Carlo Valerio Bellieni

Guidelines for procedural pain in the newborn

Despite accumulating evidence that procedural pain experienced by newborn infants may have acute and even long‐term detrimental effects on their subsequent behaviour and neurological outcome, pain control and prevention remain controversial issues. Our aim was to develop guidelines based on evidence and clinical practice for preventing and controlling neonatal procedural pain in the light of the evidence‐based recommendations contained in the SIGN classification. A panel of expert neonatologists used systematic review, data synthesis and open discussion to reach a consensus on the level of evidence supported by the literature or customs in clinical practice and to describe a global analgesic management, considering pharmacological, non‐pharmacological, behavioural and environmental measures for each invasive procedure. There is strong evidence to support some analgesic measures, e.g. sucrose or breast milk for minor invasive procedures, and combinations of drugs for tracheal intubation. Many other pain control measures used during chest tube placement and removal, screening and treatment for ROP, or for postoperative pain, are still based not on evidence, but on good practice or expert opinions.

Effect of Multisensory Stimulation on Analgesia in Term Neonates: A Randomized Controlled Trial

Many attempts have been made to obtain safe and effective analgesia in newborns. Oral glucose-water has been found to have analgesic properties in neonates. We investigated whether other sensory stimulation added to oral glucose provided more effective analgesia than oral glucose alone. In a randomized prospective double-blind trial, we studied 120 term newborns during heel prick. The babies were divided randomly into six groups of 20, and each group was treated with a different procedure during heel prick:A) control;B) 1 mL 33% oral glucose given 2 min before the heel prick;C) sucking;D) 1 mL 33% oral glucose plus sucking;E) multisensory stimulation including 1 mL 33% oral glucose (sensorial saturation);F) multisensory stimulation without oral glucose. Sensorial saturation consisted in massage, voice, eye contact, and perfume smelling during heel prick. Each heel prick was filmed and assigned a point score according to the Douleur Aiguë du Nouveau-né (DAN) neonatal acute pain scale. Camera recording began 30 s before the heel prick, so it was impossible for the scorers to distinguish procedure A (control) from B (glucose given 2 min before), C (sucking water) from D (sucking glucose), and E (multisensory stimulation and glucose) from F (multisensory stimulation and water) from the video. Procedure E (multisensory stimulation and glucose) was found to be the most effective procedure, and the analgesia was even more effective than that produced by procedure D (sucking glucose). We conclude that sensorial saturation is an effective analgesic technique that potentiates the analgesic effect of oral sugar. It can be used for minor painful procedures on newborns.

Pain management in the neonatal intensive care unit: a national survey in Italy

Background : This study assessed current medical practice in preventative analgesia and sedation for invasive procedures in neonatal intensive care units (NICU) in Italy.

Sensorial saturation: an effective analgesic tool for heel-prick in preterm infants: a prospective randomized trial.

Pain is traumatic for preterm infants and can damage their CNS. We wanted to assess whether multisensorial stimulation can be analgesic and whether this effect is only due to oral glucose or sucking. We performed a randomized prospective study, using a validated acute pain rating scale to assess pain during heel-prick combined with five different procedures: (A) control, (B) 10% oral glucose plus sucking, (C) sensorial saturation (SS), (D) oral water, and (E) 10% oral glucose. SS is a multisensorial stimulation consisting of delicate tactile, vestibular, gustative, olfactory, auditory and visual stimuli. Controls did not receive any analgesia. We studied 85 heel-pricks (5 per baby) performed for routine blood samples in 17 preterm infants (28–35 weeks of gestational age). We applied in random order in each patient the five procedures described above and scored pain. SS and sucking plus oral glucose have the greater analgesic effect with respect to no intervention (p < 0.001). The effect of SS is statistically better than that of glucose plus sucking (p < 0.01). SS promotes interaction between nurse and infant and is a simple effective form of analgesia for the NICU.

Analgesic effect of watching TV during venipuncture

Aims: To assess the analgesic effect of passive or active distraction during venipuncture in children. Methods: We studied 69 children aged 7–12 years undergoing venipuncture. The children were randomly divided into three groups: a control group (C) without any distraction procedure, a group (M) in which mothers performed active distraction, and a TV group (TV) in which passive distraction (a TV cartoon) was used. Both mothers and children scored pain after the procedure. Results: Main pain levels rated by the children were 23.04 (standard deviation (SD) 24.57), 17.39 (SD 21.36), and 8.91 (SD 8.65) for the C, M, and TV groups, respectively. Main pain levels rated by mothers were 21.30 (SD 19.9), 23.04 (SD 18.39), and 12.17 (SD 12.14) for the C, M, and TV groups, respectively. Scores assigned by mothers and children indicated that procedures performed during TV watching were less painful (p<0.05) than control or procedures performed during active distraction. Conclusion: TV watching was more effective than active distraction. This was due either to the emotional participation of the mothers in the active procedure or to the distracting power of television.

Cry Features Reflect Pain Intensity in Term Newborns: An Alarm Threshold

The purpose of this study was to assess differences in sound spectra of crying of term newborns in relation to different pain levels. Fifty-seven consecutively born neonates were evaluated during heel-prick performed with different analgesic techniques. Crying was recorded and frequency spectrograms analyzed. A pain score on the DAN (Douleur Aiguë du Nouveau-né) scale was assigned to each baby after the sampling. Three features were considered and correlated with the corresponding DAN scores:1) whole spectral form; 2) the fundamental frequency of the first cry emitted (F0); and 3) root mean square sound pressure normalized to its maximum. After emission of the first cry, babies with DAN scores >8, but not with DAN scores ≤8 (p < 0.001), showed a pattern (“siren cry”) characterized by a sequence of almost identical cries with a period on the order of 1 s. A statistically significant correlation was found between root mean square (r2 = 89%, p < 0.01), F0 (r2 = 32%, p < 0.05), siren cry (r2 = 68.2%, p = 0.02), and DAN score. F0 did not show significant correlation with DAN score in the subset of neonates with DAN scores ≤8 (r2 = 1.4%, p = 0.94), and babies with a DAN score >8 had a significantly higher F0 than those with lower DAN scores (p = 0.016). An alarm threshold exists between high (>8) and low (≤8) DAN scores: crying has different features in these two groups. When pain exceeds a DAN score of 8, usually a first cry at a high pitch is emitted, followed by the siren cry, with a sound level maintained near its maximum.

Effects of Lutein on Oxidative Stress in the Term Newborn: A Pilot Study

Background: Oxidative stress (OS) plays a crucial role in pathological conditions during the early neonatal period. The newborns are susceptible to oxidative damage due to high metabolic rate and low levels of antioxidant enzymes. Lutein has been found to have protective functions in adult humans as antioxidant. Aim: To evaluate the effects of lutein on OS in newborns. We tested the hypothesis that lutein would act both by increasing antioxidant capacity and inhibiting OS. Methods: This was a randomized, double-blind, placebo-controlled, single-center study. 20 healthy term newborns were assigned to receive lutein or placebo (lutein and control group, respectively) at 12 and 36 h after birth. Total hydroperoxides (TH), as marker of OS, and biological antioxidant potential (BAP), as marker of antioxidant power, were detected on cord blood and at 48 h of life in all babies. Results: TH significantly increased from birth to 48 h in the control group (p = 0.02), but not in the lutein group. In the lutein group, BAP significantly increased after 48 h (p = 0.02), showing a strengthening of antioxidant activity due to lutein. At 48 h of life, compared with those in the control group, neonates assigned to receive lutein had significantly lower TH levels (p = 0.04) and higher BAP levels (p = 0.028). Conclusions: Lutein administration in newborns increases the levels of BAP decreasing TH. The enhancement of antioxidant activity in plasma clearly results in protecting newborn from perinatal OS. These preliminary results, adding a new contribution in antioxidant strategies, strongly require to be confirmed by RCT.

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.

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.

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.