Benjamin Israel Kopelman

Differences in pain expression between male and female newborn infants

Abstract The study of neonatal gender differences in pain expression is important since neonatal pain behavior occurs prior to any learned reaction pattern. The objective of this study was to verify the presence of gender differences in pain expression in preterm and term newborn infants. Sixty‐five consecutive neonates (37 female and 28 male infants) with gestational age between 28 and 42 weeks and with 25–120 h of life were studied. Healthy term neonates required a capillary puncture for PKU screening and clinically stable premature infants needed a capillary puncture for glucose dosage. The Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS) were evaluated at bedside prior to the puncture, when patients were at rest, during foot heating; during capillary puncture; and at 1, 3, and 5 min after heel lancing. Results were analyzed by repeated‐measures ANOVA followed by the Multiple Comparison Method of Bonferroni. A significant difference among the mean NFCS scores during the six study periods was noted for the whole group of neonates (P<0.000001). Also, a significant interaction between the NFCS score profile in female and male neonates at the different study periods was observed (P=0.025). Regarding NIPS, ANOVA showed only a significant difference among the mean NIPS scores during the six study periods for the whole group of neonates (P<0.000001). No significant interactions between gestational age and time, nor between gestational age and gender were noted, for both NFCS and NIPS. In conclusion, recently born female neonates of all gestational ages expressed more facial features of pain than male infants, during the capillary puncture and 1 min afterwards. Maybe differences in pain processing and/or pain expression among genders may explain this finding.

Physiological, hormonal, and behavioral responses to a single fentanyl dose in intubated and ventilated preterm neonates

OBJECTIVE To study the responses of ventilated preterm neonates to a single dose of opioid. STUDY DESIGN In a randomized, double-blind, controlled trial, 22 mechanically ventilated preterm infants (< or = 32 weeks) were observed before medication and at 30 and 60 minutes after administration of fentanyl (3 micrograms/kg) or placebo. Heart rate, blood pressure, arterial blood gases, ventilator settings, and behavioral measures (Neonatal Facial Coding System and Modified Postoperative Comfort Score) were recorded during each period. Blood cortisol, growth hormone, glucose, and lactate were measured before and at 60 minutes after analgesia. Behavioral measures were assessed at the bedside and from video films recorded during each observation period. RESULTS Patients presented high basal levels of cortisol, growth hormone, and lactate. Behavioral scales indicated the presence of pain before any medication. In the fentanyl group, the maximum and minimum heart rate decreased and growth hormone level increased after analgesia. At the video analysis of behavioral measures, postoperative comfort score increased and neonatal facial coding system score decreased in the fentanyl group. CONCLUSION Single doses of fentanyl analgesia can reduce the physiologic/behavioral measures of pain and stress associated with mechanical ventilation in preterm infants.

Validity of behavioral and physiologic parameters for acute pain assessment of term newborn infants

CONTEXT The subjectivity of pain causes enormous difficulties in evaluating neonatal pain with a single, practical and easy-to-apply tool. Pain evaluation in the neonatal period should be performed by valid, safe, useful and feasible methods. OBJECTIVE To evaluate the validity of the Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), heart rate (HR) and O2 saturation (O2 sat) for neonatal pain assessment. DESIGN Prospective, double-blind randomized trial. SETTING A secondary level maternity hospital. PARTICIPANTS 70 healthy neonates requiring bilirubin dosage were randomly assigned to receive a venous puncture (P: n = 33, BW 3.2 kg, SD 0.6; GA 39 wk, SD 1; 59 h of life, SD 25) or an alcohol swab friction (F: n = 37; BW 3.1 kg, SD 0.5; GA 39 wk, SD 1; 52 h of life, SD 17). INTERVENTION All measurements were taken prior to (PRE), during (TO), and 1 (T1), 3(T3), 5(T5) and 10(T10) minutes after the procedure. MEASUREMENTS A neonatologist evaluated NFCS, NIPS, HR and O2 sat by pulse oxymetry. RESULTS Median NFCS and NIPS results at T0, T1 and T3 were higher in P group, compared to F. More P neonates presented NFCS > 2 and/or NIPS > 3 at T0, T1 and T3. HR was lower in P group at T1. Average O2 sat was above 90% during the whole study period in both groups. CONCLUSION NFCS and NIPS are suitable instruments for neonatal pain evaluation. Heart rate and O2 saturation can be used only as auxiliary methods.

Neonatal late-onset bloodstream infection: attributable mortality, excess of length of stay and risk factors.

Background: Bloodstream infection represents a major threat among neonates under intensive care with considerable impact on morbidity and mortality. This study evaluated extra stay, attributable mortality and the risk factors associated with late-onset bloodstream infection (LO-BSI) among neonates admitted to a neonatal intensive care unit during a 4-year period. Methods: A retrospective matched cohort study was conducted. For each case, there was one control patient without LO-BSI matched for sex, birth weight, gestational age, duration of hospitalization prior to the date of LO-BSI in the respective cases, underlying illness and birth date. A novel test, sequential plan, was employed for attributable mortality analysis in addition to standard tests. Multiple logistic regression was employed for risk factor analysis. Results: Fifty pairs of cases and controls were compared. LO-BSI prolonged hospital stay of 25.1 days in pairs where both subjects survived. Overall attributable mortality was 24% (95% CI: 9–39% p < 0.01) and specific attributable mortality due to Staphylococcus epidermidis was 26.7% (95% CI: 23–30.4%; p = 0.01). Blood and/or blood components transfusion was independently associated with neonatal LO-BSI (OR: 21.2; 95% CI: 1.1–423). Conclusions: LO-BSI infection prolongs hospital stay and is associated with increased mortality among neonates. In the present series, blood transfusion was a significant risk factor for LO-BSI.

Strict red blood cell transfusion guideline reduces the need for transfusions in very-low-birthweight infants in the first 4 weeks of life: a multicentre trial

Background and Objectives  Very‐low‐birthweight infants are among the most heavily transfused patients. The objective of this study was to verify if the introduction of a strict guideline would reduce the need for red blood cell transfusions in the first 4 weeks of life in these neonates.

Reliability of two behavioral tools to assess pain in preterm neonates

CONTEXT One of the main difficulties in adequately treating the pain of neonatal patients is the scarcity of validated pain evaluation methods for this population. OBJECTIVE To analyze the reliability of two behavioral pain scales in neonates. TYPE OF STUDY Cross-sectional. SETTING University hospital neonatal intensive care unit. PARTICIPANTS 22 preterm neonates were studied, with gestational age of 34 +/- 2 weeks, birth weight of 1804 +/- 584 g, 68% female, 30 +/- 12 hours of life, and 30% intubated. PROCEDURES Two neonatologists (A and B) observed the patients at the bedside and on video films for 10 minutes. The Neonatal Facial Coding System and the Clinical Scoring System were scored at 1, 5, and 10 minutes. The final score was the median of the three values for each observer and scale. A and B were blinded to each other. Video assessments were made three months after bedside evaluations. MAIN MEASUREMENTS End scores were compared between the observers using the intraclass correlation coefficient and bias analysis (paired t test and signal test). RESULTS For the Neonatal Facial Coding System, at the bedside and on video, A and B showed a significant correlation of scores (intraclass correlation score: 0.62), without bias between them (t test and signal test: p > 0.05). For the Clinical Scoring System bedside assessment, A and B showed correlation of scores (intraclass correlation score: 0.55), but bias was also detected between them: A scored on average two points higher than B (paired t test and signal test: p < 0.05). For the Clinical Scoring System video assessment, A and B did not show correlation of scores (intraclass correlation score: 0.25), and bias was also detected between them (paired t-test and signal test: p < 0.05). CONCLUSION The results strengthen the reliability of the Neonatal Facial Coding System for bedside pain assessment in preterm neonates.

O que os pediatras conhecem sobre avaliação e tratamento da dor no recém-nascido?

OBJETIVO: analisar os conhecimentos dos pediatras que atuam com pacientes neonatais em relacao a avaliacao e o tratamento da dor do recem-nascido. METODOS: estudo transversal com 104 pediatras (de um total de 110) que trabalhavam em 1999 a 2001, nas sete unidades de terapia intensiva e nos 14 bercarios da cidade de Belem, e responderam a um questionario escrito com perguntas a respeito do seu perfil demografico e do conhecimento de metodos de avaliacao e de tratamento da dor no recem-nascido. RESULTADOS: cem por cento dos medicos referiram acreditar que o recem-nascido sente dor, mas apenas um terco deles conhecia alguma escala para avaliar a dor nessa faixa etaria. A maioria dos entrevistados referia perceber a presenca de dor no recem-nascido por meio de parâmetros comportamentais. O choro foi o preferido para avaliar a dor do bebe a termo; a mimica facial para o prematuro, e a frequencia cardiaca para o neonato em ventilacao mecânica. Menos de 10% dos entrevistados diziam usar analgesia para puncoes venosas e capilares; 30 a 40% referiam empregar analgesia para puncoes lombares, dissecacoes venosas, drenagens de torax e ventilacao mecânica. Menos da metade dos entrevistados referiu aplicar medidas para o alivio da dor no pos-operatorio de cirurgia abdominal em neonatos. O opioide foi o medicamento mais citado para a analgesia (60%), seguido pelo midazolam (30%). CONCLUSAO: os pediatras demonstraram pouco conhecimento a respeito dos metodos de avaliacao e tratamento da dor no periodo neonatal. Ha necessidade de reciclagens e de atualizacao no tema para os profissionais de saude que atuam com recem-nascidos doentes.

Bacterial Sepsis in Brazilian Children: A Trend Analysis from 1992 to 2006

BACKGROUND The objective of this study was to determine the epidemiology of hospitalized pediatric sepsis in Brazil (1992-2006) and to compare mortality caused by sepsis to that caused by other major childhood diseases. METHODS AND FINDINGS We performed a retrospective descriptive study of hospital admissions using a government database of all hospital affiliated with the Brazilian health system. We studied all hospitalizations in children from 28 days through 19 years with diagnosis of bacterial sepsis defined by the criteria of the International Classification of Diseases (ICD), (Appendix S1). Based on the data studied from 1992 through 2006, the pediatric hospital mortality rate was 1.23% and there were 556,073 pediatric admissions with bacterial sepsis with a mean mortality rate of 19.9%. There was a case reduction of 67% over 1992-2006 (p<0.001); however, the mortality rate remained unchanged (from 1992-1996, 20.5%; and from 2002-2006, 19.7%). Sepsis-hospital mortality rate was substantially higher than pneumonia (0.5%), HIV (3.3%), diarrhea (0.3%), undernutrition (2.3%), malaria (0.2%) and measles (0.7%). The human development index (HDI) and mortality rates (MR) by region were: North region 0.76 and 21.7%; Northeast region 0.72 and 27.1%; Central-West 0.81 and 23.5%; South region 0.83 and 12.2% and Southeast region 0.82 and 14.8%, respectively. CONCLUSIONS We concluded that sepsis remains an important health problem in children in Brazil. The institution of universal primary care programs has been associated with substantially reduced sepsis incidence and therefore deaths; however, hospital mortality rates in children with sepsis remain unchanged. Implementation of additional health initiatives to reduce sepsis mortality in hospitalized patients could have great impact on childhood mortality rates in Brazil.

As representações maternas acerca do bebê que nasce com doenças orgânicas graves

The birth of a baby with serious organic diseases has deep implications in the constitution of the initial link mother-baby. This research aims at investigating the maternal psychic representations about this birth. This qualitative study is based on the psychoanalytic-theoretical field. Semi- structured individual interviews with 11 mothers were carried out during the period of the baby hospitalization in the neonatal ICU. The obtained data were submitted to the content analysis method and showed that the birth of the baby with organic disturbances affects the maternal role, as it disorganizes the representations that were directed before to the idealized healthy baby, marking a recurrent tendency to the equivalence of this baby with his/her disease diagnosis. This birth implies, therefore, in the mourning of the desired child and in the decrease of the maternal self-esteem. The participation in the interviews had therapeutical effects, suggesting the need of an analytycal listening of these mothers during the period the baby remains in the hospital.

A very strict guideline reduces the number of erythrocyte transfusions in preterm infants.

Background and Objectives  Benefits of adopting restrictive guidelines for erythrocyte transfusions are still controversial. The objective of this study was to verify if a very strict guideline could reduce erythrocyte transfusions in preterm infants without adverse outcomes.