Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!

BACKGROUND: Almost 20% of neonates experience pain during delivery or the period following birth. AIM: To describe the practices of pain assessment in the maternity wards in the greater Paris area, France. METHODS: An e-mail questionnaire was sent to each practitioner in the 96 maternity units in Île de France between December 2013 and February 2014. RESULTS: In all, 63 (65%) questionnaires were completed. Pain was assessed in 43 (68%) maternity units, mostly using the French scale "échelle de douleur et d'inconfort du nouveau-né" (EDIN). In total, 20 maternity units (32%) reported no pain assessment, mainly because they considered it to be too time-consuming, or because they argued that no pain scale was adequate; they relied on clinical signs or on the obstetric history for assessing and treating pain. About 40% of the maternity units using the EDIN scale judged it unsuitable for evaluating pain in term neonates in maternity units. CONCLUSION: This first regional study on pain assessment in the maternity ward showed that nearly two thirds of centers assessed pain. This rate may be overestimated because of the reporting method used. The EDIN scale is the most widely used tool but seems unsuitable especially for the delivery room setting. Studies should be conducted to test other tools for assessing neonatal pain in the delivery room.

Management of healthy newborns in the delivery room and maternal satisfaction.

INTRODUCTION: The first exchanges between a newborn baby and its mother are essential. Any separation can have negative effects on the establishment of the first connections as well as breastfeeding. OBJECTIVE: To establish the current state of management of healthy newborn babies in the delivery room and assess the reasons for possible separation and the feelings of mothers facing this separation. MATERIALS AND METHODS: Observational descriptive single-center study, made up of two parts: 1/a questionnaire given to the mothers, postpartum; 2/the collection of data concerning the transfer of healthy newborn babies to the nursery. RESULTS: The study took place over a period of 8 weeks. Eighty-five mothers were interviewed. Seventy-two percent of the newborn babies left the delivery room during the first 2h of life. For 67 %, the duration of skin-to-skin contact was less than 1h. For 49 %, the main reason was the performance of routine care. The mothers were satisfied with the care provided in the delivery room. CONCLUSION: Too many healthy newborn babies are separated from their mothers during the first 2h of life, mainly for routine care. Skin-to-skin contact must be part of the physiological reception of newborn babies in the delivery room. The medical staff and parents must be informed of this aspect and its beneficial effects. It is necessary to reconsider the organization of practices to propose a management system that promotes the establishment of a strong mother-child bond.

[Do analgesic sweet solutions in neonates influence glycemia? A literature review]. / Les solutions sucrées à visée antalgique chez le nouveau-né modifient-elles la glycémie ? Synthèse de la littérature.

Sweet solutions are one of the most widely used nonpharmacologic analgesics used for newborns. They alleviate mild to moderate pain induced by painful procedures. They are used daily in neonatal intensive care units before a venepuncture or a heel stick, especially for a blood-sugar measurement. It is agreed that analgesic sweet solutions do not modify glycemia results. This nevertheless remains a recurrent question that the present review attempts to answer.

[Implementation of a specific premedication protocol for tracheal intubation in the delivery room. Practice in two level-III hospitals]. / Impact d'un protocole de sédation avant intubation trachéale en salle de naissance. Pratiques dans deux centres de niveau III.

UNLABELLED: Tracheal intubation in neonates is a painful procedure performed daily in the delivery room despite the widespread development of noninvasive ventilation. Specific analgesia is not commonly performed. The objective of this observational study was to compare practices between two level-III centers: one with a specific protocol for premedication before tracheal intubation of newborns in the delivery room, the other without. RESULTS: One hundred and fifteen neonates were intubated in the delivery room and included over a 4-month period: 25% of them received specific premedication before intubation, exclusively in the center with the protocol. None of the extreme premature neonates (age≤28 gestational weeks) received analgosedation before the procedure. Nalbuphine, midazolam, and sufentanil were mainly used, via the intravenous or intrarectal route. Infants receiving a premedication were significantly heavier and had a greater gestational age than the others (1500 g [range, 1180-2260 g] vs. 1170 [range, 860-1680 g] P=0.003, and 31 GW [range, 29-34 GW] vs. 29 [range, 27-32 GW] P=0.014, respectively). Most pediatricians (85-100%) favored a specific protocol for sedation before tracheal intubation. Implementation of a specific protocol allows specific analgesia to be implemented for newborns undergoing tracheal intubation. Further studies should be conducted to determine the best strategies for pain management during tracheal intubation of neonates, especially in the delivery room.

[Epididymo-orchitis in a newborn: rare illness revealing late-onset Streptococcus agalactiae meningitis]. / Orchi-épididymite néonatale : une affection rare révélatrice d'un sepsis secondaire à streptocoque du groupe B.

Acute scrotum is unusual during the neonatal period. Testicular torsion is a surgical emergency aimed at salvaging the affected testis. Epididymo-orchitis is the main differential diagnosis, but few cases have been described in the newborn. Here, we report the case of a late-preterm infant who presented with late-onset group B streptococcal sepsis revealed by unilateral epididymo-orchitis.

[Premedication before tracheal intubation in French neonatal intensive care units and delivery rooms]. / Sédation-analgésie avant intubation trachéale en réanimation néonatale et en salle de naissance: pratiques en France métropolitaine.

UNLABELLED: Tracheal intubation is a painful procedure commonly used in the neonatal intensive care units and in the delivery rooms. It can be complicated by changes in vital signs. OBJECTIVE: To ascertain the use of sedatives and/or analgesics before tracheal intubation in French neonatal intensive care units and delivery rooms. METHODS: A survey by questionnaire sent to 58 neonatal intensive care units and 58 maternities. RESULTS: We obtained 46 responses (79,3%) from the neonatal intensive care units and 38 (65,5%) from the delivery rooms. In neonatal intensive care units, 74% of the newborns received a sedative and/or an analgesic before being intubated, and 60% of the units had specific written guidelines. Opioïds and benzodiazepines were the main drugs used. In the delivery rooms, sedatives or analgesics were only used in 21% of the centres. CONCLUSION: The use of sedation-analgesia seems to improve in neonatology but is still insufficient in the delivery rooms. The development of specific guidelines and a best learning about the different drugs are necessary.

[Paediatricians involvement in paediatric emergency care. A study in hospitals and paediatricians offices in the North of France]. / Implication des pédiatres dans l'accueil des urgences. Enquête "un jour donné" auprès des centres hospitaliers et des pédiatres libéraux de la région Nord - Pas de Calais.

UNLABELLED: Paediatrician involvement in paediatric emergency care is often considered insufficient. OBJECTIVES: To assess paediatrician involvement in paediatric emergency care, and how paediatric emergencies were dealt with in emergency department, paediatric emergency department, paediatric department and paediatrician offices. METHODS: Prospective multicentric study, January 29th, 2001, including all the emergency visits of children admitted to an emergency department, paediatric emergency department, paediatric department or in paediatrician offices. RESULTS: Paediatricians examined an average number of 21 children, 58% were considered as "urgent" (mean: 53% +/- 25% by paediatrician). Thirty five percent of paediatricians were available on call that night. In the 18 hospitals, 705 children were admitted that day, 42% to an emergency department, 40% to a paediatric emergency department, 18% to a paediatric department. The mean age was 6 years +/- 5 years. Trauma represented 40% of all cases and was more frequent in emergency department than in paediatric emergency department or paediatric department (63% versus 33% and 2%, p < 10(-8)). Hospitalisation rate was lower in paediatric emergency department than in emergency department and paediatric department, especially for non-traumatic conditions. CONCLUSION: Our findings prove paediatrician involvement in paediatric emergency care, in paediatrician offices and in hospital. This study points out the complementarity and insufficiencies of these different services.

[Practice for insulin infusion in preterm infants]. / Modalités d'administration de l'insuline par voie intraveineuse chez le nouveau-né prématuré.

UNLABELLED: Transient neonatal hyperglycemia is commonly observed during the first week of life in the preterm infants less than 30 weeks of gestational age. Continuous insulin infusion is an effective treatment in this situation. OBJECTIVE: To ascertain how insulin is administered in different french neonatal intensive care units. MATERIAL AND METHODS: We surveyed 49 neonatal intensive care units with a questionnaire. Response rate was 77.5% (38/49). RESULTS: Thirty four of 38 neonatal intensive care units reported the use of insulin infusions in this setting. Glucose level indicating insulin therapy and the initial insulin doses were quite variable according to the different units (respectively 7-16.5 mmol/l and 0.01-0.1 U/kg/h). A range of minimal insulin concentrations was used (0.01-0.1 U/ml), 57% utilizing concentration between 0.05 and 0.2 U/ml. Flow rates below 0.3 ml/h were used at time by 76%. Albumin was rarely added. Fifty seven percent of the neonatal intensive care units took counter-measures such as preconditioning and flushing the tubing to control insulin loss due to adsorption. The counter-measures were differently applied. Despite these measures, hyperglycemia and insulin resistance were frequently observed (respectively 30% and 47%). The different practices are discussed according to the literature. CONCLUSION: In order to deliver insulin reliably, we suggest an insulin delivery method for the preterm infants.

Admission plasma vasopressin levels in children with meningococcal septic shock.

OBJECTIVE: Vasopressin (AVP) response has been reported to be inappropriately low in adult established septic shock. We studied admission AVP levels in children with meningococcal septic shock (MSS). PATIENTS AND METHODS: All children with meningococcal infection admitted to our PICU between May 2001 and August 2002 were classified as MSS (persistent hypotension despite fluid therapy, with perfusion abnormalities and the need for vasoactive drug infusion for at least 24 h or until death), or meningococal infection without shock (fever and purpura, with or without meningitis). Blood samples were collected at admission and AVP levels were subsequently determined using Nichols Institute Diagnostics vasopressin assay. Eighteen of 19 children with MSS (7 deaths) and 15 without shock (no death) were included. RESULTS: In children with MSS median admission AVP level was 41.6 pg/ml (1.4-498.9) and in those without 3.3 pg/ml (1.6-63.8). In children with MSS the AVP level was not correlated with duration of shock and fluid expansion prior to AVP sampling, or with age-adjusted blood pressure and natremia at the time of blood sampling. AVP levels were higher in nonsurvivors, but not significantly so. Only one nonsurvivor had an admission AVP level below 30 pg/ml. CONCLUSIONS: In our children with established MSS who died the admission AVP level Delta were not inappropriately low. Further studies including serial AVP level assessments are needed before concluding that AVP administration is of little interest in children with MSS.

The Richieri-Costa and Pereira form of acrofacial dysostosis: first case in a non-Brazilian infant.

We report on a French boy with cleft mandible, pre/postaxial hand anomalies, and clubfoot born to consanguineous parents. These findings are comparable to those of previous cases of the autosomal recessive Richieri-Costa and Pereira syndrome of short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfoot. This is the first case in a non-Brazilian infant.