Rita de Cássia Xavier Balda

Differences in pain expression between male and female newborn infants

Abstract The study of neonatal gender differences in pain expression is important since neonatal pain behavior occurs prior to any learned reaction pattern. The objective of this study was to verify the presence of gender differences in pain expression in preterm and term newborn infants. Sixty‐five consecutive neonates (37 female and 28 male infants) with gestational age between 28 and 42 weeks and with 25–120 h of life were studied. Healthy term neonates required a capillary puncture for PKU screening and clinically stable premature infants needed a capillary puncture for glucose dosage. The Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS) were evaluated at bedside prior to the puncture, when patients were at rest, during foot heating; during capillary puncture; and at 1, 3, and 5 min after heel lancing. Results were analyzed by repeated‐measures ANOVA followed by the Multiple Comparison Method of Bonferroni. A significant difference among the mean NFCS scores during the six study periods was noted for the whole group of neonates (P<0.000001). Also, a significant interaction between the NFCS score profile in female and male neonates at the different study periods was observed (P=0.025). Regarding NIPS, ANOVA showed only a significant difference among the mean NIPS scores during the six study periods for the whole group of neonates (P<0.000001). No significant interactions between gestational age and time, nor between gestational age and gender were noted, for both NFCS and NIPS. In conclusion, recently born female neonates of all gestational ages expressed more facial features of pain than male infants, during the capillary puncture and 1 min afterwards. Maybe differences in pain processing and/or pain expression among genders may explain this finding.

Skin-to-Skin Contact and/or Oral 25% Dextrose for Procedural Pain Relief for Term Newborn Infants

OBJECTIVE: The goal was to compare the efficacy of oral 25% dextrose treatment and/or skin-to-skin contact for analgesia in term newborns during intramuscular injection of a hepatitis B vaccine. METHODS: A prospective, randomized, partially blinded, clinical trial was performed with 640 healthy term newborns. Infants at 12 to 72 hours of life were assigned randomly to receive an intramuscular injection of hepatitis B vaccine in the right thigh according to 4 analgesia groups, that is, no analgesia (routine); oral 25% dextrose treatment, given 2 minutes before the injection; skin-to-skin contact, initiated 2 minutes before the injection and persisting throughout the procedure; and a combination of the oral dextrose treatment and skin-to-skin contact strategies. For all groups, Neonatal Facial Coding System and Neonatal Infant Pain Scale scores were evaluated before the procedure, during thigh cleansing, during the injection, and 2 minutes after the injection. Premature Infant Pain Profile scores also were assessed for all infants. Pain scores were compared among the 4 groups. RESULTS: The use of oral 25% dextrose treatment reduced the duration of procedural pain in the studied population. Skin-to-skin contact decreased injection pain and duration. The combination of the 2 analgesic measures was more effective than either measure separately for term newborns. CONCLUSIONS: Nonpharmacologic analgesic measures were effective for the treatment of procedural pain in term infants. The combination of oral 25% dextrose treatment and skin-to-skin contact acted synergistically to decrease acute pain in healthy neonates.

The frequency of pharmacological pain relief in university neonatal intensive care units

OBJECTIVE To evaluate the use of drugs to relieve procedural pain of newborn infants hospitalized in Neonatal Intensive Care Units (NICU) of university hospitals. METHODS A prospective cohort study of all newborn infants hospitalized in four NICU during October 2001. The following data were collected: demographic data of patients; clinical morbidity; number of potentially painful procedures and frequency of analgesic administration. Multiple linear regression analysis was performed to study the factors associated with the use of analgesia in this cohort of patients with SPSS 8.0. RESULTS Ninety-one newborn infants were admitted to the NICU during the study period (1,025 patient-days). Only 25% of the 1,025 patient-days received any systemic analgesia. No specific drug was administered to relieve acute pain during any of the following painful procedures: arterial, venous, capillary and lumbar punctures and tracheal intubation. For chest tube insertion, 100% of newborn infants received specific analgesia. For the insertion of central catheters, 8% of the newborn infants received analgesia. Only nine of the 17 newborn infants that underwent surgical procedures received any dose of analgesics during the postoperative period. Regarding patients who received analgesia, the drug of choice was fentanyl in 93%. The presence of mechanical ventilation increased 6.9 times the chance of the newborn receiving analgesia and the presence of a chest tube increased this chance by 5.0 times. CONCLUSION It is necessary to train health professionals in order to shorten the lag between scientific knowledge regarding newborn pain and clinical practice.

O que os pediatras conhecem sobre avaliação e tratamento da dor no recém-nascido?

OBJETIVO: analisar os conhecimentos dos pediatras que atuam com pacientes neonatais em relacao a avaliacao e o tratamento da dor do recem-nascido. METODOS: estudo transversal com 104 pediatras (de um total de 110) que trabalhavam em 1999 a 2001, nas sete unidades de terapia intensiva e nos 14 bercarios da cidade de Belem, e responderam a um questionario escrito com perguntas a respeito do seu perfil demografico e do conhecimento de metodos de avaliacao e de tratamento da dor no recem-nascido. RESULTADOS: cem por cento dos medicos referiram acreditar que o recem-nascido sente dor, mas apenas um terco deles conhecia alguma escala para avaliar a dor nessa faixa etaria. A maioria dos entrevistados referia perceber a presenca de dor no recem-nascido por meio de parâmetros comportamentais. O choro foi o preferido para avaliar a dor do bebe a termo; a mimica facial para o prematuro, e a frequencia cardiaca para o neonato em ventilacao mecânica. Menos de 10% dos entrevistados diziam usar analgesia para puncoes venosas e capilares; 30 a 40% referiam empregar analgesia para puncoes lombares, dissecacoes venosas, drenagens de torax e ventilacao mecânica. Menos da metade dos entrevistados referiu aplicar medidas para o alivio da dor no pos-operatorio de cirurgia abdominal em neonatos. O opioide foi o medicamento mais citado para a analgesia (60%), seguido pelo midazolam (30%). CONCLUSAO: os pediatras demonstraram pouco conhecimento a respeito dos metodos de avaliacao e tratamento da dor no periodo neonatal. Ha necessidade de reciclagens e de atualizacao no tema para os profissionais de saude que atuam com recem-nascidos doentes.

Disagreement between parents and health professionals regarding pain intensity in critically ill neonates

OBJECTIVE To verify whether parents and health professionals homogeneously evaluate presence and intensity of neonatal pain. METHODS This cross-sectional study enrolled 52 neonates and 154 adults. Inclusion criteria for neonates were admission to neonatal intensive care unit, presence of gastric tube, tracheal tube, and venous lines. Each newborn was observed by a different group of three adults (parent, nurse assistant and pediatrician) for 1 minute at the same time to evaluate presence and intensity of infants pain. Homogeneity of pain evaluation was analyzed by a modified Bland-Altman plot and by intraclass correlation coefficient (ICC). Multiple linear regression analysis was used to evaluate association of neonatal characteristics and heterogeneity of pain scores for adults. RESULTS ICC showed disagreement of the pain scores given by the three groups of adults (ICC 0.066, agreement > 0.75). Bland-Altman analysis showed agreement among adults when they thought pain was absent. When they thought pain was present, there was heterogeneity of opinions regarding intensity of neonatal pain. Multiple regression analysis indicated that 10% of this disagreement could be explained by infants gender and mode of delivery. CONCLUSIONS Disagreement among adults about intensity of neonatal pain is a marker of the difficulty in deciding the need for analgesia in preverbal patients.

Discordância entre pais e profissionais de saúde quanto à intensidade da dor no recém-nascido criticamente doente

OBJETIVO: Verificar se pais e profissionais de saude que trabalham em unidades de terapia intensiva neonatal avaliam de maneira semelhante a presenca e a magnitude da dor no recem-nascido (RN). METODOS: Estudo transversal com 52 RN e 154 adultos. Os criterios de inclusao foram: internacao em unidade de terapia intensiva neonatal, presenca de sonda gastrica, cânula traqueal e acesso venoso. Cada RN foi observado de modo simultâneo por um trio diferente de adultos (pai/mae, pediatra e auxiliar de enfermagem) durante 1 minuto para avaliar presenca e intensidade da dor do paciente. A analise quanto a homogeneidade da avaliacao de dor foi realizada por meio do grafico de Bland-Altman modificado e do coeficiente de correlacao intraclasses (CCI). A associacao de fatores proprios do recem-nascido com a heterogeneidade da avaliacao da dor do RN pelos adultos foi avaliada por meio de regressao linear multipla. RESULTADOS: O CCI mostrou discordância entre os tres grupos de adultos quanto a avaliacao da dor (CCI 0,066, concordância > 0,75). A analise de Bland-Altman mostrou que houve concordância entre os adultos quanto a ausencia de dor no RN. Porem, quando os adultos achavam que a dor estava presente, houve heterogeneidade na avaliacao da intensidade de dor neonatal. A analise de regressao multipla indicou que apenas 10% desta heterogeneidade foi explicada pelo sexo e via de parto do RN. CONCLUSOES: A heterogeneidade na avaliacao feita por adultos da intensidade da dor de RN e um marcador da dificuldade de se decidir a respeito da necessidade de analgesia em pacientes pre-verbais.

Multidimensional pain assessment of preterm newborns at the 1st, 3rd and 7th days of life

CONTEXT AND OBJECTIVE It is challenge to assess and treat pain in premature infants. The objective of this study was to compare the multidimensional pain assessment of preterm neonates subjected to an acute pain stimulus at 24 hours, 72 hours and seven days of life. DESIGN AND SETTING Prospective cohort study, at Universidade Federal de São Paulo. METHODS Eleven neonates with gestational age less than 37 weeks that needed venepuncture for blood collection were studied. The exclusion criteria were Apgar score < 7 at five minutes, presence of any central nervous system abnormality, and discharge or death before seven days of life. Venepuncture was performed in the dorsum of the hand, and the heart rate, oxygen saturation and pain scales [Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP)] were assessed at 24 hours, 72 hours and 7 days of life. NFCS and NIPS were evaluated prior to procedure (Tpre), during venepuncture (T0), and two (T2) and five (T5) minutes after needle withdrawal. Heart rate, O2 saturation and PIPP were measured at Tpre and T0. Mean values were compared by repeated-measurement analysis of variance. RESULTS The pain parameters did not differ at 24 hours, 72 hours and 7 days of life: heart rate (p = 0.22), oxygen saturation (p = 0.69), NFCS (p = 0.40), NIPS (p = 0.32) and PIPP (p = 0.56). CONCLUSION Homogeneous pain scores were observed following venepuncture in premature infants during their first week of life.

Fatores que interferem no reconhecimento por adultos da expressão facial de dor no recém-nascido

Objective: To evaluate the factors related to adult observers that interfere on their recognition of facial expression of pain in term newborn infants. Methods: 405 adults were interviewed: 191 health professionals and 214 parents. Adults’ demographic and socio-economical characteristics were surveyed. At the end of the interview, each adult looked at three series of pictures of three different newborns, each series with eight pictures of the face of each newborn, in eight different moments (M1, M3, M6 e M8: resting; M2: light stimulus; M4 and M5: heel rubbing; M7: heel stick) and answered to the following question: In which picture of these do you think the newborn is feeling pain? The 405 adults were analyzed according to the number of right answers for the three series of pictures by multiple linear regression analysis. Results: A smaller number of right answers in the three series of pictures was noticed to adults without a partner, with more children, higher family income and, if health professionals, with less years in school or, if parents, with more years in school. Adults with these characteristics, therefore, presented more difficulty to recognize the expression of pain in the newborn’s face. Conclusions: The heterogeneity of factors that interfere in the recognition of neonatal pain by adults emphasizes the need of using validated pain assessment tools in the care of critically ill neonates.

Reconhecimento da dor no recém-nascido por alunos de medicina, residentes de pediatria e neonatologia

JUSTIFICATIVA E OBJETIVOS: O aprendizado a respeito do fenomeno doloroso durante a formacao medica molda a pratica clinica futura. O objetivo deste estudo foi avaliar a percepcao e o conhecimento dos alunos de graduacao em Medicina, residentes de Pediatria e de Neonatologia a respeito da dor no recem-nascido (RN). METODO: Estudo transversal com 180 alunos do 1o ao 6o anos de Medicina, 42 residentes de Pediatria e 20 de Neonatologia, no periodo de 2009 e 2010. Foram aplicadas 12 questoes teoricas sobre dor no RN. Os entrevistados examinaram 3 fotos: prematuro em ventilacao mecânica, a termo recebendo injecao e pre-termo submetido a aspiracao traqueal, e assinalaram em escala analogica visual a intensidade da dor. Cada aluno examinou 2 paineis de 8 fotos da face de dois RN a termo, sendo 1 foto por painel com mimica facial de dor presente; e o aluno apontava a foto do RN com dor. Na analise estatistica empregaram-se os testes Qui-quadrado e ANOVA. RESULTADOS: Nas questoes teoricas, o numero medio de acertos se elevou de 9 nos alunos do 1o e 2o anos do curso de Medicina, para 11 nos residentes em Neonatologia. Nos paineis 1 e 2, menos de 75% dos entrevistados reconheceram a face de dor, sem diferencas entre alunos e residentes. Nao houve diferencas entre alunos e residentes quanto aos escores assinalados para as duas fotos do prematuro. Para o RN a termo recebendo injecao, os residentes em Pediatria (p = 0,008) e Neonatologia (p = 0,036) atribuiram mais dor do que os alunos do 3o e 4o anos do curso medico. CONCLUSAO: Os alunos do curso de medicina e residentes nao diferiram quanto ao reconhecimento da presenca de dor em recem-nascidos.

Behavioral Scales are Sensitive Tools for Pain Assessment in Preterm Infants. 896

This prospective study was designed to establish the sensitivity and specificity of 2 behavioral pain scales at different gestational ages (GA), during an acute painful procedure. 133 clinically stable neonates, 3) and the Neonatal Infant Pain Scale (NIPS: 0-7 pts, pain>3). All evaluations were performed prior to P or F, without (pr) and with foot heating (h), during (0), 1′ and 3′ after P or F. Reliability was assessed in 20% of the sample by a second observer. Agreement rate was: NFACS-97%, NIPS-95%.