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Objective: To describe the perception of physiotherapists in neonatal units regarding pain, the use of measurement scales and strategies that minimize pain. Methods: Interviews were conducted with physiotherapists in hospitals with neonatal units between 2013 and 2015 in Rio de Janeiro. The questions concerned the knowledge of the feeling of pain, from its recognition to its care or treatment. The description of the results was done by comparing public and private hospitals (Fisher’’s Exact exact Testtest), considering p

Pain assessment is a vital part of newborn treatment in Intensive Care Units. However, clinical pain assessment is highly subjective and does not support continual pain monitoring. Automated tools have been introduced to address this problem, but their performance is limited by inadequate training data and unsuitable pain annotations. In addition, current automated tools focus on pain detection rather than severity estimation, which is the unmet need in medical treatment. In this paper, we present: a) the Acute Pain in Neonates (APN-db) database, a public dataset to support research in this field and allow for benchmarking of new automated tools; b) a novel L1-point Neonatal Face and Limb Acute Pain Scale (NFLAPS), a visual behaviour-centric pain measurement tool, which is an adaptation of the Neonatal Infant Pain Scale (NIPS) and the Neonatal Facial Coding System (NFCS); and c) a system for neonatal pain assessment which encodes pain indicative-features using handcrafted algorithms and deep-learned features. Experiments show that our system performs well with an RMSE of 1.9 compared to human error of 1.65 on the same dataset, demonstrating its potential application to newborn health care.

Background: Neonates frequently experience pain as a result of diagnostic or therapeutic interventions or as a result of a disease process. Neonates cannot verbalize their pain experience and depend on others to recognize, assess and manage their pain. Neonates may suffer immediate or long-term consequences of unrelieved pain. Accurate assessment of pain is essential to provide adequate management. Observational scales, which include physiological and behavioral responses to pain, are available to aid consistent pain management. Pain assessment is considered as the fifth vital sign. Objectives: Aims of the present study were (1) to compare two commonly cited neonatal pain assessment tools, Neonatal Pain, Agitation and Sedation Scale (N-PASS) and modified Pain Assessment Tool (mPAT), with regard to their psychometric qualities, (2) to explore intuitive clinicians' ratings by relating them to the tools' items and (3) to ensure that neonates receive adequate pain control. Methods: Two coders applied both pain assessment tools to 850 neonates while undergoing a painful or a stressful procedure. Each neonate was assessed before, during and after the procedure. The evaluation before and after the procedure was done using NPASS, while pain score during the procedure was assessed by mPAT. Analyses of variances and regression analyses were used to investigate whether tools could discriminate between the procedures and whether tools' items were predictors of pain severity. Results: Internal consistency, reliability and validity were high for both assessment tools. N-PASS tool discriminated between painful and stressful situations better than mPAT. There was no relation between the age of neonate and the pain score. Moreover, P-value was statistically significant between mPAT score and post procedural assessment score as well as between pre and post procedural assessment scores. Conclusion: Both assessment tools performed equally well regarding physiologic parameters. However, N-PASS makes it possible to assess pain during sedation. It was noticed that gaps exist between practitioner knowledge and attitude regarding neonatal pain.

Background: Neonatal pain is an extensive research field and there are many possibilities to treat pain in neonates. Acupuncture is one new and non-pharmacological option and a promising tool to reduce pain in neonates undergoing minor painful interventions during routine medical care. Objectives: This review summarises trials of acupuncture for pain reduction in neonates undergoing painful interventions during routine medical care. Data source: MEDLINE, Embase, CINAHL, electronic clinical trials registry platforms and reference lists were systematically screened for trials from their dates of inception to February 2017 (English language database search). Study selection: Inclusion criteria were (1) preterm or term neonates, (2) acupuncture for painful medical interventions and (3) formal pain assessment as a primary or secondary study outcome. We included only randomised controlled trials. Data extraction: Data were extracted using a standardised protocol and individual risk of bias was assessed. Results: The literature search revealed a total of 12 196 records. After application of inclusion criteria, five studies were included in this review. Two studies demonstrated significant pain reduction, one found equal outcomes in comparison to standard care, and two showed significantly higher pain scores with acupuncture alone. Limitations: The main limitation of the results is the heterogeneity across trials in acupuncture modality, acupuncture point selection, control groups and pain assessment (heterogeneity: I2=87%). Conclusion: The results of this review suggest that acupuncture may have a positive pain-relieving effect in neonates. However, due to the low number of available high-quality trials and heterogeneity across the studies it is not possible to state clear recommendations.

The current standard for assessing neonatal pain is discontinuous and suffers from inter-observer variations, which can result in delayed intervention and inconsistent treatment of pain. Therefore, it is critical to address the shortcomings of the current standard and develop continuous and less subjective pain assessment tools. Convolutional Neural Networks have gained much popularity in the last decades due to the wide range of its successful applications in medical image analysis, object recognition, and emotion recognition. In this paper, we propose a Neonatal Convolutional Neural Network, designed and trained end-to-end to detect neonatal pain. We evaluated the proposed network in two data sets of neonates and compared its performance to the performance of ResNet architecture in the same data sets. Our proposed method outperformed ResNet in recognizing neonates’ pain and achieved around 91.00% accuracy. While further research is needed, our preliminary results suggest that the presented network can be used for automatic pain assessment, and possibly similar applications. It also suggests that the automatic recognition of neonatal pain provides a viable and more efficient alternative to the current standard of pain assessment.

Neonatal pain assessment has gained more and more attention from clinical care, and pain scales are usually adopted as the main assistants for neonatal pain rankings. Due to the large time and manpower consumption of pain scales, automatic pain assessment for neonates during painful clinical procedures is of great requirements. A video database of neonatal facial expression, containing pain intensity labels obtained from two different pain scales, is constructed in this paper as a pre-work for automatic pain score evaluation. Uniform and rotation invariant local binary patterns (LBP) are implemented as feature descriptors and the effectiveness of the extracted features is validated. As a result, a feature set of 144 dimensionalities is established and with the implementation of dimension reduction, new feature sets ranging from 40 to 60 dimensionalities, accounting for more than 90% of original data, are preserved as the input data for future pain classification.

Background: The care of high-risk neonates in intensive care units is a relatively new field in resource-limited countries. Consequently, pain management of neonates has not been included or considered as part of neonatal care. Neonatal pain is more difficult to assess than adult pain, as they are unable to self-report. Nurses and midwives caring for neonates have a professional responsibility to recognise and manage neonatal pain. Objectives: To assess the knowledge, attitude, and practice of nurses and midwives providing neonatal pain management at two hospitals in Kigali. Methodology: A descriptive cross-sectional design was used. Data were collected from a convenience sample of 66 nurses and midwives providing neonatal care. Data analysis was achieved through descriptive and inferential statistics. Results: The majority (74.2%) demonstrated a low level of knowledge of neonatal pain and its management. Over half (51.5%) had a positive attitude toward neonatal pain management, though over three quarters (84.8%) reported a low level of integrating pain management into practice. Conclusions: There is a knowledge deficit among the nurses and midwives providing neonatal pain management. A gap lies between their attitude and practice. More educational opportunities are needed to better assess and manage pain in the neonatal patient. Keywords: Neonate, NICU, pain management, knowledge, attitude, practices

1. IntroductionA comprehensive assessment of pain extends beyond measuring the intensity of pain to also include: site and radiation of pain; onset, aggravating and relieving factors; character of pain; associated symptoms; effect on activities and sleep; treatment and response; medical history; and

Introduction In the Neonatal Intensive Care Unit (NICU), prematurely born infants undergo a range of skin breaking and painful procedures. At the same time, the spinal nociceptive system is in a sensitive developmental stage. Both neonatal repetitive painful procedures and their treatment can induce plasticity of the neonatal spinal nociceptive system, causing long-lasting alterations to pain processing and pain reactivity. Methods This review focuses on developmental processes related to the nociceptive network in the spinal dorsal horn and more specifically at mechanisms related to 1. Modulation of afferent systems; 2. The role of interneurons; 3. Descending inhibitory pathways; and 4. The central neuro-immune responses and microglial cell responses. The effects and possible mechanisms underlying the long-term effects of repetitive painful procedures on the developing nociceptive system as well as subsequent pharmacological treatment (acetaminophen, morphine) in early life are discussed. Results Repetitive stimulation of the nociceptive system in a rat model with use of needle pricks in the hind-paw closely mimics the clinical situation for infants in the NICU. Conclusion Activity dependent plasticity in early postnatal life induces long-lasting alterations that then may cause altered pain perception in adulthood. For a future choice of optimal analgesic drugs these considerations have to be taken into account beyond the classical classes of drugs used nowadays.

Introduction: In the Neonatal Intensive Care Unit (NICU), prematurely born infants undergo a range of skin breaking and painful procedures. At the same time, the spinal nociceptive system is in a sensitive developmental stage. Both neonatal repetitive painful procedures and their treatment can induce plasticity of the neonatal spinal nociceptive system, causing long-lasting alterations to pain processing and pain reactivity.Methods: This review focuses on developmental processes related to the nociceptive network in the spinal dorsal horn and more specifically at mechanisms related to 1. Modulation of afferent systems; 2. The role of interneurons; 3. Descending inhibitory pathways; and 4. The central neuro-immune responses and microglial cell responses. The effects and possible mechanisms underlying the long-term effects of repetitive painful procedures on the developing nociceptive system as well as subsequent pharmacological treatment (acetaminophen, morphine) in early life are discussed.Results: Repetitive stimulation of the nociceptive system in a rat model with use of needle pricks in the hind-paw closely mimics the clinical situation for infants in the NICU.Conclusion: Activity dependent plasticity in early postnatal life induces long-lasting alterations that then may cause altered pain perception in adulthood. For a future choice of optimal analgesic drugs these considerations have to be taken into account beyond the classical classes of drugs used nowadays.

Background From the time a neonate is admitted into the neonatal intensive care unit (NICU), they are exposed to several painful procedures especially, intravenous (IV) catheter insertions. An increase use of sucrose is essential to improve pain management in neonates exposed to IV insertions. The proper administration and storage location of sucrose plays an integral role in neonatal pain management. Purpose The purpose of implementing the quality improvement (QI) project is to improve the quality of care within the neonatal population by improving neonatal nurses' beliefs, knowledge, and practices regarding neonatal pain. Methods A quality improvement process to re-locate sucrose from the Pyxis (medication dispenser) to central supply unit to increase sucrose usage was completed along with distributing a 40-item pre and post questionnaire regarding neonatal pain to a convenience sample of nurses in a level II/III NICU in the Southeast Florida region. Pre and post intervention observation audits were also utilized to differentiate practice change throughout the QI initiative in the level II NICU. Results Twenty nurses agreed to participate in the QI initiative and completed both pre and post intervention questionnaires. Results reflect an increase in nurses' knowledge and beliefs and improved pain management practices. As a group, there was a significant difference between the utilization of sucrose two minutes prior to insertion of intravenous catheter (p Conclusion There is significant evidence that increased knowledge in neonatal pain management, the proper administration of sucrose including increased sucrose utilization will result in better pain management among neonates exposed to intravenous insertions.

Introduction Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models. peerreview_statement: The publishing and review policy for this title is described in its Aims & Scope. aims_and_scope_url: http://www.tandfonline.com/action/journalInformation?show=aimsScope&journalCode=ierj20 ispartof: Expert Review of Clinical Pharmacology vol:10 issue:1 pages:111-126 ispartof: location:England status: published

Neonatal pain and stress induce long-term changes in pain sensitivity. Therefore their interrelation is a topical subject of clinical and basic research. The present study investigated the effects of inflammatory peripheral pain and stress of maternal deprivation (MD)-isolation in 1-2- and 7-8-day-old Wistar rats (P1,2 and P7,8 respectively, ages comparable to preterm and full-term human babies) on basal pain and pain sensitivity in conditions of inflammatory pain (formalin test) during adolescence. The neonatal impacts were: pain (formalin injection, FOR in the paw), stress (a short 60-min MD), or pain+stress combination (FOR+MD), and appropriate controls. We found that stress of short-term maternal deprivation-isolation and inflammatory pain on P1,2 and P7,8 significantly increased the vulnerability of the nociceptive system to inflammatory pain. Maternal deprivation-isolation on P1,2 as compared with a similar impact on P7,8 had a greater effect on pain sensitivity of the adolescent rats, but the influence of early pain was independent of the injury age. Only adolescent rats with an early combination of pain and maternal deprivation-isolation showed hypoalgesia in the hot plate (HP) test. However licking duration (reflecting pain sensitivity) in these rats did not exceed licking duration in animals exposed only to maternal deprivation-isolation or pain. This study adds new data to the growing body of work demonstrating that early noxious impacts have long-term consequences for the functional activity of the nociceptive system. Our new findings may help to understand the impact of pain and maternal separation in the neonatal intensive care unit.

The oral transmucosal (OTM) route for administration of comfort medication in infants at the end-of-life has long been favored by our pediatric palliative care team but has rarely been described in the literature.To determine the feasibility of implementing a standardized comfort care protocol using OTM medications in dying neonates.A comfort protocol prescribing medication by the OTM route and standardized assessment were established. Each infant included in the study was assessed with the Neonatal Pain, Agitation, and Sedation Scale (N-PASS). Caretakers' satisfaction was assessed using a questionnaire. The feasibility of implementing the protocol was determined by the proportion of assessments done when required, the rate of termination of the protocol, and the feedback from nurses using the protocol.Twelve patients were enrolled. Regular evaluations were performed 85% of the time. When the medication was given as needed, 71% of cases were evaluated before versus 63% when regular doses were given. The as-needed doses were followed by an assessment 30 minutes later in 49% of cases and in 41%, 60 minutes later, for a total of 64% in the hour after medication administration. The protocol was discontinued only for two patients who were discharged to continue end-of-life care at home. There were no significant adverse events reported. Finally, 17 of 18 nurses said they would recommend this protocol to other institutions.In the context of neonatal palliative care, the implementation of a standardized protocol for administration of drugs by the OTM route is feasible and safe. However, in the context of this study, adherence was limited because of too-frequent evaluations and misunderstanding of the protocol.

Introduction: A neonate is subjected to pain in a variety of invasive and non-invasive activities. It is significant that the midwife assesses for pain in the neonate due to their inability to give verbal expression to their pain. The study aimed to gain an in-depth understanding of Advanced Midwifery students’ attitudes, knowledge and perceptions on pain assessment in neonates. Method: A qualitative content analysis using Elo and Knynas’ (2008) approach, explored the participants’ experiences of neonatal pain assessment. Purposive sampling allowed for the selection of Advanced Midwifery and Neonatal Nursing Science students from a select university. Data were collected through a focus group discussion for an extended period to ensure data saturation and that no new information emerged. Results: The following three categories emerged: elimination process, restricted assessment and non-standardised approach. Conclusion: Pain was not given primacy as an indicator of neonatal discomfort. There was a paucity of knowledge on the assessment tools, with haphazard assessment, which lacked a scientific approach.

3rd Congress of Joint European Neonatal Societies (jENS 2019), 17–21 September 2019 in Maastricht, the Netherlands.

There is significant evidence that shows that untreated pain in the neonatal and infant population can lead to worsening outcomes later in life. Thus, it is prudent to properly treat neonatal pain. However, in order to properly treat one’s pain, one must use a proper pain measurement tool to assess the child.

Neonatal pain assessment in clinical environments is challenging as it is discontinuous and biased. Facial/body occlusion can occur in such settings due to clinical condition, developmental delays, prone position, or other external factors. In such cases, crying sound can be used to effectively assess neonatal pain. In this paper, we investigate the use of a novel CNN architecture (N-CNN) along with other CNN architectures (VGG16 and ResNet50) for assessing pain from crying sounds of neonates. The experimental results demonstrate that using our novel N-CNN for assessing pain from the sounds of neonates has a strong clinical potential and provides a viable alternative to the current assessment practice., Comment: Accepted to IEEE HI-POCT 2019

BACKGROUND AND OBJECTIVES: Despite the solid results on pain management strategies in neonatology, it is necessary to identify and explore the barriers that may hamper the attention to pain and the implementation of the scientific evidence widely disseminated in the literature in the care practice. The objective of this study was to describe the barriers encountered by the healthcare professionals of a neonatal intensive care unit regarding the management, evaluation, and treatment of newborn pain. METHODS: Descriptive, exploratory, quantitative study carried out in a maternity hospital in the city of Rio de Janeiro. Forty-two nursing technicians, 22 nurses, 20 physicians, and 2 physiotherapists participated in the study. The data was collected in an interview using a form and the data was analyzed by descriptive statistics. RESULTS: Among the barriers found it stands out the lack of training on neonatal pain, no use of scales, the absence of routine and protocols for the treatment of pain, and the need for greater safety for the evaluation and treatment of pain. It was also observed that there is a gap between knowledge and care practice in the unit. CONCLUSION: The identification of these barriers is essential to establish strategies based on knowledge-transfer to overcome the obstacles and improve the care given to newborns in the neonatal intensive care unit.

3rd Congress of Joint European Neonatal Societies (jENS 2019), 17–21 September 2019 in Maastricht, the Netherlands.

Background Neonates that have been subjected to perinatal asphyxia and fulfill criteria for therapeutic hypothermia are cooled to 33.5 °C for 72 h. There is no consensus regarding sedation and analgesic use during hypothermia, but there is evidence supporting the importance of pain relief and adequate sedation. There is a need for assessment of the neonates need for pain relief and sedation, and for adjustments of medication to ensure adequate treatment. There are many different scoring tools available. We found the N-PASS (Neonatal Pain, Agitation and Sedation Scale) scoring tool to be the most suitable for this patient group as it assesses both pain and sedation. Methods We translated the scoring tool according to guidelines published by Wilder et al., and scored neonates treated with therapeutic hypothermia. Sedation and analgesia were adjusted according to scoring results. At the end of the study a questionnaire was filled out by the nurses in charge of this group of patients. Results Both pain and sedation scores did not reach the desired levels until day 3. The nurses reported a high level of satisfaction (79.7% were extremely of very satisfied), and 96.7% of the nurses found the neonates to be better pain relieved after the initiation of the study. Conclusion The implementation of the N-PASS scoring tool in our unit has been successful, and has led to better pain relief and sedation than before the implementation.

Until 1985, it was widely believed that neonates did not experience pain. However, after years of neglect, there is starting to be research done on this topic and a bigger focus on trying to relieve pain in these infants. Some of this research specifically focuses on how the nervous system changes in response to noxious stimuli and untreated pain.

In this paper we present three different learning models for the automatic assessment of neonatal pain during clinical procedures. Given that few data are publicly available for the training and evaluation of these systems, we develop solutions that try to get the most out of the data that are available. To accomplish this, we choose a convolutional neural network (CNN) architecture as the discriminator with a reduced number of trainable parameters that are used efficiently. Furthermore, we develop two solutions based on the generative adversarial network (GAN) framework in order to improve discriminator power by transforming it into a multitask classifier and by training it with a combination of real and synthetic samples. Experimental results on the publicly available infant Classification Of Pain Expressions (iCOPE) database show superior results compared to previous works in the state of the art.

Neonates do not have the ability to either articulate pain or communicate it non-verbally by pointing. The current clinical standard for assessing neonatal pain is intermittent and highly subjective. This discontinuity and subjectivity can lead to inconsistent assessment, and therefore, inadequate treatment. In this paper, we propose a multi-channel deep learning framework for assessing neonatal pain from videos. The proposed framework integrates information from two pain indicators or channels, namely facial expression and body movement, using convolutional neural network (CNN). It also integrates temporal information using a recurrent neural network (LSTM). The experimental results prove the efficiency and superiority of the proposed temporal and multi-channel framework as compared to existing similar methods., Comment: Accepted to IEEE SMC 2019

There are many neonatal pain assessment tools available. However, systematic psychometric comparisons between tools are lacking, particularly those comparing tools regarding their ability to differentiate between pain and stressful procedures. The aim of the present study was to compare 5 widely used neonatal pain assessment tools: Neonatal Facial Coding System-Revised, Premature Infant Pain Profile-Revised, Neonatal Pain, Agitation and Sedation Scale, Neonatal Infant Pain Scale, and Bernese Pain Scale Neonates.Two coders applied all pain assessment tools to videos of 42 neonates who were videotaped during a pain and a stressful procedure.Interrater reliability and relative convergent validity were high and internal consistency good to excellent for all 5 assessment tools. All tools discriminated between painful and stressful events. Tools differed regarding their overall effect sizes as well as their items' effect sizes. Behavioral items tended to have larger effect sizes than physiological ones. Yet, effect sizes of items from one behavioral category differed greatly, which may be due to different operationalization of coding schemes.Given that the tools investigated in the present study appear to be fairly comparable psychometrically. Aspects of their clinical utility are discussed and ways of improvement identified.

For the neonatal pain expression recognition task, the recognition precision of the algorithms based on traditional machine learning isn't robust to the illumination and pose variations. The recognition algorithms based on deep learning usually rely on large-scale labeled training datasets, the recognition performance of these algorithms will be low when the labeled neonatal pain expression image dataset is small. To overcome these drawbacks, we present a neonatal pain expression recognition approach based on pre-trained deep convolutional neural network (DCNN) model with transfer learning. In this work, the introduction of transfer learning technology avoids the occurrence of over-fitting and accelerate the training procedure. Firstly, some typical DCNNs which have been trained on the ImageNet dataset, such as AlexNet, VGG-16, Inception- V3,ResNet-50 and Xception, are selected as the basic models to extract the general features of images. Then, in order to enhance the generalization ability of the DCNNs, the pre-trained DCNNs are fine-tuned by using the neonatal pain expression image dataset, and so that the feature transfer from the general image to the neonatal expression image is realized. Finally, we use different transfer learning methods to test the fine-tuned DCNN models. The experiment results show that the fine-tuned VGG-16 model achieved the best recognition accuracy (78.3 %) on the small neonatal pain expression image dataset, which indicates that the fine-tuning method can effectively obtain a DCNN model with good performance, and the transfer learning is an effective method for training DCNN when the available labeled training dataset is small. The effectiveness of DCNN and transfer learning for neonatal pain expression recognition shows promising application for clinical diagnosis.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2018-07-20T19:48:50Z No. of bitstreams: 1 Andr?? Gustavo Moura Guimar??es.pdf: 1691381 bytes, checksum: b4f575802538a0af96f868e24171236c (MD5) Made available in DSpace on 2018-07-20T19:48:50Z (GMT). No. of bitstreams: 1 Andr?? Gustavo Moura Guimar??es.pdf: 1691381 bytes, checksum: b4f575802538a0af96f868e24171236c (MD5) Previous issue date: 2018-03-06 Introduction: neonatal pain results in neurobiological effects, and changes in behavioral reactions of children who were born prematurely. There is no clear description about the pain caused by chest physiotherapy technique, nor about the possible non-pharmacological interventions to prevent it. Objective: to evaluate neonatal pain and physiological parameters during the chest physiotherapy in premature neonates (PTNB) in neonatal intensive care. Method: a randomized controlled trial, not blinded, in which 120 PTNB in mechanical ventilation were studied. They were randomized into four groups: control group (CG), diaphragmatic stimulation group (EDG), manual hyperinflation group (MHG), thoracic vibration group (VTG), containing 30 individuals in each one. The protocol consisted of 3 phases, the first phase being considered the control, and the other associated with non-pharmacological techniques to reduce pain: application of the technique (phase 1), application of technique + facilitated tucking (phase 2), application of technique + glucose (phase 3). Heart rate (HR), respiratory rate (RR), SpO2, Behavioral pain scale Indicators of Infant Pain (BIIP, ranges from 0 to 10) and Neonatal Infant Pain Scale (NIPS, ranges from 0 -7) were recorded at pre, during and after (15 minutes) the procedures described. Results: 62 (51.66%) RNPT were female, and most considered small for gestational age (83, 69%). Physiological variables (HR, FR, and SpO2) behaved in a similar manner in all groups (CG, MHG, EDG, VTG), being greater in phase 1, however these variables were reduced at phase 2 and 3 (p < 0.05). This means that during the application of non-pharmacological intervention (facilitated tucking or glucose) there was reduction of those variables. BIIP and NIPS scales showed increased in all of the groups in the phase 1 during the application of the techniques, however, similar to the physiological variables, these scales had reduced scores when applied to facilitated tucking (phase 2) or glucose (phase 3), p < 0.05. The number of individuals who have had pain assessed by BIIP (> 3 points) at the moment after in the phase 1 was 83 (69%), in phase 2 was 22 (18%), and in phase 3 of 34 (28%), p < 0.001. Conclusions: The chest physiotherapy techniques can increase the pain in PTNB, however, the non-pharmacological techniques, such as facilitated tucking and glucose, were able to reduce it. Introdu????o: A dor neonatal desencadeia efeitos neurobiol??gicos agudamente, e altera????es nas rea????es comportamentais da crian??a nascida prematuramente. N??o h?? descri????o clara sobre a dor ocasionada por t??cnicas manuais de fisioterapia respirat??ria, tampouco sobre as poss??veis interven????es n??o farmacol??gicas na preven????o da mesma. Objetivo: Avaliar a dor neonatal e par??metros fisiol??gicos durante a fisioterapia respirat??ria em neonatos prematuros na UTI neonatal. Metodologia: ensaio cl??nico randomizado controlado, n??o cego, no qual foram estudados 120 rec??m-nascidos prematuros (RNPT), de ambos os sexos, em ventila????o mec??nica. Foram randomizados em quatro grupos: grupo controle (GC), grupo estimula????o diafragm??tica (GED), grupo hiperinsufla????o manual (GHM), grupo vibra????o tor??cica (GVT), contendo 30 indiv??duos em cada. O protocolo constou de 3 fases, sendo a primeira fase considerada a controle, e as demais associadas a t??cnicas n??o farmacol??gicas de redu????o da dor: aplica????o da t??cnica (fase 1), aplica????o da t??cnica e conten????o (fase 2), aplica????o da t??cnica e glicose (fase 3). A frequ??ncia card??aca (FC), respirat??ria (FR), SpO2, escala de dor Behavioral Indicators of Infant Pain (BIIP, varia de 0 a 10) e Neonatal Infant Pain Scale (NIPS, varia de 0 -7) foram registradas pr??, durante e ap??s (15 minutos) dos procedimentos em cada fase descrita. Resultados: 62 (51,66%) dos RNPT do sexo feminino, e a maioria considerados pequenos para idade gestacional (83 ???69%???). As vari??veis fisiol??gicas (FC, FR, e SpO2) se comportaram de maneira semelhante, em todos os grupos, sendo maior na fase 1, reduzindo nas fases 2 e 3 (p 3 pontos) no momento ap??s na fase 1 foi 83 (69%), na fase 2 foi 22 (18%), e na fase 3 de 34 (28%) p< 0,001. Conclus??es: As t??cnicas de manuais de fisioterapia respirat??ria demonstraram gerar dor nos RNPT, entretanto, t??cnicas n??o farmacol??gicas como conten????o e glicose foram capazes de reduzi-la.

In young rats, below 12 days old, the rostroventral medulla exerts a tonic descending facilitation of spinal nociception, independent of ascending sensory input., The rostroventral medial medulla (RVM) is part of a rapidly acting spino-bulbo-spinal loop that is activated by ascending nociceptive inputs and drives descending feedback modulation of spinal nociception. In the adult rat, the RVM can facilitate or inhibit dorsal horn neuron inputs but in young animals descending facilitation dominates. It is not known whether this early life facilitation is part of a feedback loop. We hypothesized that the newborn RVM functions independently of sensory input, before the maturation of feedback control. We show here that noxious hind paw pinch evokes no fos activation in the RVM or the periaqueductal gray at postnatal day (P) 4 or P8, indicating a lack of nociceptive input at these ages. Significant fos activation was evident at P12, P21, and in adults. Furthermore, direct excitation of RVM neurons with microinjection of DL-homocysteic acid did not alter the net activity of dorsal horn neurons at P10, suggesting an absence of glutamatergic drive, whereas the same injections caused significant facilitation at P21. In contrast, silencing RVM neurons at P8 with microinjection of lidocaine inhibited dorsal horn neuron activity, indicating a tonic descending spinal facilitation from the RVM at this age. The results support the hypothesis that early life descending facilitation of spinal nociception is independent of sensory input. Since it is not altered by RVM glutamatergic receptor activation, it is likely generated by spontaneous brainstem activity. Only later in postnatal life can this descending activity be modulated by ascending nociceptive inputs in a functional spinal-bulbo-spinal loop.

A provincial-wide online survey was conducted to: 1) ascertain frequency of use of breastfeeding (BF), skin-to-skin care (SSC) and sucrose for pain reduction during heel lance and venipuncture in maternal newborn units and neonatal intensive care units (NICUs), and 2) to identify barriers to using these strategies for pain reduction. An invitation and link to an electronic survey were emailed to nurse managers of 91 maternal newborn units and NICUs in Ontario, Canada, and 40 completed surveys were submitted (44%). Results showed variable but infrequent use of pain reduction strategies. Barriers were coded as health care provider (HCP), infant, parent and organizational factors. Most barriers related to BF and SSC and included: preference to perform blood sampling without parents; parental preference to not be involved during blood sampling; unit cultures; out of date policies; insufficient time, knowledge and education; and staff being uncomfortable performing blood sampling with infants BF or held SSC.

Preterm infants are exposed to many stressors while in the neonatal intensive care unit including pain and reduced maternal care. Both stressors can have a profound negative impact on brain development, and the present study sought to investigate some of the biological mechanisms underlying this phenomenon. Rat pups underwent a series of repetitive needle pokes and/or reduced maternal care through a novel tea-ball infuser encapsulation model during the first four days of life. On postnatal day four, pups were sacrificed and serum was analyzed for corticosterone, while brains were tested for various neurotransmitters and brain metabolites through magnetic resonance spectroscopy. We found that exposure to maternal isolation and neonatal pain produced an increase in serum corticosterone but decreased glutamate levels in the hippocampus and frontal cortex. These alterations in stress responding and neurochemistry in response to the early-life stressors may help explain some of the negative outcomes seen in preterm infants.

BACKGROUND AND OBJECTIVES: Neonates have special peculiarities, and these should be much more widespread in the scientific environment, both for the knowledge of professionals and students, and for the mothers’ help. The objective of this study was to evaluate the knowledge, attitude and practice of the nursing team in management of neonatal pain. CONTENTS: This is a bibliographical research with a descriptive study conducted from 2013 to 2017, through a survey in the Medline (International Literature in Health Sciences), Scielo (Scientific Electronic Library Online) and LILACS (Latin American Literature in Health Sciences) electronic database. Twenty scientific articles were selected and detailed studied with the purpose of grouping the similar information and verify its particularities to be exposed in categories. CONCLUSION: There is a need to insert this theme in undergraduate and postgraduate courses and training in maternity units on a continuous basis so that the professional can relate the theory to practice and then offer the best therapy to the newborn and orientations to the mothers.

Relief of human suffering is one of the most important goals of all healthcare providers. Advances in neonatology have significantly reduced neonatal morbidity and mortality, but pain, discomfort, and stress remain sad realities for babies in the neonatal intensive care unit (NICU). Assessing, managing, and trying to limit these clinical realities, particularly while caring for critically ill neonates, remain challenging and increasingly controversial. Fortunately, considerable clinical and laboratory research and clinical dialogue continue to push neonatal providers toward best clinical practices in this problematic arena. This chapter describes the history, developmental biology, and public policies that have informed and shaped current clinical practices; it also summarizes relevant clinical and basic research regarding clinical assessment tools and both pharmacologic and nonphar¬macologic management approaches. Finally, future directions in this field are suggested.

WOS: 000484450300016, PubMed ID: 31236029, Pain control is an important ethical issue to be considered and constitutes the basis of treatment in premature and term newborns. The inadequacy of pain control in these infants in neonatal intensive care units leads to neurodevelopmental and behavioral problems in the long term. For this reason, it is extremely important to raise awareness of the presence of pain in newborn infants, to reduce invasive procedures applied to infants as much as possible, and to minimize pain with non-pharmacologic or pharmacologic treatments when it is inevitable.

Diagnostic and therapeutic skin-breaking procedures have become ubiquitous in current medical practice and neonatology does not constitute an exception. One of the main sources of neonatal pain is procedure-induced pain. It has recently become clear that pain prevention must be a health care priority. Non-pharmacological approaches constitute a first option for the analgesia of common procedures performed in neonatology. This article reviews the non-pharmacological treatments most frequently used in this context: swaddling, tucking, containment, sweet solutions, non-nutritive sucking (NNS), breastfeeding analgesia, breast milk and music. In practice, the dose of 1 to 2mL of 24% or 30% sucrose solution or 30% glucose solution immediately followed by NNS can be given for minor painful procedures in term neonates or those weighing more than 2500g. In the preterm, 0.3mL of a sweet solution (sucrose or glucose) can be given for infants weighing less than 1500g and 0.5mL for those weighing between 1500 and 2500g. The synergistic effect of sweet solutions and NNS has been clearly shown and thus their association is largely justified in practice. For breast-fed term neonates, breastfeeding can be given to sooth procedure-induced pain. All these non-pharmacological options can be effective to relieve pain from minor or moderate procedures. However, when more painful procedures are performed, stronger analgesics must be used.

Objective The objective of this study was to compare neonatal pain, duration of crying and procedure time following use of automatic or manual heel lancets. Methods This randomized trial was conducted with neonates undergoing heel prick procedures in a neonatal intensive care unit for routine blood bilirubin monitoring. An information form, an observation form and the Neonatal Infant Pain Scale (NIPS) were used. Pain before, during and after (1 and 3 min) was assessed using NIPS scoring. Results Seventy neonates were included (automatic lancet, n = 35; manual lancet, n = 35); there was no difference between the groups (p > 0.01). Pain scores were significantly lower, with automatic lancets compared with manual lancets (p = 0.001). The duration of crying after the procedure (p = 0.001) and procedure time (p = 0.001) was significantly shorter with automatic lancets compared with manual lancets. Conclusion Automatic heel lancets in neonates are more effective than manual lancets at reducing pain, and shorten the procedure time and duration of post-procedural crying.

Background: Despite scientific advances on pain measurement and intervention, pain management for infants has remained a challenge for health teams. This is because infants are not able to talk and defend themselves when they are in pain. Prevention of pain is important, not only because it is an ethical expectation, but also because repeated painful exposures can have harmful consequences. The aim of this study was to explore factors influencing neonatal pain management from the perspectives of nurses and physicians in a neonatal intensive care unit (NICU). Methods: A qualitative content analysis study was carried out. The participants were the nurses and physicians working in the NICU of Alavi medical training center in Ardabil, Iran. Twenty-five nurses took part in focus group discussions and five physicians attended private interviews. Four focus group discussions and five interviews were carried out until data saturation was ensured. Data analysis was performed using conventional content analysis. All the participants were provided with information about the purpose and the nature of the study, and provided informed consent. Results: Data analyses indicated two effective themes about barriers of implementation of infant pain management, namely “Individual Factors” and “Organizational Factors”. The first theme consisted of the categories “knowledge of the personnel” and “commitment of the personnel”. The second theme included three categories namely “pain control policy”, “work environment condition” and “management issues”. Conclusions: Our findings indicated that lack of educational courses, absence of an infant pain management policy, and management issues were the main obstacles in the way of implementation of infant pain management by nurses and physicians at the NICU. Therefore, strategies are required to reduce or remove these barriers.

OF THE THESIS INCREASING NURSES' KNOWLEDGE OF NEONATAL PAIN ASSESSMENT THROUGH INSERVICE EDUCATION PROGRAM.

Introduction: Pain management is important, especially for neonates who are not able to verbally express their pain. Therefore, stress reduction and pain management are essential components of neonatal care. Aim: The aim of this study was to explore the key factors in implementation of neonatal pain management in Neonatal Intensive Care Unit (NICU). Materials and Methods: A qualitative study using conventional content analysis method was conducted with participation of nurses, physicians and nurse managers working in Alavi Educational Medical Center in Ardabil, Iran during July 2016 to October 2016. Twenty-five nurses took part in focus group discussions, five paediatrician and five nurse managers attended private interviews. Four focus group discussions and ten interviews were performed until data saturation was ensured. Results: Data analysis indicated two effective categories on implementation of infant’s pain management which included “knowledge of the personnel” and “attitude and commitment of the personnel”. The first category consisted of six subcategories “symptoms of pain”, “outcomes of pain”, “pain interventions”, “sideeffects of drugs”, “parent’s role”, and “education of personnel.” The second category consisted of three subcategories including “personnel’s conscience”, “personnel’s emotions”, and “personnel’s belief.” Conclusion: According to the main findings of this study, there is a need for empowerment of the personnel about pain management and assessment.

Objective: to dimension the exposure of premature infants to painful procedures, relating the distribution of the exposure to contextual factors, as well as to describe the pharmacological and non-pharmacological interventions health professionals use during the first two weeks of the infant’s hospitalization at two neonatal services. Method: descriptive-exploratory study in which the professionals registered the painful procedures and pain relief interventions on a specific form in the patient file. Results: the daily average of the 89 premature infants was 5.37 painful procedures, corresponding to 6.56 during the first week of hospitalization and 4.18 during the second week (p

Neonatal inflammation produces nociception by a local decrease of growth hormone and an increment of the insulin growth factor 1-1R. Systemic growth hormone prevents the development of nociception., Growth hormone (GH) and insulin growth factor 1 (IGF1) are implicated in nociceptive processing; it has been reported that the latter participates in neonatal inflammatory nociception. In the target article, the authors propose that local inflammation evoked by carrageenan administration in mice produces a decrease in the local GH levels and an increment of IGF1 receptors type 1 expression, this produces behavioral nociception and peripheral sensitization that can be prevented by GH systemic administration pretreatment.

Aim of this paper is a critical examination of the use of neonatal pain assessment tools. It emerged that neonatal pain scales for acute pain are complex to use, give a score when the maneuver is over, and they are not validated for levels of pain higher than those due to a heel-prick. Nonetheless, they are useful for research, and those for prolonged pain, in particular for post-surgery or intubated babies, can help to modulate the use of analgesics.