Verbal Communication with the Patient Is Not Enough: The Six Languages of the Sick.

Evidence shows that verbal communication is just one of the ways patients indicate their wishes. For a sufficiently careful communication, we should also grasp other five unusual though evident languages: (a) body language, (b) the way patients manage their environment, (c) unconscious language, (d) lab-evidenced language, and (e) the way they master technology. So, we have six languages that should be intertwined to understand the real language of the sick. Grasping these languages helps health professionals frame the patient's mood, their level of suffering or mental growth, and understand what words alone cannot express. Words cannot express completely what a patient senses: for subjection, shyness, because some patients are still non-verbal or because verbal communication is just a useful way of freezing concept but has not the same fluidity and liberty of the other above-described languages. It is mandatory for caregivers to wonder how many of these languages they are actually decrypting during an interview with the patient. On the other hand, caregivers unconsciously communicate much through two unexpected languages: the architectural language and the language of medical procedures. The way they welcome or obstruct the patient, their hesitations across a treatment, or in showing a serene collegiality are forms of subtle communication. A paradigmatic scenario where all these languages should be implemented is the "informed consent" process, which should be turned into a "shared therapeutic pathway", summing up all the communicative modes illustrated in the text.

Management of pain in newborn circumcision: a systematic review.

Male circumcision (MC) is one of the most common surgical procedures performed on neonates. In the last decades, there have been consistent advances in the understanding of pain mechanisms in newborns, and analgesia has become a fundamental part of neonatal care. MC is still often performed with inappropriate analgesic methods, and there is still great variability among the various centers about surgical and anesthethic techniques to do it. The purpose of this review is to summarize the findings in the literature about pain management and analgesia during newborn MC. We performed a systematic review of neonatal MC studies published in the last 20 years. The most effective technique appeared to be the combination of pharmacological and non-pharmacological methods of analgesia.Conclusion: Combining local anesthesia with non-pharmacological analgesic strategies appears to be effective preventing procedural pain during MC. However, a standardized protocol for analgesia during MC is yet to be determined. Sensorial saturation appeared to help when used in conjunction with the local anesthesia techniques. What is Known: • Male circumcision is a painful procedure and it is frequently performed with inappropriate analgesic methods. • A gold standard practice in analgesia during male circumcision is still lacking and there is a great variability in the modus operandi between centers. What is New: • The combination of RB + EMLA + sucrose appears to be an analgesic strategy superior to other approaches. • We advocate for the integration of sensorial saturation during male circumcision in order to improve the efficacy of current analgesic practices.

Modified Sensory Stimulation Using Breastmilk for Reducing Pain Intensity in Neonates in Indonesia: A Randomized Controlled Trial.

PURPOSE: Several studies have shown that oral sucrose reduces pain in newborns. However, sucrose has no efficacy in eliminating pain and long-term effects remain unclear. Breast milk may be useful as an alternative, safe sweet solution. Sensorial saturation (SS) is a multisensory analgesic non-pharmacological treatment, which includes touch and sounds as distractors. This study aimed to compare the analgesic effects of SS with sucrose (SSS), SS with breast milk (SSB), and oral sucrose alone (S24%) in neonates undergoing venipuncture. DESIGN AND METHODS: This was a randomized controlled trial conducted on 108 neonates who underwent venipuncture at neonatology wards. All babies were randomly assigned to one of three groups: two intervention groups and one control group. Pain response was assessed using the premature infant pain profile-revised (PIPP-R). Data analysis was conducted using the Kruskal-Wallis test and Mann-Whitney U test. RESULTS: SSB and SSS were more effective than S24% (p = 0.001). No difference was observed between SSB and SSS (p = 0.669). CONCLUSION: Multisensory stimulation is more effective in reducing pain than unimodal (oral sucrose) analgesia. Breast milk can be used as a sensory gustatory stimulus in multisensory stimulation to reduce pain intensity in neonates, and demonstrates a similar analgesic effect to sucrose. PRACTICE IMPLICATIONS: The study findings suggest that neonatal nurses could use SSB for management of pain. This intervention could serve as an effective, inexpensive, and safe non-pharmacological analgesic. Additional testing of this intervention is warranted to support its use as an evidence-based pain reduction approach.

Electromagnetic fields in neonatal incubators: the reasons for an alert.

BACKGROUND: Neonatal incubators are important tools for sick newborns in the first few days of life. Nevertheless, their electric engine, often very close to the newborn's body, emits electromagnetic fields (EMF) to which newborns are exposed. Aim of this paper is to review the available literature on EMF exposure in incubators, and the effects of such exposures on newborns that have been investigated. METHODS: We carried out a systematic review of studies about EMF emissions produced by incubators, using Medline and Embase databases from 1993 to 2017. RESULTS: We retrieved 15 papers that described the EMF exposure in incubators and their biological effects on babies. EMF levels in incubators appear to be between 2 and 100 mG, depending on the distance of the mattress from the electric engine. In some cases, they exceed this range. These values interfere with melatonin production or with vagal tone. Even caregivers are exposed to high EMF, above 200 mG, when working at close contact with the incubators. CONCLUSION: EMF have been described as potentially hazardous for human health, and values reported in this review are an alert to prevent babies' and caregivers' exposure when close to the incubators. A precautionary approach should be adopted in future incubator design, to prevent high exposures of newborns in incubators and of caregivers as well.

Evidence-based clinical guidelines on analgesia and sedation in newborn infants undergoing assisted ventilation and endotracheal intubation.

AIM: This review informed pain control guidelines for clinicians performing mechanical ventilation, nasal continuous positive airway pressure and endotracheal intubation on term and preterm newborn infants. METHODS: We reviewed literature published between 1986 and June 2017 on analgesia and sedation during assisted ventilation and before endotracheal intubation in newborn infants admitted to neonatal intensive care units. The subsequent guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Our review produced five strong standard of care recommendations. One, reduce neonatal stress and use nonpharmacological analgesia during invasive ventilation. Two, favour intermittent boluses of opioids, administered after pain scores and before invasive procedures, during short expected periods of mechanical ventilation, mainly in preterm infants affected by respiratory distress syndrome. Three, do not use morphine infusion in preterm infants under 27 gestational weeks. Four, always use algometric scores to titrate analgesic drugs doses. Five, use premedication before endotracheal intubation for a more rapid, less painful, less traumatic and safer manoeuvre. We also developed 30 conditional recommendations on therapeutic options. CONCLUSION: Our review produced 35 recommendations on standard care and therapeutic options relating to the analgesia and sedation of newborn infants during ventilation and before endotracheal intubation.

Literature review informs clinical guidelines for pain management during screening and laser photocoagulation for retinopathy of prematurity.

AIM: The aim of this study was to carry out a literature review and develop clinical guidelines for pain prevention and control during screening and laser photocoagulation for retinopathy of prematurity (ROP) in neonatal intensive care units (NICUs). METHODS: The Italian Society of Neonatology assessed papers published between 1986 and June 2017 and used the Grading of Recommendations, Assessment, Development and Evaluation approach, to develop new guidelines on pain and ROP. RESULTS: The Society's pain experts assessed the full texts of 47 papers, including randomised or quasi-randomised controlled trials and case-control studies on nonpharmacological and pharmacological measures used in NICUs during the screening and laser photocoagulation of neonates for ROP. The literature suggested methods for reducing the stress and pain associated with ROP screening procedures. The panel concluded that the literature showed that it was feasible to provide laser photocoagulation for ROP in spontaneously breathing patients with adequate analgesia. CONCLUSION: This literature review on managing pain in infants with ROP in NICUs led to the development of national guidelines, which will help physicians and nurses to reduce the stress and pain experienced by premature newborn infants during unavoidable screening and treatment for ROP.

Sensorial saturation and neonatal pain: a review.

AIM: Sensorial saturation (SS) is an analgesic approach to babies' pain that includes three types of stimulations: oral sugar, massage and caregivers' voice. The aim of this review is to assess its efficacy. METHODS: We performed an analysis of scientific literature from 2001 to 2017, retrieving those clinical trials where SS had been compared with other analgesic treatments during procedural pain in babies. RESULTS: We retrieved 14 studies. Pain sources were heel-prick in nine, eye examination and intramuscular shots in two each, and endotracheal aspiration in one. SS was the most effective treatment in all cases, except in endotracheal suctioning. No drawbacks were reported in any study using SS. CONCLUSION: SS is a safe and effective approach to neonatal pain due to heel-prick, more effective than oral sucrose or glucose in both term and preterm babies; it seems also effective in other types of acute procedural pain like eye examination or intramuscular injections, but more studies are needed to confirm these preliminary data. More studies are also needed to test SS efficacy for other procedures, and for older infants.

Systematic review of nonpharmacological analgesic interventions for common needle-related procedure in newborn infants and development of evidence-based clinical guidelines.

The aim of this literature review was to develop clinical guidelines for the prevention and control of needle-related 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. CONCLUSION: There was sufficient evidence to strongly support the use of nonpharmacological interventions for common needle-related procedures in newborn infants. Combined interventions seemed to be more effective in relieving procedural pain.

Cardiac Adaptation to Severe Congenital Diaphragmatic Hernia.

OBJECTIVE: Prenatal heart adaptations to congenital diaphragmatic hernia (CDH) could help define postnatal outcome. METHODS: We retrospectively analyzed post-mortem tissues from fetuses with severe CDH (n = 7). Histology and immunohistochemical distribution of desmin, muscle actin [HHF35], endothelin-1 [ET-1] and TGF-ß were evaluated. RESULTS: In the atrium, desmin, HHF35, ET-1, TGF-ß were found expressed only in preterm CDH. Dishomogeneous ventricular distribution of cardiac growth factors were detected in term CDH. The cardiomyocyte nucleus/cytoplasmatic ratio in CDH was higher compared with controls (p = 0.01). Small intramyocardial artery density and vascular wall thickness was increased in CDH compared with controls (p = 0.03 and p < 0.01). In comparison with the ventricles, the interventricular septum showed a greater vessel density (p = 0.01) and a greater vascular wall thickness, particularly compared with the CDH right ventricle (p = 0.02). CONCLUSION: Left ventricle immaturity seems to be a cardiac adaptive response of severe CDH in utero.

Fetal surgery and maternal cortisol response to stress. The myelomeningocele sheep model.

BACKGROUND: Prenatal surgery represents a multifactorial stressor event for mother and fetus. The stress response to fetal surgery was evaluated by measuring maternal plasma and amniotic fluid (AF) cortisol levels in the myelomeningocele (MMC) sheep model. SUBJECTS AND METHODS: Pregnant ewes (n = 8) underwent general anesthesia for MMC-induction (step 1: 75 d gestation), surgical defect repair (step 2: 110 d gestation), and delivery (step 3: 140 d gestation). Maternal blood samples were taken before surgery (surgical stage T1), after laparotomy and uterine exposure (surgical stage T2), at the end of the procedure (surgical stage T3). Fetal stress was evaluated by measuring cortisol levels in AF after hysterotomy at steps 1-3. RESULTS: Maternal cortisol concentrations at T2 and T3 increased compared with T1 (p = 0.019 and p = 0.046). AF cortisol response increased from 1 to 3 surgical steps and during pregnancy. The AF cortisol level was lower than maternal serum levels (induction p < 0.001; repair p < 0.001; caesarean section p < 0.001). CONCLUSIONS: Hysterotomy was the most stressful event in the ewes. Fetuses seemed to be partially protected from the high maternal cortisol levels. The fetal stress response to prenatal surgery increased with gestational age. Pain perception development, fetal maturation, and "pain memory" are probably associated with this increase.

Should we assess pain in newborn infants using a scoring system or just a detection method?

UNLABELLED: Newborn infants' pain should be scored indirectly using dedicated pain scales. Unfortunately, while some scales for prolonged pain have given good results, a gold standard to assess acute pain does not exist. Acute pain scales still have weak points, most are complex and are scarcely used in neonatal departments. Moreover, carefully scoring pain in clinical practice seems redundant, because any avoidable pain is a concern. This suggests that researchers must find new ways to assess acute pain. A possible approach is to settle for pain detection instead of pain scoring in selected cases. Here, we describe a two-point method that illustrates this approach. CONCLUSION: For everyday practice, detecting pain is more useful than scoring it; acute pain scales should be reserved for research, for those clinical settings where the personnel has received a careful training and where overcrowding and hurry are absent.

Music provided through a portable media player (iPod) blunts pain during physical therapy.

This research studied, 25 adult patients who underwent physical therapy to assess the analgesic effect of distraction with the use of music during physical therapy. Patients randomly underwent physical therapy once with music provided by an iPod and once without music. In both sessions patients underwent identical physical procedures. At end of both sessions patients filled in 5-item questionnaire where they scored pain and other parameters, such as stress, enjoyment, interaction, and satisfaction, on 10-cm visual analog scale. The mean scores (range, 0-10) of the two sessions were statistically compared. Mean pain scores were significantly lower (p = .031) during the session in which patients received music (4.8 ± 2.5) than during the session without music (5.8 ± 2.3). The other items of the questionnaire did not disclose any statistically significant difference when the sessions with versus without music were compared. Enjoyment (8.5 ± 1.6), interaction (8.3 ± 1.9), and satisfaction (8.6 ± 1.7) scores with music did not significantly differ in the sessions without music (8.5 ± 2.1, 8.5 ± 1.9, and, 8.5 ± 1.5, respectively); mean stress score was, 3.9 in both sessions. The conclusion of the study is that music provided through a portable media player has an analgesic effect. This can be an effective analgesic strategy during painful physical therapy.

Pain assessment in human fetus and infants.

In humans, painful stimuli can arrive to the brain at 20-22 weeks of gestation. Therefore several researchers have devoted their efforts to study fetal analgesia during prenatal surgery, and during painful procedures in premature babies. Aim of this paper is to gather from scientific literature the available data on the signals that the human fetus and newborns produce, and that can be interpreted as signals of pain. Several signs can be interpreted as signals of pain. We will describe them in the text. In infants, these signs can be combined to create specific and sensible pain assessment tools, called pain scales, used to rate the level of pain.

Is newborn melatonin production influenced by magnetic fields produced by incubators?

BACKGROUND: During permanence in most incubators, newborns are very close to the electric engine, which represents a source of electromagnetic fields (EMF). Previous studies demonstrated a decrease in melatonin production in adults and animals exposed to EMF. AIMS: To assess melatonin production in a group of newborns exposed to EMF, and to evaluate whether removing the babies from the source of MF can affect melatonin production. STUDY DESIGN AND SUBJECTS: We have recruited 28 babies (study group), who had spent at least 48 h in incubator where we had previously assessed the presence of significant EMF. We have measured their mean 6-hydroxy-melatonin-sulfate (6OHMS) urine excretion at the end of their permanence in the incubators, and compared it with their mean 6OHMS excretion after having been put in cribs, where EMF are below the detectable limit (<0.1mG). We have also measured urine 6OHMS twice, with an interval of 48h, in a control group of 27 babies who were not exposed to EMF during both samples. RESULTS: Mean 6OHMS/cr values were respectively 5.34±4.6 and 7.68±5.1ng/mg (p=0.026) when babies were exposed to EMF in incubators, and after having been put in the crib. In the control group, mean 6OHMS/cr values in the first and in the second sample were respectively 5.91±5.41 vs 6.17±3.94ng/mg (p=0.679). CONCLUSIONS: The transitory increase in melatonin production soon after removing newborns from incubators demonstrates a possible influence of EMF on melatonin production in newborns. Further studies are needed to confirm these data.

Sensorial saturation for infants' pain.

INTRODUCTION: Sensorial saturation (SS) is a multisensorial stimulation consisting of delicate tactile, gustative, auditory and visual stimuli. This procedure consists of simultaneously: attracting the infant's attention by massaging the infant's face; speaking to the infant gently, but firmly, and instilling a sweet solution on the infant's tongue. METHODS: We performed a systematic Medline search of for articles focusing on human neonatal studies related to SS. The search was performed within the last 10 years and was current as of January 2012. RESULTS: We retrieved 8 articles that used a complete form of SS and 2 articles with an incomplete SS. Data show that the use of SS is effective in relieving newborns' pain. Oral solution alone are less effective than SS, but the stimuli without oral sweet solution are ineffective. the partial forms of SS have some effectiveness, but minor than the complete SS. Only one article showed lack of SS as analgesic method, after endotracheal suctioning. CONCLUSIONS: SS can be used for all newborns undergoing blood samples or other minor painful procedures. It is more effective than oral sugar alone. SS also promotes interaction between nurse and infant and is a simple effective form of analgesia for the neonatal intensive care unit.

Neonatal risks from in vitro fertilization and delayed motherhood.

Delayed childbearing (DC) is common in most Western countries. The average age of first-time mothers increased in United States from 21.4 years in 1970 to 25.0 years in 2006 and from 25.4 to 30.8 years in Australia in the same period. It is commonly believed that this has no ominous consequences. But several negative consequences of this behavior are described: stillbirth, prematurity, twins, birth anomalies. Age also decreases women's fertility, thus many couples undergo in vitro fertilization. And we highlight a paradox: medical reproduction techniques decreases their effectiveness with maternal age, but their availability can be an incentive to postpone parenthood. Of course the risks of delayed parenthood involve a minority of cases, but are parents entitled to accept any risk on the behalf of their baby A complete information would make people cautious before deciding to postpone childbearing, though this is often an obliged rather that a free choice: the consumerist society pressure and the difficulty to find an employment have their heavy weight in this choice. But if this choice is not really free, people's interest is to overcome these pressures and to claim for a real broad choice on when becoming parent, despite the pressures made by their cultural environment to postpone parenthood. Moreover, even reproductive techniques have some risks. Unfortunately, mass media often praise and endorse DC, disregarding the increase of premature babies born because of DC, a real alarm for public health. Pediatricians should discourage the culture that makes DC a normal event.

Is fetal pain a real evidence?

UNLABELLED: Due to the progress in fetal surgery, it is important to acquire data about fetal pain. MATERIAL AND METHODS: We performed a Medline research from 1995, matching the following key words: "pain" and "fetus", with the following: "subplate", "thalamocortical", "myelination", "analgesia", "anesthesia", "brain", "behavioral states", "substance p". We focused on: (a) fetal development of nociceptive pathways; (b) fetal electrophysiological, endocrinological and behavioral reactions to stimuli and pain. RESULTS: We retrieved 217 papers of which 157 were highly informative; some reported similar data or were only case-reports, and were not quoted. Most endocrinological, behavioral and electrophysiological studies of fetal pain are performed in the third trimester, and they seem to agree that the fetus in the 3rd trimester can experience pain. But the presence of fetal pain in the 2nd trimester is less evident. In favor of a 2nd trimester perception of pain is the early development of spino-thalamic pathways (approximately from the 20th week), and the connections of the thalamus with the subplate (approximately from the 23rd week). Against this possibility, some authors report the immaturity of the cortex with the consequent lack of awareness, and the almost continuous state of sleep of the fetus. CONCLUSIONS: Most studies disclose the possibility of fetal pain in the third trimester of gestation. This evidence becomes weaker before this date, though we cannot exclude its increasing presence since the beginning of the second half of the gestation.

Ethical charter of Union of European Neonatal and Perinatal Societies.

The Union of European Neonatal and Perinatal Societies, worried for the lack of unanimous guidelines in the ethical domain, propose a 10-point charter about the ethical rights of the newborns. It is complementary to other charters, such as the United Nations charter of children's rights, but it adds some specific and debated points, to find a common denominator, hopefully useful to the ongoing debate.

Whole body hypothermia and oxidative stress in babies with hypoxic-ischemic brain injury.

According to increasing evidence, hypothermia can significantly improve outcomes in term neonates manifesting asphyxic insult and hypoxic-ischemic encephalopathy. Oxidative stress plays a key role in hypoxic-ischemic and inflammatory brain injuries. We investigated the impact of hypothermia on oxidative stress in babies with hypoxic-ischemic encephalopathy. Term infants were randomly selected for treatment with moderate whole body hypothermia or standard care on normothermia, after perinatal asphyxia. Total hydroperoxides as biochemical markers of oxidative stress, and C-reactive protein as a marker of inflammation, were assayed in blood samples drown at 6, 12, 24, 48, and 72 postnatal hours. In both hypothermic and normothermic groups, total hydroperoxides and C-reactive protein exhibited a continuous increase in the first days after birth. Nevertheless, a tendency was evident for slower and smaller elevations of total hydroperoxides and C-reactive protein in hypothermic compared with normothermic infants. A significant correlation was observed between total hydroperoxides and C-reactive protein in all patients, indicating an association between inflammation and oxidative stress during asphyxia. The slower increase and lower peaks of total hydroperoxides in the hypothermic group support the hypothesis that postasphyxic oxidative stress may be reduced by hypothermia.