality of evidence was moderate. Five studies (3 RCTs and 2 NRTs) reported on important outcomes. The risk of bias was low for two RCTs and high for one RCT and moderate to serious for the two NRTs. Parental knowledge about pain management strategies (SMD 0.54, 95% CI 0.26, 0.82), parental confidence in their ability to manage pain (SMD 0.24, 95% CI 0.14, 0.34), parental satisfaction with education (MD 1.18, 95% CI 0.84, 1.52) and parental satisfaction with pain management (RR 1.05. 95% CI 1.01, 1.08) were increased in the pain education group. None of the included studies reported on procedural outcomes. No adverse events with the pain education nor the use of pain management interventions were reported in one study. Conclusions Parental education in the neonatal period was effective in increasing utilization of pain management strategies during painful procedures. Reduction of pain in infants is based on one study of moderate quality. Furthermore, parental education increased parental knowledge about pain management strategies, confidence in their ability to manage infant pain, and satisfaction with the education and pain management. Parental pain education should be incorporated into postnatal care.
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Affiliation(s)
- Carol McNair
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Nevart Chirinian
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Bonnie Stevens
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mary McAllister
- Nursing Practice, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Linda S Franck
- Department of Family Health Care Nursing, University of California, San Francisco, CA, USA
| | - Anna Taddio
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
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14
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Abstract
With improving survival at the lowest gestations an increasing number of tiny and vulnerable infants are being cared for, and optimal outcomes require an approach to care that takes their specific characteristics into account. These include immature organ function and a risk for iatrogenic injury, and parental/familial strain due to the high degree of uncertainty, infant-mother separation, and long hospital stay. While the challenges in providing nursing care to these infants are obvious it is also clear that this field has tremendous potential to influence both short and long-term outcomes of this population. This mini-review discusses aspects of the nursing care provided to infants born at the very lowest gestations and their families, with focus on doing less harm by establishing an adequate care environment, actively promoting parental closeness and care-giving, and conservative skin care.
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A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit. Adv Neonatal Care 2022; 22:203-209. [PMID: 34407057 DOI: 10.1097/anc.0000000000000941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications. PURPOSE The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU). METHODS A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period. RESULTS Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period. IMPLICATIONS FOR PRACTICE The development of a dedicated, local team played a key role in improving vascular access in the NICU. IMPLICATIONS FOR RESEARCH Proximity of specialized teams provides a solution to address gaps in care in the NICU.
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16
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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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Theubo M, O’Reilly D, Foran A. No pain, neurodevelopmental gain: Time to avoid painful placebo injections in neonatal research. Acta Paediatr 2022; 111:1476-1478. [PMID: 35451100 PMCID: PMC9543618 DOI: 10.1111/apa.16369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/06/2022] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Muller Theubo
- Department of Neonatology Rotunda Hospital Dublin 1 Ireland
| | - Daniel O’Reilly
- Department of Paediatrics Regional Hospital Mullingar Ireland
| | - Adrienne Foran
- Department of Neonatology Rotunda Hospital Dublin 1 Ireland
- Department of Paediatrics RCSI Dublin 2 Ireland
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18
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McPherson C, Frymoyer A, Ortinau CM, Miller SP, Groenendaal F. Management of comfort and sedation in neonates with neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101264. [PMID: 34215538 PMCID: PMC8900710 DOI: 10.1016/j.siny.2021.101264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ensuring comfort for neonates undergoing therapeutic hypothermia (TH) after neonatal encephalopathy (NE) exemplifies a vital facet of neonatal neurocritical care. Physiologic markers of stress are frequently present in these neonates. Non-pharmacologic comfort measures form the foundation of care, benefitting both the neonate and parents. Pharmacological sedatives may also be indicated, yet have the potential to both mitigate and intensify the neurotoxicity of a hypoxic-ischemic insult. Morphine represents current standard of care with a history of utilization and extensive pharmacokinetic data to guide safe and effective dosing. Dexmedetomidine, as an alternative to morphine, has several appealing characteristics, including neuroprotective effects in animal models; robust pharmacokinetic studies in neonates with NE treated with TH are required to ensure a safe and effective standard dosing approach. Future studies in neonates treated with TH must address comfort, adverse events, and long-term outcomes in the context of specific sedation practices.
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Affiliation(s)
- Christopher McPherson
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA.
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, 750 Welch Road, Suite 315, Palo Alto, CA, 94304, USA.
| | - Cynthia M. Ortinau
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA
| | - Steven P. Miller
- Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, 555 University Avenue, Toronto, ON, Canada
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Lundlaan 6, 3584 EA, Utrecht, Netherlands.
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19
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King BC, Richardson T, Patel RM, Lee HC, Bamat NA, Hall M, Slaughter JL. Prioritization framework for improving the value of care for very low birth weight and very preterm infants. J Perinatol 2021; 41:2463-2473. [PMID: 34075201 PMCID: PMC8514333 DOI: 10.1038/s41372-021-01114-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Create a prioritization framework for value-based improvement in neonatal care. STUDY DESIGN A retrospective cohort study of very low birth weight (<1500 g) and/or very preterm (<32 weeks) infants discharged between 2012 and 2019 using the Pediatric Health Information System Database. Resource use was compared across hospitals and adjusted for patient-level differences. A prioritization score was created combining cost, patient exposure, and inter-hospital variability to rank resource categories. RESULTS Resource categories with the greatest cost, patient exposure, and inter-hospital variability were parenteral nutrition, hematology (lab testing), and anticoagulation (for central venous access and therapy), respectively. Based on our prioritization score, parenteral nutrition was identified as the highest priority overall. CONCLUSIONS We report the development of a prioritization score for potential value-based improvement in neonatal care. Our findings suggest that parenteral nutrition, central venous access, and high-volume laboratory and imaging modalities should be priorities for future comparative effectiveness and quality improvement efforts.
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Affiliation(s)
- Brian C. King
- grid.416975.80000 0001 2200 2638Department of Pediatrics, Section of Neonatology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Troy Richardson
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Ravi M. Patel
- grid.189967.80000 0001 0941 6502Division of Neonatology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Henry C. Lee
- grid.168010.e0000000419368956Division of Neonatology, Stanford University, Stanford, CA USA
| | - Nicolas A. Bamat
- grid.239552.a0000 0001 0680 8770Division of Neonatology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Matthew Hall
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Jonathan L. Slaughter
- grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
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