Evaluation of the PECARN rule for traumatic brain injury applied to infants younger than 3 months and creation of a modified, age-specific rule.

Infants < 3 months with minor head trauma (MHT) are a particularly vulnerable group, though few studies have focused specifically on these patients. We aimed to evaluate the application of the PECARN prediction rule, designed for clinically important traumatic brain injury (ciTBI) in children < 2 years in infants < 3 months, and create a specific prediction rule for this population. We conducted a prospective multicenter observational study in 13 pediatric emergency departments (PEDs) in Spain. The PECARN rule was applied to all patients. A new specific prediction rule for infants < 3 months of age was created. The main outcome measures were (1) ciTBI, (2) TBI evidenced on computed tomography (CT) scan, and (3) isolated skull fracture (ISF). Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 21,981 children with MHT, 366 (1.7%) were < 3 months old and 195 (53.3%) underwent neuroimaging, including 37 (10.1%) with CT scan. The sensitivity and negative predictive value (NPV) of the PECARN prediction rule for ciTBI were 100% (95% CI, 20.7-100) and 99.7% (95% CI, 98.4-100%), respectively. Of the 230 infants (62.8%) who met the PECARN low-risk criteria, none had ciTBI, 1 (0.4% overall, 95% CI, 0-2.4) had TBI on CT, and 2 (0.9% overall; 95% CI, 0.1-3.1) had an ISF. Among the 136 infants (37.2%) who did not meet the PECARN low-risk criteria, 1 (0.3% overall; 95% CI, 0-1.5) had ciTBI, 11 (8.1% overall; 95% CI, 4.1-14.0) had TBI on CT, and 18 (13.2% overall; 95% CI, 8-20.1) had an ISF. The sensitivity and NPV of the Spanish prediction rule for ciTBI were 100% (95% CI, 20.7-100) and 100% (95% CI, 98.4-100%), respectively. No infants in the registry developed complications during follow-up. CONCLUSION: The PECARN rule for infants < 2 years old accurately identified infants < 3 months old at low risk for ciTBI in our population, although the adapted Spanish rule presented here could be even more accurate. WHAT IS KNOWN: • Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination. • A low threshold for CT scan is recommended in this population. WHAT IS NEW: • PECARN rule for infants < 2 years old is an adequate tool with which to identify infants < 3 months old at low risk for clinically important traumatic brain injury. • Spanish rule could identify even more low-risk infants without overlooking important outcomes but it should be validated to confirm its predictive capacity.

Evaluación del sistema parasimpático durante procedimientos dolorosos en neonatología / Parasympathetic evaluation for procedural pain assessment in neonatology

Introducción: El monitor NIPE (Newborn Infant Parasympathetic Evaluation) es una herramienta rápida, continua y objetiva de evaluación del disconfort neonatal. Los objetivos fueron describir los cambios del NIPE tras una extracción sanguínea y los factores implicados en su variación. Material y métodos: Estudio observacional analítico con recogida de datos prospectiva. Se incluyeron los recién nacidos ingresados en cuidados intensivos entre junio y diciembre de 2021 a quienes se les realizó extracción sanguínea. Se recogieron variables demográficas, las relacionadas con la realización del procedimiento, la puntuación NIPE, la frecuencia cardiaca previa y en los minutos 1, 2, 3, 4, 5, 10 y 15 posteriores. Resultados: Se incluyeron 86 registros de 49 pacientes. Durante los primeros cuatro minutos tras el procedimiento hubo un descenso significativo en la puntuación NIPE, siendo el descenso máximo de un 22,8% respecto al valor basal, produciéndose el nadir a los 2,79 minutos. El mayor descenso del NIPE ocurrió en pacientes prematuros, varones, con menor Apgar a los cinco minutos, en procedimientos ya realizados previamente, tras cesárea y en horario matutino. No hubo diferencias con la realización en canguro. La correlación entre NIPE y frecuencia cardíaca fue débil. Conclusiones:Tras un procedimiento doloroso, como una extracción sanguínea, el monitor NIPE mostró un descenso significativo los primeros cuatro minutos, agudizándose el descenso con la prematuridad, la reiteración de procedimientos o el nacimiento tras cesárea. El monitor NIPE puede ayudar a identificar eficazmente a aquellos neonatos que sufren dolor agudo tras un procedimiento, complementándose con las escalas de valoración clínica. (AU)

Introduction: The Newborn Infant Parasympathetic Evaluation (NIPE) index is an instrument that enables continuous, fast and objective assessment of neonatal discomfort. The aim of the study was to analyse changes in NIPE values after performance of blood draws and the factors involved in this variation. Material and methods: We conducted a prospective observational study. We included infants admitted to the neonatal intensive care unit between June and December 2021 who underwent blood draws. We recorded demographic data, aspects related to the procedure, the NIPE index and the heart rate at baseline and 1, 2, 3, 4, 5, 10 and 15min after the procedure. Results: The study included 86 records for 49 patients. In the first 4min after the procedure, there was a significant decrease in the NIPE index, with a maximum decrease of 22.8% relative to baseline and the nadir at 2.79min. The decrease in NIPE values was greater in infants born preterm, male, with lower 5-min Apgar scores and following procedures that had been performed previously, after caesarean section or in the morning. There were no differences when the blood draw was obtained during kangaroo care. The correlation between the NIPE index and the heart rate was weak. Conclusions: After a painful procedure, such as a blood draw, the NIPE monitor showed a significant decrease in the first 4min, which was more pronounced in preterm infants, in repeated procedures or after caesarean delivery. The NIPE index could help identify infants experiencing acute procedural pain, complementing clinical rating scales. (AU)

Parasympathetic evaluation for procedural pain assessment in neonatology.

INTRODUCTION: The Newborn Infant Parasympathetic Evaluation (NIPE) index is an instrument that enables continuous, fast and objective assessment of neonatal discomfort. The aim of the study was to analyse changes in NIPE values after performance of blood draws and the factors involved in this variation. MATERIAL AND METHODS: We conducted a prospective observational study. We included infants admitted to the neonatal intensive care unit between June and December 2021 who underwent blood draws. We recorded demographic data, aspects related to the procedure, the NIPE index and the heart rate at baseline and 1, 2, 3, 4, 5, 10 and 15 min after the procedure. RESULTS: The study included 86 records for 49 patients. In the first 4 min after the procedure, there was a significant decrease in the NIPE index, with a maximum decrease of 22.8% relative to baseline and the nadir at 2.79 min. The decrease in NIPE values was greater in infants born preterm, male, with lower 5-min Apgar scores and following procedures that had been performed previously, after caesarean section or in the morning. There were no differences when the blood draw was obtained during kangaroo care. The correlation between the NIPE index and the heart rate was weak. CONCLUSIONS: After a painful procedure, such as a blood draw, the NIPE monitor showed a significant decrease in the first 4 min, which was more pronounced in preterm infants, in repeated procedures or after caesarean delivery. The NIPE index could help identify infants experiencing acute procedural pain, complementing clinical rating scales.

Epidemiology of minor blunt head trauma in infants younger than 3 months.

Specific knowledge of the features of minor head trauma in infants is necessary to develop appropriate preventive strategies and adjust clinical management in pediatric emergency departments (PEDs). The aim of this study is to describe the epidemiology of minor blunt head trauma in infants < 3 months who present to PEDs. We performed a prospective study of infants evaluated in any of 13 Spanish PEDs within 24 h of a minor head trauma (Glasgow Coma Scale scores of 14-15) between May 2017 and November 2020. Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 1,150,255 visits recorded, 21,981 children (1.9%) sustained a head injury, 386 of whom (0.03%) were under 3 months old. Among the 369 patients who met the inclusion criteria (0.03%), 206 (56.3%) were male. The main causes of trauma were fall-related (298; 80.8%), either from furniture (138/298; 46.3%), strollers (92/298; 30.9%), or a caregiver's arms (61/298; 20.5%). Most infants were asymptomatic (317; 85.9%) and showed no signs of injury on physical exam (210; 56.9%). Imaging studies were performed in 195 patients (52.8%): 37 (10.0%) underwent computed tomography (CT) scan, 162 (43.9%) X-ray, and 22 (6.0%) ultrasound. A clinically important traumatic brain injury (ciTBI) occurred in 1 infant (0.3% overall; 95% CI, 0-1.5), TBI was evidenced on CT scan in 12 (3.3% overall; 95% CI, 1.7-5.7), and 20 infants had an isolated skull fracture (5.5% overall; 95% CI, 3.4-8.3). All outcomes were caused by falls onto hard surfaces. CONCLUSION:  Most head injuries in infants younger than 3 months are benign, and the rate of ciTBI is low. Prevention strategies should focus on falls onto hard surfaces from furniture, strollers, and caregivers' arms. Optimizing imaging studies should be a priority in this population. WHAT IS KNOWN: • Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination. • A low threshold for CT scan is recommended in this population. WHAT IS NEW: • Most cases of blunt head trauma in infants younger than 3 months have good outcomes, and the rate of clinically important traumatic brain injury is low. • Optimizing imaging studies should be a priority in this population, avoiding X-ray examinations and reducing unnecessary CT scans.