Jarkko Kirjavainen

Oral Glucose and Parental Holding Preferable to Opioid in Pain Management in Preterm Infants

ObjectivesThe purpose of this study was to compare the effectiveness of “facilitated tucking by parents” (FTP) in which a parent holds by her hands the infant in a side-lying flexed position offering support and skin contact, oral glucose, opioid (oxycodone), and placebo (oral water) in the context of heel stick and pharyngeal suctioning in very preterm infants. We hypothesized that nonpharmacologic methods equal the pharmacologic method and are superior to placebo in pain management. MethodsA prospective randomized placebo-controlled crossover trial. The study patients (n=20) were born at a mean gestational age of 28+1 weeks and were studied at postconceptional age of 28 to 32 weeks. Pain measurements with Premature Infant Pain Profile and Neonatal Infant Pain Scale covered the first 30 seconds after the beginning of the painful stimulus. ResultsPremature Infant Pain Profile scores were significantly lower with oral glucose (mean: 4.85±1.73, P≤0.001) and FTP (mean: 5.20±1.70, P=0.004) when compared with placebo (mean: 7.05±2.16) after heel stick. During pharyngeal suctioning, the scores were lowest with oral glucose (mean: 11.05±2.31, P=0.014) and FTP (mean: 11.25±2.47, P=0.034) compared with placebo (mean: 12.40±2.06). Opioid equaled placebo in both procedures. Neonatal Infant Pain Scale scores were significantly lower with FTP (P≤0.001) and opioid (P=0.018) after heel stick, and during pharyngeal suctioning with FTP (P=0.001) compared with placebo. We found significantly more short-term adverse effects per administration with oral glucose (21.25%) and oral water (12.5%) compared with opioid (5%) or FTP (5%). DiscussionOur study demonstrated that FTP is not just equal, but preferable to other pain management methods when both efficacy and safety are considered.

Mismatch negativity and late discriminative negativity in sleeping human newborns

Event-related potentials were recorded from sleeping newborns to compare amplitudes and latencies of mismatch negativity (MMN) and late discriminative negativity (LDN) in active and quiet sleep stages. MMN and LDN were obtained in response to changes in semi-synthesized vowels from 20 healthy newborn infants. MMN and LDN responses were significant for both active and quiet sleep. The amplitude and latency of MMN or LDN did not differ between the sleep stages. Thus, in contrast to adult studies that show a significant drop in the MMN amplitude and an increase in the MMN latency as the sleep gets deeper, arousal stages do not seem to effect either MMN or LDN characteristics in newborns. These results suggest functional differences between infant and adult sleep.

Sleep of Excessively Crying Infants: A 24-Hour Ambulatory Sleep Polygraphy Study

Objective. Parents’ reports suggest that excessively crying or colicky infants sleep less compared with control subjects. The aim of this study was to determine the sleep-wake structure of excessively crying infants throughout a 24-hour cycle. Methods. A 24-hour sleep polygraphy study was conducted at home for 24 excessively crying infants and 23 control subjects at the age of 6 weeks. In addition, parental diaries were kept for 4 days. Results. In sleep polygraphy recordings, no major differences between study groups were observed in either the duration or the structure of the 24-hour sleep. In the diaries, the parents overestimated the amount of sleep in both study groups. The parents of the control infants overestimated the amount of sleep more than the parents of excessively crying infants (69.8 minutes [standard deviation: 79.3] compared with 27.1 minutes [standard deviation: 65.4], respectively). In excessively crying infants, the proportion of rapid eye movement sleep was higher during the 3-hour period from the beginning of the first long sleep in the evening and lower during the preceding 3-hour period compared with the control group. Conclusions. The results of this study suggest that diary-based studies are prone to be biased as the parents of the control infants are more likely to overestimate the amount of infant’s sleep and, therefore, report more sleep than the parents of the crying infants. Although no differences in the total amount of sleep or proportions of sleep stages were observed, excessively crying infants may be characterized by a disturbance that affects rapid eye movement and non–rapid eye movement sleep stage proportion during evening hours.

Effects of pain management on sleep in preterm infants

Background: This study was conducted to gain better understanding of the prolonged effects of pain and pain management on preterm infants’ sleep.

The balance of the autonomic nervous system is normal in colicky infants.

Excessively crying, hard‐to‐soothe infants are described as colicky. The self‐limiting course of infantile colic during early infancy suggests an etiology of transient developmental dysmaturation. It has been proposed that emotional characteristics such as temperament and self‐soothing ability are correlated with the balance of the autonomic nervous system. Heart rate variability (HRV) analysis was used for evaluating the balance of the autonomic nervous system in colicky and control infants during and after the colicky period. HRV analysis was carried out on 12 colicky infants and 14 control infants at the age of 2 mo, and repeated on 10 colicky and 11 normal infants at the age of 7 mo. Measurements were performed during polygraphically confirmed slow‐wave sleep (sleep stages 3 and 4). Three HRV frequency bands were defined, including a high (0.2–1.0 Hz), middle (0.12–0.2 Hz) and low (0.025–0.12 Hz) frequency variability. There were no differences between the study groups in any of the three HRV frequency bands analyzed. The high frequency variability increased significantly with age in both study groups (p= 0.009).

Relation of prematurity and brain injury to crying behavior in infancy.

OBJECTIVES. The objective of this study was to assess crying behavior during infancy in very preterm infants with or without brain injury. METHODS. A total of 125 very low birth weight infants survived during January 2001 to July 2004 in Turku University Hospital, Finland. They were categorized according to the most pathologic brain finding either in ultrasound or MRI. Baby Day Diary was used to assess crying behavior at term, 6 weeks, and 5 months of corrected age. The behavior of a group of term control infants (n = 49) was assessed at 5 months. RESULTS. Severe brain injuries in very low birth weight infants did not affect the duration of fussing or crying. In very low birth weight infants, brain injuries did not affect the frequency of fussing or crying bouts or the development of circadian rhythm in crying behavior. At 5 months of corrected age, fussing bouts were more frequent in very low birth weight infants compared with term control infants (6.4 per day vs 4.5 per day), and very low birth weight infants were held more (169 minutes [97] vs 130 minutes [69], respectively). CONCLUSIONS. This prospective study using a validated cry diary showed that brain injuries that are related to prematurity do not have major effects on crying behavior or development of circadian rhythm. Prematurity does not increase the duration but increases the frequency of fussing and crying at 5 months of corrected age compared with term control infants. It also seems that prematurity and brain pathology may increase caregiving activity in the form of holding.

Crying behaviour in early infancy is associated with developmental outcome at two years of age in very low birth weight infants

Aim: To evaluate the association between infant fussing and crying and developmental outcome in very low birth weight (VLBW) infants.

Heart rate variability in response to the sleep-related movements in infants with and without colic

The activity of the autonomic nervous system depends on sleep stage. The imbalance of the autonomic nervous system together with over-reactivity to stimuli has been suggested to be an etiologic factor for infantile colic. This study was designed to estimate the reactivity of the autonomic nervous system to a sleep-time stimulus in non-rapid eye movement (NREM) and rapid eye movement (REM) sleep stages and in colic and control infants. Overnight sleep polygraphic recordings were performed for 12 colic and 14 control infants at the age of 8 weeks. Movements were detected by a static-charge-sensitive bed. Extent of heart rate variability (HRV) was measured in response to spontaneous sleep-related movements. HRV analysis was performed over 2-min segments during NREM and REM sleep before and after 5-36-s long movement periods. Total (0.04-1.0 Hz), low (0.04-0.15 Hz) and high frequency (0.15-1.0 Hz) HRV increased after the movement periods in light NREM sleep (p < 0.001). These changes were not observed in REM sleep. No differences were found between the colic and the control groups in HRV. The observed difference in the response of the HRV between sleep stages is likely to reflect the different characteristics of heart rate control in NREM and REM sleep, but our results do not suggest that colic infants would have abnormal autonomic reactivity to stimuli while asleep.