Franca Benini

Randomised controlled trial of low dose fentanyl infusion in preterm infants with hyaline membrane disease.

Aim—To evaluate the effects of low dose fentanyl infusion analgesia on behavioural and neuroendocrine stress response and short term outcome in premature infants ventilated for hyaline membrane disease. METHODS Twenty seven ventilated preterm infants were randomly assigned to receive a mean fentanyl infusion of 1.1 (0.08 SE) μg/kg/h for 75 (5) hours, and 28 untreated infants were considered a control group. A behavioural sedation score was used to assess the infants’ behaviour. Urinary metanephrine and the normetanephrine:creatinine molar ratio were determined at 0, 24, 48 and 72 hours. Outcome data and ventilatory indexes were recorded for each infant. RESULTS The fentanyl group showed significantly lower behavioural stress scores and O2 desaturations than controls and lower urinary concentrations of metanephrine and normetanephrine at 24, 48, 72 hours. The two groups showed no significant difference in ventilatory variables or short term outcome. CONCLUSIONS A short course of low dose fentanyl infusion reduces behavioural sedation scores, O2desaturations and neuroendocrine stress response in preterm ventilated infants.

Evaluating pain induced by venipuncture in pediatric patients with developmental delay

Objectives:Little attention has been paid to the assessment of pain in children with developmental delay. The aim of this study was to explore several methods for assessing pain during venipuncture in this population of children, using classic and modified scales to evaluate the children’s response to simplified tools. Methods:Sixteen children with mild or moderate developmental delay were evaluated using three standard self-rating scales (Visual Analog Scale [VAS], Eland Scale, and Faces Scale) and three modified methods (Cube Test, Modified Eland Scale, and Modified Faces Scale), recording subjective self-ratings and behavioral expressions of pain during a venipuncture procedure, apart from the initial fear. The children’s pain and reaction time were assessed by an outside observer, while their pain and fear were also evaluated by the parents. Results:The VAS was used without difficulty by all the children and revealed a good consistency with the Cube Test. The parents’ and neutral observer’s indirect pain assessment was also consistent with the child’s evaluations. The Eland Scale proved difficult to use, especially for Down’s syndrome children, while its modified version was easier. Results emerging from the original and modified Faces Scales were inconsistent. Frightened children attributed higher pain scores, demonstrating that negative emotions exacerbate the experience of pain in developmentally delayed children. The patients showed a limited capacity for verbal and behavioral expression in reaction to the painful stimulus (especially the Down’s cases). Discussion:These findings support the conviction that even developmentally delayed children can use self-rating methods effectively. This sector demands further, more extensive study, including the development of simplified tools, to ensure an adequate pain assessment and optimal antalgic approach to this particular pediatric population.

Metabolic and respiratory effects of theophylline in the preterm infant

BACKGROUND Methylxanthines are often administered to preterm infants for the treatment of apnoea. AIMS To study the effects of theophylline on energy metabolism, physical activity, and lung mechanics in preterm infants. METHODS Indirect calorimetry was performed for six hours before and after administration of a bolus of theophylline (5 mg/kg) in 18 preterm infants while physical activity was recorded with a video camera. Lung mechanics measurements were performed at baseline and 12 and 24 hours after theophylline treatment. RESULTS Theophylline increased mean (SEM) energy expenditure by 15 (5) kJ/kg/day and augmented carbohydrate utilisation from 6.8 to 8.0 g/kg/day, but fat oxidation was unchanged. After theophylline treatment, preterm infants had faster respiration, lower transcutaneous CO2, and improved static respiratory compliance without increased physical activity. CONCLUSIONS A bolus of 5 mg/kg theophylline increased energy expenditure independently of physical activity, increased carbohydrate utilisation, and improved respiratory compliance. The increased energy expenditure could be detrimental to the growth of the preterm infant.

Exercise performance in very low birth weight children at the age of 7–12 years

Fifteen very low birth weight children, 9 appropriate for gestational age (AGA, mean birth weight 1302 ± 164 g) and 6 small for gestational age children (SGA, mean birth weight 1263±117 g), were studied at the age of 7–12 years, and compared to a group of 26 healthy, age-, sex-, and height-matched children born at term. None of the VLBW children had developed chronic bronchopulmonary disease. Pulmonary function tests and progressive exercise tests on a treadmill were performed. Forced vital capacity, forced expiratory volume at 1 s and forced expiratory flow between 25% and 75% of vital capacity were normal for all subjects. No differences were found in maximum oxygen consumption, anaerobic threshold and maximal heart rate between the AGA and SGA children and the respective controls. Both in the AGA and SGA subgroups, the pre-exercise oxygen uptake results were comparable to those of the controls. In the SGA subgroup the energy cost of running was significantly higher with respect to the controls, while no difference was found between the AGA and the control children. In conclusion, children with birth weight less than 1501 g have normal values of aerobic fitness. In SGA children the efficiency of running is slightly reduced.

Analysis of the Bispectral Index During Natural Sleep in Children

The Bispectral Index (BIS) is a system used to measure sedation levels. Some investigators recently analyzed changes in the BIS during natural sleep in adults and found that the BIS diminished considerably as sleep became deeper. No such studies have been undertaken to investigate changes in the BIS in sleeping children. The aim of this work was to assess the trend of the BIS in the various stages of sleep in a group of children, performing a descriptive analysis on a limited number of cases. We evaluated 15 children with negative clinical findings and a normal electroencephalogram (EEG) as part of their follow-up for prior episodes of epilepsy, recording the BIS and EEG in a waking state, in the various stages of sleep and on reawaking. For each stage, the mean value, the standard deviation, and the range of BIS values were calculated. The results showed that the BIS decreased progressively as sleep became deeper. The correlation between the stage of sleep and the BIS was significant. On reawaking, a slow increase was apparent in the BIS.

Intrathecal synthesis of oligoclonal bands in rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation syndrome: new evidence supporting immunological pathogenesis.

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation syndrome (ROHHADS) is a rare, but potentially lethal, pediatric disorder. To date, nearly 80 patients have been reported in the literature; however, the etiopathogenesis is still unclear and debated. Both genetic and paraneoplastic or immune-mediated causes have been supposed to be involved in this syndrome. Nonetheless, at this time, a diagnostic biomarker is not available and diagnosis is based exclusively on clinical criteria. Aiming to establish the immune-mediated pathogenesis, we report 2 children with a clinical picture consistent with ROHHADS and whose cerebrospinal fluid analysis disclosed an intrathecal synthesis of oligoclonal bands. Even if many aspects remain to be explained, this finding suggests that ROHHADS could share similar pathogenetic mechanisms with other immune-mediated central nervous system disorders, and even more important, it might pave the way to a therapeutic chance for these patients by means of immunotherapy.

Safety and efficacy of propofol administered by paediatricians during procedural sedation in children.

The aim of this study was to determine the safety and the efficacy of paediatrician‐administered propofol in children undergoing different painful procedures.

Attention and reaction to distress in infancy: A longitudinal study.

The primary aim of this study was to verify whether early individual differences in look duration are related to general mechanisms of the infant nervous system that draw together attention and emotion. Thirty-one infants were observed at 3, 5, and 11 months of age. Facial expressions of pain and distress were observed by means of C. Izards (1979) Maximally Discriminative Facial Movement Coding System 90 s after routine pediatric vaccinations. Several measures of visual attention were taken experimentally in a separate testing session. Significant correlations between measures of attention and duration of facial expressions of pain and distress were found at each age level. Infants who showed pain or distress for a shorter time period also paid attention for a shorter time period and vice versa. The main conclusion is that individual differences combining control of both pain and attention can be identified from early infancy.

The Cold Pressor Test for the Pediatric Population: Refinement of Procedures, Development of Norms, and Study of Psychological Variables

OBJECTIVE The aims of the study were: (a) to propose focal refinements to the cold pressor test (CPT) for the pediatric population, contributing to the development of subjective and behavioral norms; (b) to analyze the influence of personal (gender, age, and skin-fold thickness), and psychological (anxiety, depression, internalization, and externalization) variables on pain perception and its correlation with room temperature. METHODS After a phase of adaptation in a water bath (24-27 degrees C), the child immersed one arm in cold water (10 degrees C) and reported pain threshold and tolerance. RESULTS The test was conducted on 141 healthy children. Pain tolerance was reached within the first minute by 50% of the children. Pain intensity affected the childrens emotional status. Older children tolerated pain for longer. Gender, psychological, and environmental variables did not influence pain perception. CONCLUSION This study provides methodological refinements to the CPT contributing to the development of norms for children.

Pediatric palliative care.

The WHO defines pediatric palliative care as the active total care of the childs body, mind and spirit, which also involves giving support to the family. Its purpose is to improve the quality of life of young patients and their families, and in the vast majority of cases the home is the best place to provide such care, but for cultural, affective, educational and organizational reasons, pediatric patients rarely benefit from such an approach. In daily practice, it is clear that pediatric patients experience all the clinical, psychological, ethical and spiritual problems that severe, irreversible disease and death entail. The international literature indicates a prevalence of incurable disease annually affecting 10/10,000 young people from 0 to 19 years old, with an annual mortality rate of 1/10,000 young people from birth to 17 years old. The needs of this category of patients, recorded in investigations conducted in various parts of the world, reveal much the same picture despite geographical, cultural, organizational and social differences, particularly as concerns their wish to be treated at home and the demand for better communications between the professionals involved in their care and a greater availability of support services. Different patient care models have been tested in Italy and abroad, two of institutional type (with children staying in hospitals for treating acute disease or in pediatric hospices) and two based at home (the so-called home-based hospitalization and integrated home-based care programs). Professional expertise, training, research and organization provide the essential foundations for coping with a situation that is all too often underestimated and neglected.