Pain perception in NICU: a pilot questionnaire.

PURPOSE: Neonatal pain management has made a great step forward over the last several years. Despite the drafting of International guidelines, an under-treatment of neonatal pain is still reported. MATERIALS AND METHODS: Medical and paramedical personnel working in five Italian NICUs were asked to complete a questionnaire about pain management. The questionnaire was comprised of three sections: (i) brief explanation of the purpose; (ii) demographic information, including age, profession, religious beliefs, and hospital level; (iii) questionnaire about pain management and prevention. RESULTS: One-hundred and forty caregivers participated in this study. Non-pharmacological analgesia during heel prick or venipuncture was used by 64% and 60% of them, respectively; topical analgesia was performed in 13% of venipunctures; no analgesia was used in 30% of cases for both heel prick and venipuncture. In the case of lumbar puncture, 35% of participants used topical analgesia, 15% non-pharmacological approach, 10% opioids, and 6% intravenous paracetamol. While 65% of participants gave a score of 4 out of 5 about the importance of pain treatment, 39% of them reported that in their department no pain scales were used. CONCLUSIONS: Pain treatment in these NICUs is still far to be optimal. This nonetheless reflects a worldwide trend, which requires more attention on pain prevention, assessment, and treatment.

Systematic review of nonpharmacological analgesic interventions for common needle­related procedure in newborn infants and development of evidence­based clinical guidelines

The aim of this literature review was to develop clinical guidelines for the prevention and control of needle­related pain in newborn infants. The guidelines were developed by the Italian Society of Neonatology, using the Grading of Recommendations, Assessment, Development and Evaluation approach, based on the assessment of 232 papers published between 1986 and 2015. The quality of the evidence was high or moderate for some behavioural and nonpharmacological interventions.

Oxidative Stress as a Physiological Pain Response in Full-Term Newborns.

This research paper aims to investigate if oxidative stress biomarkers increase after a painful procedure in term newborns and if nonpharmacological approaches, or sex, influence pain degree, and the subsequent OS. 83 healthy term newborns were enrolled to receive 10% oral glucose or sensorial saturation (SS) for analgesia during heel prick (HP). The ABC scale was used to score the pain. Advanced oxidation protein products (AOPP) and total hydroperoxides (TH) as biomarkers of OS were measured at the beginning (early-sample) and at the end (late-sample) of HP. The early-sample/late-sample ratio for AOPP and TH was used to evaluate the increase in OS biomarkers after HP. Higher levels of both AOPP and TH ratio were observed in high degree pain (4-6) compared with low degree pain score (0-3) (AOPP: p = 0.049; TH: p = 0.001). Newborns receiving SS showed a significantly lower pain score (p = 0.000) and AOPP ratio levels (p = 0.021) than those without. Males showed higher TH levels at the end of HP (p = 0.005) compared to females. The current study demonstrates that a relationship between pain degree and OS exists in healthy full-term newborns. The amount of OS is gender related, being higher in males. SS reduces pain score together with pain-related OS in the newborns.

How painful is a heelprick or a venipuncture in a newborn?

OBJECTIVE: Neonates undergo many painful procedures daily, in particular venipunctures and heelpricks. Our aim was to assess how painful these procedures actually are, and how effective are the common analgesic strategies to blunt this pain. METHODS: We performed a MEDLINE/PubMed research from 1999 to 2013. We retrieved all papers in English language that evaluated pain during neonatal heelprick or venipuncture and that used as score the Premature Infant Pain Profile (PIPP), a widely used scale for evaluate acute pain in term and preterm babies. RESULTS: Fifteen papers met the inclusion criteria, using different analgesic methods. Just in one case two studies used the same analgesic method. Most analgesic procedures show a relevant level of pain. We didn't find univocal difference between heelprick and venipuncture. Topic creams, systemic analgesics, posture and oral glucose 10% have scarce analgesic effectiveness. The most effective procedures are the use of oral sweet solutions (sucrose or glucose) at concentrations greater than 20%, multisensory stimulations and non-nutritive sucking used along with 10% glucose. CONCLUSIONS: A large amount of analgesic methods was used, making comparisons difficult. Nevertheless, in the absence of analgesic treatment, heelpricks and venipunctures are moderately-severely painful, and among the proposed analgesic procedures, few seem to be effective.

C-reactive protein: a marker of neonatal stress?

AIM: To assess whether blood values of C-reactive protein (CRP) in healthy term newborns, are influenced by stress. MATERIAL AND METHODS: Since different types of delivery (vaginal delivery [VD], emergency C-section [EMCS] and elective C-section [ELCS]) are notoriously characterized by different levels of stress for the baby, these three groups were used as models of different levels of stress. The mean CRP values of the three groups obtained in the first hours of life were compared. RESULTS: We retrieved 1012 babies. Median values (3rd-97th ct) were: 0.05 (0.01-0.46), 0.17 (0.02-1.54), 0.30 (0.04-1.77), 0.43 (0.05-1.31), 0.40 (0.04-1.13) at 12, 24, 48, 72 and 96 h, respectively. Mean values in babies born after VD were statistically higher than those born after C-section, and higher CRP values were present in EMCS with respect to ELCS. CONCLUSION: This study described normal blood CRP values in a wide population of term babies. An influence of the type of delivery on blood CRP is evident, and this may be explained by the different amount of perinatal stress induced by anyone of the three types of delivery we considered.

Intramuscular injections in newborns: analgesic treatment and sex-linked response.

AIM: To compare the analgesic effect of three treatments to relieve the pain produced by intramuscular injections (IMI) in term newborns, and to assess sex-linked differences in their response to pain. MATERIAL AND METHODS: We studied 62 babies. Each baby received antibiotic IMIs for clinical aims. During each IMI, one of the following analgesic treatments was utilized: oral 33% glucose (OG), sensorial saturation (SS), or topic anesthetic cream (TAC). SS is a validated analgesic method, based on the combination of three stimulations (tactile, acoustic and gustative). During the IMI, pain level was assessed with the use of the DAN scale, a validated neonatal pain scale. All babies who received three distinct analgesic procedures for three distinct IMIs were enrolled. Mean pain scores of the three analgesic treatment groups were compared. We then compared mean pain scores of females vs males in the whole cohort and within each treatment group. RESULTS: The 95% Confidence Intervals of pain scores were 5.6-6.5 for TAC, 1.4-2.3 for OG and 0.6-1.2 for SS: when treated with TAC, babies' pain scores were significantly higher than with OG or SS (p <0.0001); when treated with OG, babies' pain scores were higher than SS (p = 0.002). Females' mean pain score was significantly higher than males' mean pain score: (95% CI: 2.9-4.1 vs 2.0-3.1; p = 0.01). OG and SS produced significantly higher mean DAN scores in females than in males. Also in the TAC group females' mean DAN scores were higher than males, though this last difference was not statistically significant. CONCLUSION: This is the first study to show the effectiveness of nonpharmacologic analgesia in relieving IMI pain. It is also the first study to clearly show that the sex differences in pain perception are present since birth.

[Which legal consequences for those who provoke pain to infants?]. / Quali conseguenze per chi provoca dolore al neonato?

The advances in perinatal care have led to a significant increase in neonatal survival rate but also to the rise of the number of invasive procedures. Several scientific studies show that newborns are able to feel pain more intensely than adults. Despite this evidence, neonatal pain and the right to an appropriate analgesia are systematically underestimated, ignoring ethical and moral principles of beneficence and non-maleficence. Infants are more susceptible to pain and the prolonged exposure to painful sensations can alter the neural development and the response to pain causing hyperalgesia. Anyone who caused pain without using any analgesic procedure due to negligence or incompetence, should be severely punished. The right to analgesia, fundamental principle, is fully incorporated in the Italian code of Medical deontology (article 3). The doctor who does not use analgesia for newborns' treatment can be indicted by the Italian penal code (art.582 and 583), aggravated by being the victim an infant, who is unable to defend himself. To avoid penal consequences, a careful education and attention are needed: "pediatric analgesia" should become a basic teaching in Universities and in specialization schools; analgesic treatments should be mandatory and annotated in the patient's file even for minor potentially painful procedures.

Exposure to electromagnetic fields from laptop use of "laptop" computers.

Portable computers are often used at tight contact with the body and therefore are called "laptop." The authors measured electromagnetic fields (EMFs) laptop computers produce and estimated the induced currents in the body, to assess the safety of laptop computers. The authors evaluated 5 commonly used laptop of different brands. They measured EMF exposure produced and, using validated computerized models, the authors exploited the data of one of the laptop computers (LTCs) to estimate the magnetic flux exposure of the user and of the fetus in the womb, when the laptop is used at close contact with the woman's womb. In the LTCs analyzed, EMF values (range 1.8-6 µT) are within International Commission on Non-Ionizing Radiation (NIR) Protection (ICNIRP) guidelines, but are considerably higher than the values recommended by 2 recent guidelines for computer monitors magnetic field emissions, MPR II (Swedish Board for Technical Accreditation) and TCO (Swedish Confederation of Professional Employees), and those considered risky for tumor development. When close to the body, the laptop induces currents that are within 34.2% to 49.8% ICNIRP recommendations, but not negligible, to the adult's body and to the fetus (in pregnant women). On the contrary, the power supply induces strong intracorporal electric current densities in the fetus and in the adult subject, which are respectively 182-263% and 71-483% higher than ICNIRP 98 basic restriction recommended to prevent adverse health effects. Laptop is paradoxically an improper site for the use of a LTC, which consequently should be renamed to not induce customers towards an improper use.

Increased risk of brain injury in IVF babies.

AIM: The aim of this paper was to assess brain injury occurrence among in vitro fertilization (IVF) babies. METHODS: We examined all babies born in our hospital in the triennium 2004-2006, comparing the presence of brain injuries between IVF babies and the rest of the population. RESULTS: In IVF group (180 babies), brain injury was present in 4 babies, while in the rest of population (n=3602) it was present in 23 babies (P=0.042, RR: 3.18). IVF babies have a higher risk of being born with a birthweight less than 2 500 grams (P<0.0001; RR: 5.133). When we considered only babies born with a birth weight less than 2 500 grams, the difference of brain injury between the two groups was not significant. CONCLUSION: In IVF babies, brain injury occurred more frequently than in the rest of population. This is probably due to a higher rate of premature births and low birth weight in IVF population. Anyway, this data should be disclosed to future parents to make an informed decision.

[Influence of prolonged treatment with octreotide on GH, IGF I, insulin, ACTH, cortisol, T3, T4 and TSH secretion in a case of congenital chylothorax]. / Influenza del trattamento prolungato con octreotide sulla secrezione di GH, IGFI, insulina, ACTH, cortisolo, T3, T4 e TSH in un caso di chilotorace congenito.

Congenital chylothorax is a rare condition characterized by the accumulation of lymph fluid in the pleural space that causes respiratory and circulatory dysfunctions, immune deficiencies, hypoalbuminemia, electrolyte imbalance and alterations of the coagulation. Mortality rates are elevated and can rise to 50%. Therapy consists in conservative treatment based on thoracic drainage combined with total parenteral nutrition or use of low-fat high-protein diet supplemented with medium chain triglycerides. In case of failure surgical intervention may be considered. During the last years some authors have experienced the use of octreotide with doubtful results. In no case the drug impact on insulin, GH and cortisol secretion in neonatal age has been investigated and only in one case the effect on thyroid hormones has been assessed. We report the case of a 36-week baby with congenital chylothorax treated with octreotide for 42 days. The drug was well tolerated but hormonal level measurements showed a deep depression of insulin secretion unaccompanied by alterations of glucose levels. Levels of GH and TSH showed only a transitory decrease. ACTH and cortisol remained normal. At 5 months, the measurements of hormonal levels did not show significant alterations. It is not possible to determine if such a drug played an essential role in the solution of the pleural effusion, but it is important to emphasize that a prolonged treatment with octreotide has not caused, in our case, persistent hormonal alterations.

[Survival rates in a single neonatal intensive care unit (period 2002-2007). Neuro-developmental outcome and survival for infants born at 23-25 weeks of gestation]. / Sopravvivenza in una unità di terapia intensiva neonatale (periodo 2002-2007). Outcome neurologico e sopravvivenza dei nati di età gestazionale 23-25 settimane.

AIM: The aim of this study was to evaluate survival rates in a single Neonatal Intensive Care Unit (NICU) (period 2002-2007), with a special focus on the survival data and outcome at one-year of corrected age for infants born at 23-25 weeks of gestation. METHODS: All infants who had evidence of heart activity at birth were actively resuscitated, regardless of birth weight or gestational age. Survival rate was calculated as a function of the following variables: birth weight and gestational category; gender in infants of birth weight < or = 1000 g ; appropriate (AGA) or small (SGA) weight for gestational age; inborn or outborn. Twenty-eight newborns (23-25 weeks of gestation) completed follow-up at one-year of corrected age. RESULTS: During the examined period, no infants died in the delivery room; 833 newborns were admitted to the NICU. Overall survival rates were as following: <500 g (37%), 501-750 g (59%), 751-1,000 g (82%), 1,001-1,250 g (96%), 1251-1,500 g (97%), 1,501-2,000 g (100%), 2,001-2,500 g (98%), >2,500 g (99%); 23-25 weeks of gestation (50%); 26-27 weeks (77%), 28-32 weeks (90%); males < or = 1,000 g (68%), females < or = 1,000 g (68%); AGA < or = 1,000 g (63%), SGA < or = 1,000 g (79%), AGA < or =28 weeks (63%), SGA < or = 28 weeks (67%); inborn (54%), outborn (25%). A fraction of 64% (infants of 23-25 weeks of gestation) did not show handicap at one-year of corrected age, while 25% presented severe, 7% moderate, and 4% mild handicaps. CONCLUSION: High rate of survival without handicap at one-year of corrected age at extremely low gestational age and the chance of improvements in neonatal care for newborn < or = 24 weeks, indicate the appropriateness for our strategy of resuscitating all newborns with evidence of heart activity in the delivery room.

Even routine painful procedures can be harmful for the newborn.

Stressful events can damage neonatal brain through a complexity of events including free radical (FR) generation. We examined whether pain provoked by a routine heel prick can generate an increase in potentially harmful FR in neonatal blood. To this aim, advanced oxidation protein products (AOPP) and total hydroperoxide (TH) concentrations were measured at the beginning (sample A) and at the end (sample B) of each sampling in 64 babies (corrected age: 37.2+/-2.7 weeks) who underwent heel prick for routine blood tests. We scored pain of every procedure in all newborns. No differences were detected between AOPP and TH blood concentrations at the beginning and at the end of heel prick sampling, considering the whole cohort of babies. Conversely, a significant increase was observed between AOPP and TH blood concentrations considering only those babies who showed the highest pain intensity. When babies' pain was high (ABC score >or=4), mean AOPP and TH blood levels increased significantly; in this case, mean AOPP values increased from 53.5microm/l (SD=41.6) to 63.2microm/l (SD=44.3) and TH values from 218.3UCarr (SD=89.2) to 228.7UCarr (SD=93.3), with a significant p value of 0.02 and 0.036, respectively. A significant correlation was also found between AOPP blood levels ratio (sample B/sample A) in each baby, and the correspondent level of pain. These data show that even common routine procedures can be potentially harmful for the newborn if they provoke a high level of pain.

Consumerism in prenatal diagnosis? A local Italian study.

AIM: To assess the causes of excessive use of prenatal diagnosis. MATERIAL AND METHODS: 304 questionnaires were completed anonymously by puerperae in a Siena (Italy) hospital in May-August 2006. The questionnaires contained 24 questions about the women, examinations performed during pregnancy and the reasons for them. RESULTS: The mean number of ultrasound examinations per woman was 6.5 +/- 2.5. Forty-two percent of the women in our sample (29.3% of women under 35 and 68.9% of women over 35 years of age) reported that amniocentesis/CVS had been performed; the mean age of these women was 34.1 +/- 4.5 years. Eighty-five percent of the women under 36 years of age who had amniocentesis declared that it was performed as a personal choice and 15% for the presence of risk factors. Among 131 women who performed amniocentesis, 32 performed it with a normal blood screening for Down syndrome (DS), and 76 declared to have performed no blood screening for DS. Only 45% of women stated that they thought age above 35 years was a risk factor for pregnancy, but most of them (75%) were aware that amniocentesis was performed to detect chromosomal anomalies. In 89% of the cases a source of information about prenatal testing was the woman's gynecologist. CONCLUSION: This study shows that the high use of prenatal examinations is often not justified by the presence of clinical risk factors and that both national health system and caregivers should find new strategies to inform women about the aims of prenatal tests, and promote a more serene approach to pregnancy. A broader study is needed to confirm these data.

Electromagnetic fields produced by incubators influence heart rate variability in newborns.

BACKGROUND: Incubators are largely used to preserve preterm and sick babies from postnatal stressors, but their motors produce high electromagnetic fields (EMFs). Newborns are chronically exposed to these EMFs, but no studies about their effects on the fragile developing neonatal structure exist. AIM: To verify whether the exposure to incubator motor electric power may alter autonomous nervous system activity in newborns. MATERIAL AND METHODS: Heart rate variability (HRV) of 43 newborns in incubators was studied. The study group comprised 27 newborns whose HRV was studied throughout three 5-minute periods: with incubator motor on, off, and on again, respectively. Mean HRV values obtained during each period were compared. The control group comprised 16 newborns with constantly unrecordable EMF and exposed to changes in background noise, similar to those provoked by the incubator motor. RESULTS: Mean (SD) total power and the high-frequency (HF) component of HRV increased significantly (from 87.1 (76.2) ms2 to 183.6 (168.5) ms2) and the mean low-frequency (LF)/HF ratio decreased significantly (from 2.0 (0.5) to 1.5 (0.6)) when the incubator motor was turned off. Basal values (HF = 107.1 (118.1) ms2 and LF/HF = 1.9 (0.6)) were restored when incubators were turned on again. The LF spectral component of HRV showed a statistically significant change only in the second phase of the experiment. Changes in background noise did not provoke any significant change in HRV. CONCLUSION: EMFs produced by incubators influence newborns' HRV, showing an influence on their autonomous nervous system. More research is needed to assess possible long-term consequences, since premature newborns may be exposed to these high EMFs for months.

Is prenatal bonding enhanced by prenatal education courses?

AIM: Prenatal education courses (PEC) are a way of allaying anxiety in pregnancy. PEC consist of a series of five 1-hour lessons in the first and second trimesters of pregnancy. Conducted by nurses or midwives, the course syllabus includes the basics of fetal physiology and development, singing sessions, dance sessions, massage-through-the-womb sessions. Here we investigated whether they can enhance feto-maternal bonding. METHODS: We studied 77 pregnant women (mean age: 31.5+/-4.1 years), 36 of whom attended PEC. We used the Prenatal Attachment Inventory (PAI), a validated 21-item questionnaire, to score prenatal bonding and compared the scores of the two groups. Three months after delivery, we asked the mothers to fill in another questionnaire to assess infant and maternal well-being. RESULTS: The PEC group showed a higher PAI score than the control group (65.5+/-6.9 vs. 59.9+/-6.1; P<0.05). Babies born to the PEC group had a higher frequency of unexplained crying. CONCLUSION: PEC positively influenced prenatal attachment. More studies are needed to assess whether this may be useful for the development of the mother-infant relationship.

Early oxidative stress in amniotic fluid of pregnancies with Down syndrome.

OBJECTIVE: Some evidence suggests that oxidative stress, due to an imbalance between oxidants and antioxidants, occurs in babies with Down syndrome (DS). This study tests the hypothesis that oxidative stress occurs early in DS pregnancies. DESIGN AND METHODS: Isoprostanes (IPs), a new marker of free radical-catalyzed lipid peroxidation, were measured in amniotic fluid from pregnancies with normal, growth restricted and DS fetuses, diagnosed by karyotype analysis of amniotic cells cultured. RESULTS: A nine-fold increase in IP concentrations was found in amniotic fluid of pregnancies with DS fetuses. This increase (595.15; 542.96-631.64 pg/ml, median; 95% CI), was greater than in pregnancies with fetal growth-restricted fetuses (155; 130.57-172.23 pg/ml, median; 95% CI) and normal fetuses (67; 49.82-98.38 pg/ml, median; 95% CI; p<0.0001). CONCLUSIONS: The study reveals that oxidative stress occurs early in pregnancy and supports the idea of testing whether prenatal antioxidant therapy may prevent or delay the onset of oxidative stress diseases in the DS population.