Peter Loughnan

Pain assessment and procedural pain management practices in neonatal units in Australia

Objective: To identify current pain assessment and procedural pain management practices in neonatal units in Australia.

Clinical course and medical management of neonates with severe cardiac failure related to vein of Galen malformation.

Background: Neonatal presentation of vein of Galen aneurysmal malformations (VGAMs) with intractable cardiac failure is considered a poor prognostic sign. Interventional neuroradiology with embolisation has been shown to control cardiac failure, but there is a perception that neurological outcome in survivors is poor. Objective: To determine if aggressive intensive care and anaesthetic management of cardiac failure before urgent embolisation can influence morbidity and mortality. Patients: Nine newborns (four boys, five girls) were diagnosed with symptomatic vein of Galen malformations in the neonatal period during the period 1996–2001. Eight developed intractable high output cardiac failure requiring initial endovascular treatment in the first week of life. Results: The immediate outcome after a series of endovascular procedures was control of cardiac failure and normal neurological function in six (66%) patients, one death from intractable cardiac failure in the neonatal period, and two late deaths with severe hypoxic-ischaemic neurological injury (33% mortality). Clinical review at 6 months to 4 years of age showed five infants with no evidence of neurological abnormality or cardiac failure and one child with mild developmental delay (11%). Conclusions: Aggressive medical treatment of cardiac failure and early neurointervention combined with modern neuroanaesthetic care results in good survival rates with low morbidity even in cases of high risk VGAM presenting in the immediate perinatal period with cardiac failure. Systemic arterial vasodilators improve outcome in neonates with cardiac failure secondary to VGAM. Excessive β adrenergic stimulation induced by conventional inotropic agents may exacerbate systemic hypoperfusion.

Death in the neonatal intensive care unit: changing patterns of end of life care over two decades

Background: Death remains a common event in the neonatal intensive care unit, and often involves limitation or withdrawal of life sustaining treatment. Objective: To document changes in the causes of death and its management over the last two decades. Methods: An audit of infants dying in the neonatal intensive care unit was performed during two epochs (1985–1987 and 1999–2001). The principal diagnoses of infants who died were recorded, as well as their apparent prognoses, and any decisions to limit or withdraw medical treatment. Results: In epoch 1, 132 infants died out of 1362 admissions (9.7%), and in epoch 2 there were 111 deaths out of 1776 admissions (6.2%; p<0.001). Approximately three quarters of infants died after withdrawal of life sustaining treatment in both epochs. There was a significant reduction in the proportion of deaths from chromosomal abnormalities, and from neural tube defects in epoch 2. Conclusions: There have been substantial changes in the illnesses leading to death in the neonatal intensive care unit. These may reflect the combined effects of prenatal diagnosis and changing community and medical attitudes.

Epidemiology of late onset haemorrhagic disease: A pooled data analysis

Classical haemorrhagic disease (HD) of the newborn has been recognized since the end of the last century.’ While bleeding in this condition can be severe and require transfusion, deaths and intracranial haemorrhage (ICH) are rare. In Sutherland’s clinical trial of the efficacy of Vitamin K3 in the prevention of classical HD, there were no deaths in 207 infants who bled, and ICH occurred in only 0.5% of all who bled, and 4% of those with moderate and severe bleeding.2 Moderate and severe bleeding was much more common in breast-fed infants, with 25 cases compared to one case in formula-fed infants. This study was confined to the first 5 days of life. In the mid-1960s occasional cases of unexplained severe bleeding were reported in much older infants, with laboratory evidence of Vitamin K deficiency. The earliest reports of what is now called late onset HD appeared in the late 1 9 6 0 ~ . ~ ~ Hoh’s report of 23 cases over a 5 year period in Singapore contains a detailed epidemiological analysis of risk factors3 The age range was 3-9 weeks, with a peak incidence at 4-6 weeks. All infants were exclusively breast fed, and had a normal neonatal course. There was a high mortality (56%), and most cases had intracranial haemorrhage. These very early observations have been confirmed in more recent reports.6~~ It is interesting to note that this highly relevant early study is not mentioned in major reviews of HD.7-9 In 1983, McNinch et a/. reported an increasing number of cases of late onset HD in the United Kingdom, following a change in the practice of Vitamin K prophylaxis, which occurred in the early 1980s.’O In the years before this report, a substantial number of infants in the United Kingdom did not receive prophylaxis, some received a single oral dose, 1.0 mg, whilst others received Vitamin K,, 1 .O mg, by injection. Controversy regarding the best method of prophylaxis has continued through the past d e ~ a d e . ~ The recent report of an association between the intramuscular, but not oral, usage of vitamin K,, and an increased risk of subsequent childhood cancer, has caused many clinicians to re-evaluate this issue.” For these reasons the present analysis of the epidemiology of late onset HD was undertaken. This study reports an analysis of the epidemiological factors associated with late onset HD, based upon all available report& cases up to the end of 1992.

Oral sucrose for procedural pain in sick hospitalized infants: A randomized-controlled trial

Objective:  To determine the efficacy of 25% oral sucrose in the reduction of pain during a heel lance procedure in sick hospitalized infants.

Bedside Assessment of Heel Lance Pain in the Hospitalized Infant

Objective: To evaluate a method of pain assessment to be used for hospitalized infants requiring blood test by a heel lance procedure. Design: Observational study evaluating pain measurement and interrater reliability of pain measurement in hospitalized infants. Setting: A Level III neonatal unit and a cardiac surgical unit at a major pediatric teaching hospital. Participants: 20 infants whose gestational age ranged from 28 weeks to full-term. Main Outcome Measures: Observations included behavioral measurements (facial expressions, body movements, and crying characteristics) and the physiologic measure of heart rate. Interrater reliability and the feasibility of using the procedural pain assessment method at the bedside were considered. Results: The three behavioral measurements and heart rate were responsive to the heel lance. Interrater reliability was high for facial expressions and crying scores but was low for body movements. Conclusions: Modifications have been made to the method of procedural pain assessment to be used in a subsequent study. The modified method is expected to be a reliable measure of procedural pain caused by a heel lance and can easily be used at the bedside during the course of further research.

Intracranial haemorrhage due to late onset vitamin K deficiency bleeding in Hanoi province, Vietnam

Background: In many developing countries vitamin K prophylaxis is not routinely administered at birth. There are insufficient data to assess the cost effectiveness of its implementation in such countries. Objective: To estimate the burden of intracranial haemorrhage caused by late onset vitamin K deficiency bleeding in Hanoi, Vietnam. Methods: Cases of intracranial haemorrhage in infants aged 1–13 weeks were identified in Hanoi province for 5 years (1995–1999), and evidence for vitamin K deficiency was sought. The data were compared with those on vitamin K deficiency bleeding in developed countries and used to obtain an approximation to the incidence of intracranial haemorrhage caused by vitamin K deficiency bleeding in Hanoi. Results: The estimated incidence of late onset vitamin K deficiency bleeding in infants who received no prophylaxis was unexpectedly high (116 per 100 000 births) with 142 and 81 per 100 000 births in rural and urban areas respectively. Mortality was 9%. Of the surviving infants, 42% were neurologically abnormal at the time of hospital discharge. Identified associations were rural residence, male sex, and low birth weight. A significant reduction in the incidence was observed in urban Hanoi during 1998 and 1999, after vitamin K prophylaxis was introduced at one urban obstetric hospital. Conclusions: Vitamin K deficiency bleeding is a major public health problem in Hanoi. The results indicate that routine vitamin K prophylaxis would significantly reduce infant morbidity and mortality in Vietnam and, costing an estimated US

Therapeutic lung lavage in meconium aspiration syndrome: A preliminary report

87 (£48, €72) per disability adjusted life year saved, is a highly cost effective intervention.

Does intramuscular vitamin K1 act as an unintended depot preparation

Aim:  To explore the effects of a large volume lung lavage procedure in ventilated infants with meconium aspiration syndrome.

Analgesics administered during minor painful procedures in a cohort of hospitalized infants: a prospective clinical audit.

Objective: To propose a hypothesis that the long duration of effect of intramuscular (i.m.) vitamin K1 in preventing late onset haemorrhagic disease results from a depot effect after i.m. injection.