Duccio Maria Cordelli

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.

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.

Hot water epilepsy and focal malformation of the parietal cortex development

Hot water epilepsy (HWE) refers to a specific type of reflex epilepsy precipitated by the stimulus of bathing in hot water. HWE is considered to be a geographically specific epileptic syndrome since it mainly occurs in the Indian community. Spontaneous seizures may also occur later in life. The seizure pattern includes complex partial attacks. Although the pathogenesis of HWE is still unknown, temporal lobe has been thought to take part in the epileptogenesis. This paper reports on a 4-year-old girl who, at the age of 6 months, experienced complex partial seizures triggered by bathing in hot water. Non-provoked seizures intercritical EEG showed isolated spikes and spike-and-waves in the left parietal region. Brain MRI detected a left parietal focal cortical dysplasia. This is the second patient with HWE in whom a cortical malformation has been observed. The observation present here and data reported in the literature seem to indicate that the sensory cortex might also be involved in triggering seizures precipitated by a bath in hot water. Moreover, the authors believe that MRI examination should be considered for this group of patients.

Use of Sound-Absorbing Panel to Reduce Noisy Incubator Reverberating Effects

Objectives: To assess the amplification and distortion of noise in incubators by measuring noise levels from various sources under various conditions. Study Design: We recorded sound pressure levels (SPL) of background noise, baby crying, alarms and porthole closing with the incubator hood open or closed. Then we tried to reduce the sound level in the incubator by applying a sound absorbing panel to the ceiling of the hood. Results: The sound sources analysed produced very high SPL. In free field baby crying and porthole noise were, respectively, 81–83 dB and 70–71 dB, closing the hood they raised to 84–87 and 73–74 dB: this means that the noise perceived by a baby in the incubator had twice the SPL of the same noise emitted in a free field; alarm noise was 56–57 dB inside incubators. Sound emitted inside the hood was also distorted, i.e. it had different features from the same source in a free field. The insulating panel prevented amplification and distortion due to the hood and reduced the SPL of alarms. Only background noise did not decrease with the panel. Sound absorbing panel reduced baby’s crying, porthole noise and alarm noise SPL to 82–85, 70–71 and 50–51 dB, respectively. Conclusions: Incubators are reverberating environments, which amplify the baby’s cry and other noises produced inside the hood. The frequency components of noises are altered by the hood. The sound absorbing panel reduced this phenomenon.

Intracranial Pressure during Procedural Pain

Physiological changes provoked by pain may threaten the integrity of the CNS. In particular, intracranial pressure (ICP) regulates brain perfusion, and its sudden increase may trigger brain haemorrhage. We measured ICP in 51 healthy newborns (gestational age: 35–41 weeks) during blood sampling, by means of a tonometer applied to the anterior fontanelle. Peak ICP values were compared during 3 different types of blood sampling: from the external jugular vein (JV), by heel prick and by heel prick with sensorial saturation. Sensorial saturation consists in giving sensorial stimuli during pain to arrest the transmission of pain to the cerebral cortex. ICP peak values during heel prick were higher than during JV sampling (mean = 26.22 vs. 21.036 mm Hg; p < 0.0001), though babies who underwent the latter procedure had high ICP values before sampling due to the body position required. Heel prick with sensorial saturation was associated with a lower ICP peak (mean = 11.75 mm Hg) than sampling from JV (p < 0.0001). We concluded that heel prick caused a greater rise in ICP than sampling from JV and that sensorial saturation moderated the rise associated with heel prick.

Development and validation of the ABC pain scale for healthy full‐term babies

Aim: We developed and validated a pain scale (ABC scale) for term babies based on acoustic features of crying. Methods: The scale consisted of three different cry parameters: (a) pitch of the first cry; (b) rhythmicity of the crying bout; (c) constancy of crying intensity. These parameters were previously found to distinguish between medium and high levels of pain measured by spectral analysis of crying. We validated the scale using healthy term babies undergoing routine heel prick. Concurrent validity was assessed comparing pain values obtained with our scale with those obtained with another pain scale; this relationship was also used to assess the sensitivity of the scale. To assess specificity we compared the ABC scores during a painful event (heel prick) with two non‐painful events (preliminary phase of prick in the same group of babies, and heel prick with analgesia in another group). Results: Specificity: (a) analgesic/non‐analgesic comparison, p<0.0001; (b) pain/sham comparison, p<0.0001). Sensitivity: a high correlation between scores of the ABC scale and the Douleur Aigue du Nouveau‐Né scale indicates good sensitivity. Concurrent validity: Spearman ρ=0.91. Internal consistency: Cronbachs α=0.76. Inter‐rater reliability: Cohens κ for multiple raters=0.83. Intra‐rater reliability: Cohens κ=0.85. Practicality: All nurses who used it scored the scale as “good”.

Is the ABC pain scale reliable for premature babies

Aim: We recently developed the ABC scale to assess pain in term newborns. The aim of the present study was to assess the reliability of the scale in preterm babies.

A comparative study of hydrocortisone versus deflazacort in drug-resistant epilepsy of childhood

Steroids are commonly used for the treatment of intractable epilepsy. Deflazacort has shown similar effects to prednisone, but with a less worrying adverse-effect profile. In this study, we first compared the efficacy, safety, and seizure relapse rate of deflazacort versus hydrocortisone in children affected by drug-resistant epilepsies. This was an open, non-blinded, randomized clinical study of 35 children affected by drug-resistant epilepsies. The study lasted 12 months. Group 1 (16 patients) received hydrocortisone for 6 months; group 2 (19 patients) was treated with deflazacort for the entire study period. Drug efficacy and tolerability were evaluated after 6 months of therapy. Seizure relapse rates were evaluated 12 months after the start of the study. After 6 months of therapy, hydrocortisone was effective in 44% of patients (responders, with a decrease in seizure frequency of >50%). Deflazacort was effective in 47% of patients (P=0.9). Adverse events occurred in 37% of patients using hydrocortisone and in none of those using deflazacort (P=0.002). At the end of the study, seizure relapse rate resulted significantly higher in group 1 than in group 2 (P=0.04). Hydrocortisone may be useful in the treatment of severely drug-resistant childhood epilepsies. However, its effects may be transient. Deflazacort should be considered in the therapeutic armamentarium for epileptic encephalopathies. The drug is as effective as hydrocortisone and may be used in therapy for a long period, with a less worrying adverse-effect profile.