Vibhuti Shah

Incidence and Timing of Presentation of Necrotizing Enterocolitis in Preterm Infants

OBJECTIVES: To examine the variation in the incidence and to identify the timing of the presentation of necrotizing enterocolitis (NEC) in a cohort of preterm infants within the Canadian Neonatal Network (CNN). METHODS: This was a population-based cohort of 16 669 infants with gestational age (GA) <33 weeks, admitted to 25 NICUs participating in the CNN between January 1, 2003, and December 31, 2008. Variations in NEC incidence among the participating NICUs for the study period were examined. We categorized early-onset NEC as occurring at <14 days of age and late-onset NEC occurring at ≥14 days. Multivariate logistic regression analysis was performed to identify risk factors for early-onset NEC. RESULTS: The overall incidence of NEC was 5.1%, with significant variation in the risk adjusted incidence among the participating NICUs in the CNN. Early-onset NEC occurred at a mean of 7 days compared with 32 days for late-onset NEC. Early-onset NEC infants had lower incidence of respiratory distress syndrome, patent ductus treated with indomethacin, less use of postnatal steroids, and shorter duration of ventilation days. Multivariate logistic regression analysis identified that greater GA and vaginal delivery were associated with increased risk of early-onset NEC. CONCLUSIONS: Among infants <33 weeks’ gestation, NEC appears to present at mean age of 7 days in more mature infants, whereas onset of NEC is delayed to 32 days of age in smaller, lower GA infants. Further studies are required to understand the etiology of this disease process.

Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary)

Injections for vaccinations, the most common source of iatrogenic pain in childhood,[1][1] are administered repeatedly to almost all Canadian children throughout infancy, childhood and adolescence.[2][2] The pain associated with such injections is a source of distress for children, their parents and

Inadequate pain management during routine childhood immunizations: the nerve of it.

BACKGROUND Immunization is regarded as one of the most significant medical achievements of all time. Recently, increasing attention has been paid to the pain resulting from routine childhood immunizations. OBJECTIVE This narrative review summarizes existing knowledge about: (1) the epidemiology of childhood immunization pain; (2) the pain experience of children undergoing immunization; (3) current analgesic practices; (4) barriers to practicing pain management in children; and (5) recommendations for improvements in pain management during immunization. METHODS We conducted a search of MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials for primary research and review articles published from inception of the databases through October 2008. Key search terms included immunization, pain, child/infant, vaccine, and intervention. Additional studies were identified through searches of the reference lists in the retrieved articles. No language restrictions were imposed regarding the type of article (eg, full article, abstract) or language. RESULTS Vaccine injections are the most common iatrogenic procedure performed in childhood and a major source of distress for children (of all ages), their parents, and the participating health care professionals, as well as a direct cause of vaccine nonadherence. In addition, lack of adequate pain management during immunization exposes children to unnecessary suffering and the potential for long-term consequences, such as fear of needles. Numerous pain management strategies are available to reduce vaccine injection pain, including: (1) physical interventions and injection techniques; (2) psychological interventions; and (3) phar-macologic and combined interventions. However, adoption of pain-relieving techniques into clinical practice has been suboptimal. The underutilization of pain management strategies can be attributed to a lack of knowledge about pain and effective pain prevention strategies, and the persistence of attitudes about pain that interfere with optimal clinical practices. Current analgesic practices could be improved substantially if all stakeholders involved in immunization (eg, policy makers, practitioners, consumers) participate in efforts to reduce pain. Treating pain during childhood immunization has the potential to reduce distress during the procedure and greatly improve satisfaction with the immunization experience through more positive experiences for children and their families. Other potential benefits include improved adherence to immunization schedules and reduced sequelae of untreated pain. CONCLUSION Immunization is a global health priority. Medical care can be improved if pain management becomes a routine aspect of the delivery of vaccine injections.

Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for preterm infants

Objective:To compare the feasibility of continuous positive airway pressure (CPAP) support generated by high flow nasal cannula with conventional CPAP for prevention of reintubation among preterm infants with a birth weight of ⩽1250 g.Study Design:Preterm infants were randomized to CPAP generated via high flow cannula or the Infant Flow Nasal CPAP System (VIASYS, Conshohocken, PA, USA) at extubation. Primary outcome was incidence of reintubation within 7 days. Secondary outcomes included change in oxygen use and frequency of apnea and bradycardias postextubation.Results:Forty neonates were randomized. Twelve of 20 infants randomized to high flow cannula CPAP were reintubated compared to three of 20 using Infant Flow (P=0.003). The high flow cannula group had increased oxygen use and more apneas and bradycardias postextubation.Conclusions:CPAP delivered by high flow nasal cannula failed to maintain extubation status among preterm infants ⩽1250 g as effectively as Infant Flow CPAP.

Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood immunizations: systematic review and meta-analyses.

BACKGROUND Immunization is the most common cause of iatrogenic pain in childhood. Despite the availability of various analgesics to manage vaccine injection pain, they have not been incorporated into clinical practice. To date, no systematic review has been published on the effectiveness of pharmacologic and combined interventions for reducing injection pain. OBJECTIVES The objectives of this article were to assess the effectiveness and tolerability of various pharmacologic and combined interventions for reducing the pain experienced by children during immunization. METHODS MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched to identify randomized controlled trials (RCTs) and quasi-RCTs pertaining to pharmacologic and combined interventions to reduce injection pain in children 0 to 18 years of age using validated child self-reported pain or observer-reported assessments of child pain and distress. We included trials that (1) investigated the effects of pharmacologic interventions (ie, topical local anesthetics, sweet-tasting solutions, vapocoolants, and oral analgesics [acetaminophen or ibuprofen]); (2) compared 2 different analgesic interventions; and (3) evaluated combinations of >or= 2 analgesic interventions, including breastfeeding. Meta-analyses were performed using a fixed-effects model. RESULTS Thirty-two studies, involving 3856 infants and children 2 weeks to 15 years of age, were included in this systematic review; 23 of these trials were included in meta-analyses. Ten trials, including 1156 infants and children, evaluated topical local anesthetics. In a meta-analysis of 2 trials, including 276 children, child self-reported pain ratings were lower in children who received topical local anesthetics than in those who received a placebo. The standardized mean difference (SMD) was -0.25 (95% CI, -0.49 to -0.01; P = 0.04). The use of topical local anesthetics was associated with less pain than was placebo in 4 trials (527 infants) based on the difference between Modified Behavioral Pain Scale scores (range, 0-10) before and after vaccination: the weighted mean difference (WMD) was -0.79 (95% CI, -1.10 to -0.48; P < 0.001) and the SMD was -0.43 (95% CI, -0.60 to -0.26; P = 0.001). Observer-rated pain, using visual analog scale (VAS) scores (range, 0-100 mm), was significantly lower (WMD, -16.56 mm; 95% CI, -22.11 to -11.01; P < 0.001; and SMD, -0.75; 95% CI, -1.00 to -0.49; P < 0.001). The number needed to treat (NNT) to prevent 1 child from having clinically significant pain, measured using the Faces Pain Scale (FPS; score, >-3), was 3.7 (95% CI, 2.5 to 7.7) from 1 study. Eleven trials (1452 infants and children) evaluated sweet-tasting solutions. In a meta-analysis of 6 studies (665 infants), administration of sucrose with or without non-nutritive sucking (NNS; use of a pacifier) was associated with less pain than no intervention or sterile water with or without NNS; the SMD was -0.56 (95% CI, -0.72 to -0.40; P < 0.001). Total cry duration was lower in infants who received sucrose than in those who received sterile water (WMD, -9.41 sec; 95% CI, -13.18 to -5.64; P < 0.001; and SMD, -0.43; 95% CI, -0.61 to -0.25; P < 0.001). The NNT to prevent 1 child from having clinically significant pain, using the Neonatal Infant Pain Scale (score, >3), was 1.4 (95% CI, 1.0 to 2.5). In 3 trials that evaluated sweet-tasting solutions longitudinally, administration of sucrose or glucose (vs sterile water, with or without NNS) was associated with reduced pain based on cry duration or the University of Wisconsin Childrens Hospital Pain Scale (all, P < 0.05). Data were pooled for 2 studies conducted in 100 children who received a spray with a vapocoolant or placebo at the injection site before the procedure. Child self-rated pain (4-point scale) was lower in the group treated with the vapo-coolant (SMD, -0.43; 95% CI, -0.83 to -0.02; P = 0.04); significant heterogeneity was reported for this outcome (chi(2) = 5.51; P = 0.02; I(2) = 82%). In 2 studies (117 children), no significant difference was found between vapocoolants and typical care (no treatment) based on child self-reports; significant heterogeneity was reported for this outcome (chi(2) = 9.89; P = 0.02; I(2) = 90%). None of the studies identified in the literature search evaluated oral analgesics (acetaminophen or ibuprofen). Four studies (318 infants and children) compared 2 different analgesic interventions; there was insufficient evidence to suggest superiority of 1 intervention over another. Combinations of >or=2 analgesic interventions were more effective than the individual interventions used alone. Child self-reported pain ratings were combined for 4 studies (350 children); the SMD was -0.52 (95% CI, -0.73 to -0.30; P = 0.001). Data on cry duration were pooled for 3 studies (229 infants and children); the WMD was -18.87 seconds (95% CI, -32.05 to -5.69; P = 0.005). Parent-rated child pain (VAS) scores were combined for 3 studies (365 infants and children); the WMD was -15.66 mm (95% CI, -19.74 to -11.57; P < 0.001). Nurse- or physician-rated child pain (VAS) scores were combined for 3 studies (368 infants and children); the WMD was -17.85 mm (95% CI, -21.43 to -14.28; P < 0.001). In a meta-analysis of 4 studies (474 infants), infants who were breastfed before, during, and after the procedure had less pain than did those who were not breastfed (SMD, -2.03; 95% CI, -2.26 to -1.80; P < 0.001). A meta-analysis of 3 studies (344 infants) found a shorter cry duration for infants who were breastfed than for those who were not breastfed (WMD, -38.00 sec; 95% CI, -42.27 to -33.73; P < 0.001; and SMD, -2.00; 95% CI, -2.27 to -1.73; P < 0.001). The NNT to prevent 1 infant from having clinically significant pain, using the Facial Pain Rating Scale (pain vs no pain), was 7.7 (95% CI, 4.5 to 25.0) from 1 study. CONCLUSION Topical local anesthetics, sweet-tasting solutions, and combined analgesic interventions, including breastfeeding, were associated with reduced pain during childhood immunizations and should be recommended for use in clinical practice.

Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: Systematic review of randomized controlled trials and quasi-randomized controlled trials

BACKGROUND Vaccine injections are the most common reason for iatrogenic pain in childhood. With the steadily increasing number of recommended vaccinations, there has been a concomitant increase in concern regarding the adequacy of pain management. Physical interventions and injection techniques that minimize pain during vaccine injection offer an advantage over other techniques because they can be easily incorporated into clinical practice without added cost or time. Their effectiveness, however, has not previously been studied using a systematic approach. OBJECTIVE The purpose of this review was to determine the effectiveness of physical interventions and injection techniques for reducing pain during vaccine injection in children. METHODS MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of physical interventions and injection techniques on pain during injection of vaccines in children 0 to 18 years of age, using validated child self-reported pain or assessments of child distress or pain made by others (parent, nurse, physician, observer). We sought to determine the effects of: (1) different formulations of the same vaccine; (2) position of the child during injection; (3) intramuscular versus subcutaneous injection; (4) cooling of the skin at the injection site with ice before injection; (5) stroking the skin or applying pressure close to the injection site before and during injection; (6) order of vaccine injection when 2 vaccines were administered sequentially; (7) simultaneous versus sequential injection of 2 vaccines; (8) vaccine temperature; (9) aspiration before injection; (10) anatomic location of injection; (11) aspects of the needle (gauge, length, angle of insertion, speed of injection); and (12) combinations of these interventions. All meta-analyses were performed using a fixed-effects model. RESULTS Nineteen RCTs involving 2814 infants and children (0-18 years of age) were included in the systematic review. One study included children >or=16 years and adults (n = 150). Interventions with positive findings are summarized here. In 2 trials that used child self-reports of pain during administration of measles-mumps-rubella vaccine (total, 680 children with complete data), the Priorix vaccine caused less pain than the M-M-R(II) vaccine (standardized mean difference [SMD], -0.66; 95% CI, -0.81 to -0.50; P < 0.001). In 3 trials (404 children), the number needed to treat (NNT) with Priorix to prevent 1 child from crying was 3.2 (95% CI, 2.6-4.2). In 4 trials (281 infants and children), sitting children up or having parents hold infants appeared to cause less pain than the supine position, but the difference was not statistically significant; however, significant heterogeneity was found among the studies, and a qualitative approach was used for data analysis. A benefit was observed for 3 of the 4 studies; the SMD ranged from -0.4 to -0.8 (P < 0.05 for all analyses). The negative findings observed for the remaining study may have been the result of methodologic heterogeneity. Stroking the skin close to the injection site before and during injection reduced pain in 1 trial (66 children; SMD, -0.53; P = 0.03). One study (120 children) found that when diphtheria-polio-tetanus-acellular pertussis-Haemophilus influenzae type b (DPTaP-Hib; Pentacel) and pneumococcus (Prevnar) were injected sequentially during the same office visit, observer- and parent-reported pain scores were lower when DPTaP-Hib was injected first (SMD, -0.40 and -0.57, respectively; P <or= 0.03). In 1 study (113 infants) comparing rapid intramuscular injection without aspiration and slow intramuscular injection with aspiration, the rapid injection without aspiration was associated with less pain (SMD, -0.62 to -0.97 for parent, nurse, physician, and observer behavioral pain ratings; all, P < 0.05). The NNT to prevent 1 infant from crying was 2.5 (95% CI, 1.8-4.3). CONCLUSIONS Pain during immunization can be decreased by: (1) injecting the least painful formulation of a vaccine; (2) having the child sit up (or holding an infant); (3) stroking the skin or applying pressure close to the injection site before and during injection; (4) injecting the least painful vaccine first when 2 vaccines are being administered sequentially during a single office visit; and (5) performing a rapid intramuscular injection without aspiration.

Randomised controlled trial of paracetamol for heel prick pain in neonates

AIM To evaluate the effectiveness of paracetamol in decreasing the pain from heel prick. METHODS A prospective randomised double blind placebo controlled trial was conducted of 75 term neonates undergoing heel prick. Sixty to 90 minutes before the procedure neonates received paracetamol orally in a dose of 20 mg/kg (group 1) or an equal volume of placebo (group 2). Heel prick was performed in a standardised manner. Pain assessments were made using per cent facial action (brow bulge, eye squeeze, and nasolabial fold (range 0–300%) and per cent of time spent crying (range 0–100%). RESULTS Thirty eight neonates were enrolled in group 1 and 37 neonates in group 2. There were no significant differences in the demographic characteristics between groups. Mean gestational age was 39 (SD 1.4) vs 39.4 (SD 1.2) weeks, p=0.86, mean birthweight 3.45 (SD 0.45) vs 3.44 (SD 0.42) kg; p=0.31 for groups 1 and 2, respectively. Facial action pain scores did not differ between groups (143.5 (SD 54.2)% vs 131.1 (SD 59.6)%; p=0.38). Cry scores also did not differ (29.4 (SD 19.9)%vs 26.8 (SD 20.2)%; p=0.60). No adverse effects were observed. CONCLUSION Paracetamol is ineffective for decreasing the pain from heel prick in term neonates.

Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures

Background: Sucrose is widely used to manage procedural pain in term newborns despite a lack of evidence of its effectiveness for different procedures and infant populations. Our objectives were to evaluate the effectiveness and safety of sucrose in newborns undergoing various medical procedures within 2 days of birth. Methods: We performed a double-blind, randomized controlled trial. We included newborns (≥ 36 weeks gestation) of diabetic mothers and nondiabetic mothers. Each newborn received 2 mL of a 24%-sucrose or placebo solution before all procedures. We used the Premature Infant Pain Profile to assess pain during intramuscular injection of vitamin K, venipuncture for the newborn screening test and the first 3 heel lances for glucose monitoring (newborns of diabetic mothers only). Scores ranged from from 0 (no pain) to 18 (maximum pain). Results: We included 240 newborns (120 from diabetic mothers, 120 from nondiabetic mothers). The overall mean pain score was lower among newborns who received sucrose than among those who received a placebo (mean difference –1.3, 95% confidence interval [CI] –2.0 to –0.6). We found that pain scores during intramuscular injection did not differ significantly between the sucrose and placebo groups for newborns of diabetic or nondiabetic mothers (newborns of nondiabetic mothers: mean difference –1.1, 95% CI –2.4 to 0.2; newborns of diabetic mothers: mean difference –1.0, 95% CI –2.4 to 0.4). During venipuncture, newborns who received sucrose had lower pain scores compared with those who received a placebo (newborns of nondiabetic mothers: mean difference –3.2, 95% CI –4.6 to –1.8; newborns of diabetic mothers: mean difference –2.4, 95% CI –3.8 to –1.0). Among newborns of diabetic mothers, there was no difference in pain during the first 3 heel lances or mean glucose levels between the sucrose and placebo groups (p = 0.94 and p = 0.29 respectively). Interpretation: We found a modest reduction of pain in newborns of both diabetic and nondiabetic mothers when sucrose was used for all medical procedures performed in the first 2 days after birth. However, when each procedure was analyzed separately, we found that the effectiveness of sucrose was limited to venipuncture for the newborn screening test. (http://Clinicaltrials.gov trial register no. NCT00213213.)

Influence of repeated painful procedures and sucrose analgesia on the development of hyperalgesia in newborn infants

ABSTRACT This study determined the effects of cumulative exposure to painful needle procedures and sucrose analgesia on the development of remote hyperalgesia in newborn infants, defined as an increase in response to a normally painful stimulus at a site distal from the site of injury. One‐hundred and twenty healthy newborns and 120 healthy newborn infants of diabetic mothers equally randomized to sucrose analgesia or placebo prior to all needle procedures in the first two days after birth were divided into two exposure groups according to number of needle procedures they had undergone [high (⩾5) or low (⩽4)] using the median cut‐off technique. Compared to the low exposure group, infants in the high exposure group had a higher pain response during a subsequent venipuncture distal to the site of previous injury, assessed by the Premature Infant Pain Profile (PIPP) [7.1 vs. 8.4; p = 0.012] and Visual Analog Scale (VAS) [2.5 cm vs. 3.2 cm; p = 0.047], and a trend for longer cry duration [25.7 s vs. 33.8 s; p = 0.171]. PIPP scores did not differ during a routine diaper change, suggesting a nociceptive specific mechanism for the remote hyperalgesia to venipuncture. Sucrose reduced PIPP, VAS, and cry duration scores during venipuncture, but did not prevent hyperalgesia (p > 0.05). There was a preponderance of infants of diabetic mothers in the high exposure group; however, the analysis did not demonstrate this to be a confounding factor. In conclusion, sucrose analgesia for repeated painful procedures in the first day of life does not prevent development of remote hyperalgesia in newborns.

Neonatal pain response to heel stick vs venepuncture for routine blood sampling

Neonatal pain response and adverse effects and maternal anxiety were assessed in 27 infants who were randomly allocated to venepuncture or heel stick. Pain was assessed by nurses using the Neonatal Infant Pain Scale (NIPS) and a three point scale for the mothers. NIPS scores were higher in the heel stick group compared with the venepuncture group. Maternal anxiety was higher before the procedure while perception of an infant’s pain was lower in the venepuncture group compared with the heel stick group. Venepuncture is less painful than heel stick in newborn infants undergoing routine blood sampling.