An Extensive Literature Review on Neonatal Pain Assessment & Management

Neonatal pain assessment and management is a field requiring much more research. This literature review outlines the current climate of neonatal pain assessment, compares a variety of neonatal pain scales on validity and clinical utility, and implications for how neonatal pain management can be improved. Neonates experience pain to the same degree, if not more, than everyone else. Unmanaged pain during the neonatal period leads to adverse health outcomes. In order to prevent these atrocities from this vulnerable population, NICU pain assessing needs to become the standard of care

Sepsis and antibiotic exposure in the neonatal period

Bakgrunn: Neonatalperioden (første 28 levedager) er den perioden i livet med høyest risiko for å utvikle sepsis. Tidlig nyfødt-sepsis (oppvekst i blodkultur innen første tre levedager) er assosiert med høy morbiditet og mortalitet. All antibiotika hos nyfødte startes empirisk før blodkultur foreligger da det finnes få diagnostiske hjelpemidler. Dette fører til at antibiotika er det mest brukte medikamentet i nyfødtintensivavdelinger. Flere observasjonsstudier har vist at antibiotikabehandling i første leveuke hos premature barn < 32 uker gestasjonsalder (GA) uten infeksjon er assosiert med alvorlig sykdom/død, mens noen få nyere studier har rapportert at antibiotika kan ha beskyttende effekt. Formål: Øke kunnskap om tidlig nyfødt-sepsis og antibiotika hos terminfødte og premature nyfødte for å forbedre kvalitet innen nyfødtmedisin og antibiotika reduksjonsprosjekter ved å; i) beskrive forekomst av nyfødt-sepsis, hvilke bakterier som forårsaker dette, antibiotika-resistens og antibiotika-behandling de siste 23 årene i en nyfødtintensiv avdeling i sør-vest Norge, ii) evaluere mulig assosiasjon mellom antibiotika og alvorlig sykdom/død frem til utskrivelse/død i en uselektert populasjon av premature GA < 32 uker uten infeksjon, iii ) evaluere om en diagnostisk metode med repeterte «Timesobservasjoner» trygt kan redusere bruk av unødvendig antibiotika de første tre levedøgn hos terminbarn. Metode: Studie 1 var en populasjonsbasert longitudinal observasjonsstudie av alle levende fødte (LF) med tidlig nyfødt-sepsis født på Stavanger Universitets sjukehus (SUS) i perioden 1996 tom 2018. Regresjonsmodell ble brukt for å teste trender over tid. Studie 2 var en nasjonal populasjonsbasert observasjonsstudie fra Norsk Nyfødt Kvalitetsregister og inkluderte alle LF barn GA < 32 uker uten infeksjon (overlevd syv dager uten sepsis eller NEC) i Norge fra 2009 tom 2018. Regresjonsmodell ble brukt for å evaluere assosiasjon mellom tidlig antibiotika og risiko for alvorlig NEC eller en sammensetning av alvorlig sykdom/død til utskrivelse/død etter første uke. Det ble justert for andre kjente årsaker til død og sykelighet. Studie 3 var en populasjonsbasert prospektive observasjonsstudie fra SUS der en sammenlignet andel terminfødte barn behandlet med tidlig antibiotika før (22 måneder, april 2014 til februar 2016) og etter (23 måneder, januar 2017 til november 2018) at “Timesobservasjoner” var implementert i avdelingen. Resultat: Vi fant at 101 av 104 377 LF hadde tidlig sepsis, (total forekomst 0.97/1000 LF) (studie 1). Forekomsten av Gruppe B streptokokker (GBS) og Escherichia coli var henholdsvis 0.57/1000 LF og 0.11/1000 LF). GBS var vanligste årsaken til sepsis (59/93; 63%) hos nyfødte over GA ≥ 28 uker, mens E. coli var vanligst (4/8; 50%) blant GA < 28 uker. Forekomsten av nyfødt-sepsis var uendret i løpet av 23 år. Det var lav antibiotika-resistens blant mikrober som gir tidlig nyfødt-sepsis (2/101; 2%). Blant 601 668 LF, var 5296 premature født før GA < 32 uker, inkludert 4932 (93%) uten infeksjon og inkludert i analysene (studie 2). Det var 3790/4932 (77%) som fikk antibiotika i løpet av første leveuke. Andel premature som fikk lange antibiotikakurer (≥ 5 dager), sank i løpet av perioden fra 55% to 24%. Eksposisjon for antibiotika første leveuke var assosiert med høyere justert odds ratio (aOR) for død (aOR 9.33; 95% konfidens intervall [CI] 1.10-79.5), alvorlig morbiditet (aOR 1.88; 95% CI 1.16-3.05), og alvorlig lungesykdom (bronkopulmonal dysplasi, BPD) (aOR 2.17; 95% CI 1.18-3.98) sammenlignet med barn som ikke var eksponert for antibiotika første leveuke. Vi fant høyere aOR for alvorlig NEC (aOR 2.27; 95% CI 1.02-5.06) der antibiotikakurene varte ≥ 5 dager. Blant 17 242 LF terminbarn som var født før og etter intervensjonen (studie 3), fant vi at etter at «Timesobservasjoner» var innført, refusertes andel terminbarn behandlet med antibiotika fra 2.9% til 1.3%, (57%). Tid fra fødsel til oppstart av antibiotika ble redusert fra median (IQR) 14 (5-28) til 7 (3-17) timer (50%), hos barn med infeksjon. Antall behandlingsdager falt fra 320 til 129/1000 pasientdager, og antall barn som fikk diagnosen klinisk sepsis, og antall CRP prøvetakninger ble redusert fra henholdsvis 11.8 til 6.7/1000 LF og fra 332 til 223. Forekomst av tidlig sepsis var uendret, og det var ingen nyfødte barn som døde eller ble re- innlagt med infeksjon. Konklusjon: Dette PhD-prosjektet bidrar til økt kunnskap om tidlig nyfødtsepsis og korrekt antibiotikabruk hos nyfødte barn. Forekomsten av nyfødt-sepsis og hvilke mikrober som forårsaker dette ved SUS, er sammenlignbar med andre vestlige land, og holdt seg stabil siste 23 år. Det er lav forekomst av antibiotikaresistens (studie 1). Det var en klar assosiasjon mellom antibiotikabruk først leveuke hos premature barn < GA 32 uten infeksjon, og forekomst av alvorlig sykdom/død, på tross av justering for andre årsaker til dette (studie 2). Etter å ha innført «Timesobservasjoner» i avdelingen, reduserte vi andel terminfødte barn behandlet med antibiotika på en trygg måte (studie 3). Kontinuerlig overvåkning av hvilke bakterier som forårsaker nyfødt sepsis, og resistensmønster er viktig for å kunne gi optimal antibiotika, og flere studier er nødvendig. Antibiotika reduksjonsprosjekter kan bidra til å unngå unødvendig bruk av antibiotika til termin og premature barn da det er assosiasjon mellom antibiotika og alvorlig sykdom/død hos premature. Flere studier og kvalitets forbedringsprosjekter innen dette feltet av nyfødtmedisin kan dermed gi økt kunnskapen for videre optimalisering av behandling av premature og terminfødte barn.Background: The neonatal period (≤ 28 days of life) carries the highest lifetime risk for sepsis. Neonatal early-onset sepsis (EOS) (growth of a pathogen in blood culture obtained within the first three days of life) is associated with a high morbidity and mortality. Because of diagnostic challenges, antibiotics is the most frequently prescribed medication in neonatal intensive care units (NICUs). Controversies remain if early antibiotics in uninfected preterm neonates are associated with adverse outcome. Objective/purpose: We aimed to increase knowledge on EOS and early antibiotic use in term and preterm neonates in order to optimise and improve future neonatal care and antibiotic stewardship programs. The specific aims for the three studies were; i) To describe the incidence of EOS, causative pathogens, antibiotic-resistance and antibiotic therapy over a 23-year period in a single NICU in South-West Norway. ii) To evaluate the associations between empiric antibiotic exposure within the first week of life and adverse clinical outcomes in an unselected population of uninfected very preterm neonates gestational age (GA < 32 weeks). iii) To evaluate if an approach using serial physical examinations (SPEs) could reduce the proportion of term neonates exposed to antibiotics for suspected EOS within the first 3 days of life, without affecting safety in a single NICU in South-West Norway. Materials/methods: Paper 1 was a population-based single-centre longitudinal observational study at Stavanger University hospital (SUH) on EOS in all live born (LB) neonates born during 1996-2018 (23-years). Regression model was used to test for trends over time. Paper 2 was a nationwide population-based observational study investigating associations between antibiotic exposure in the first week of life and short-term adverse outcomes to discharge, in neonates with GA < 32 weeks surviving seven days of age free of sepsis and necrotizing enterocolitis (NEC)/intestinal perforation born in Norway 2009 throughout 2018. Data from the Norwegian Neonatal Network was analysed by regression models, adjusted for confounders for mortality and morbidity. Paper 3 was a single-centre, prospective population-based study where a new management strategy, SPE for suspected EOS, was developed, implemented and evaluated for improved diagnostic assessment and hence reduction of antibiotic exposure in term neonates born at SUH during the study period 2014-2018. Results: There were101 out of 104 377 LB neonates, (incidence 0.97/1000/1000 LB) with culture-confirmed EOS (paper 1). The incidence of Group B streptococcus (GBS) and Escherichia coli were 0.57/1000, and 0.11/1000, respectively. GBS was the most common pathogen (59/93; 63%) in neonates with GA ≥ 28 weeks, and E. coli was most common (4/8; 50%) among extremely preterm infants (GA < 28 weeks). The incidence of EOS (overall), GBS and E. coli remained unchanged during the study period. The percentage of antibiotic-resistance in pathogens casing EOS was low (2/101; 2%). Of 601 668 LB neonates, 5296 were GA < 32 weeks, of whom 4932 (93%) were included in the final analysis (paper 2). Antibiotic exposure within the first week of life was strongly associated with higher adjusted odds ratios (aOR) of death (aOR 9.33; 95% confidence interval [CI] 1.10-79.5), severe morbidity (aOR 1.88; 95% CI 1.16-3.05), and severe bronchopulmonary dysplasia (BPD) (aOR 2.17; 95% CI 1.18-3.98) compared to those not exposed to antibiotics. Higher odds of severe NEC (aOR 2.27; 95% CI 1.02-5.06) was associated with antibiotics given ≥ 5 days. Most neonates were exposed to antibiotics the first week of life (3790/4932; 77%) despite a negative blood culture, but a decline in the proportion of neonates exposed to prolonged courses (≥ 5 days) from 55% to 24% was observed throughout the study period. There were 17 242 term LB born neonates included in the baseline and the post-implementation period (paper 3). After implementing SPE, the proportion of term neonates exposed to antibiotics was reduced from 2.9% in the baseline to 1.3% in the post-implementation period. The time from birth to start of treatment was reduced from median (IQR) 14 (5-28) to 7 (3-17) hours in infected neonates. The antibiotic exposure-days, the numbers of neonates diagnosed with culture-negative sepsis and numbers of blood samples taken were all reduced, from 320 to 129/1000 patient-days, from 11.8 to 6.7/1000 LB and from 332 to 223, respectively. The incidence of EOS remained unchanged, and there were no infection-attributable deaths/readmissions. Conclusions: This project contributes with increased knowledge on EOS and early antibiotic use in term and preterm neonates. The incidence of EOS and common pathogens were in line with reports from other western networks, and was stable during the 23-year period at SUH. Antibiotic-resistance was low (paper 1). There was a strong association between early antibiotics the first week of life in uninfected very preterm neonates and severe NEC, BPD and death, regardless of duration of antibiotics (paper 2). Antibiotic stewardship with SPE reduced the percentage of term neonates exposed to early antibiotics, without affecting safety (paper 3). There is a continuous need for pathogens surveillance, and antibiotic stewardships are important as early antibiotic exposure is associated with adverse outcome in preterm neonates. This knowledge is important to optimise future neonatal care, but further studies are needed.Doktorgradsavhandlin

Soothability and Growth in Preterm Neonates

This proposal seeks to understand the relationship between soothability, weight gain and length of hospital stay in premature infants when the infants receive a simple, non-invasive treatment to help them cope with the noxious environment of the special care nursery. Thousands of premature infants are born every year in the United States, and the numbers are increasing. Prematurity is the leading cause of mortality in infants. Despite numerous technological and medical advances in treatment and care, premature infants still have difficulty adapting to life outside the uterus as a result of immature nervous systems and significant differences in the pre and post delivery environments. Developmental Care and Family Centered Care have made significant improvements in the lives of hospitalized premature infants. However, care continues to be costly and complex, encouraging health care providers to continue to search for simpler and less expensive methods to care for these tiny patients. This paper describes the effect of a flax seed pillow, placed on the back of premature infants in a prone position on their ability to sooth themselves, moderate their activity, gain weight and the length of hospital stay. Each infant will receive two 15 minute treatments, twice a day, over the course of five consecutive days. Measurements will be obtained on various physiologic parameters including temperature, heart rate, respiratory rate, and pain scores and activity. The design is a randomized control study, with infants stratified for birth weight. Infants in the treatment group had decreases in heart rate, respiratory rate and pain scores significantly greater than infants in the control group. Infants in the treatment group also gained more weight in the first three weeks of life, however this difference was lost by time of discharge. Hospital length of stay did not vary between the two groups. The treatment of the flax seed pillow is a new method to assist premature infants to cope with the stressful environment of the nursery. The pillow is simple, easy to use and was not associated with any adverse events. Further research is recommended to explore the efficacy of this intervention in other populations

Neonatal Abstinence Syndrome and the Relationship Between Respiration and Feeding

Objective: The primary purpose of this study was to determine the relationship between respiratory status and feeding difficulties in infants with NAS in comparison to full-term infants with no exposure to opioids. Methods: A group of infants with NAS (262) were compared to a group of full-term infants with no exposure to opioids (279). These groups were further divided into feeding and respiratory groups based on severity. These groups were analyzed for differences in behavior and outcomes. Results: Infants with NAS are 34.23 times more likely to develop respiratory distress and 111.03 times more likely to develop severe feeding difficulty. For infants with NAS, respiratory and feeding impairment may occur in isolation, suggesting a different withdrawal-based etiology of impairment as compared to premature infants. Conclusion: This study is unique in its size, scope, and attention to the respiratory factors involved in the feeding outcomes of infants with NAS

2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 8. Neonatal resuscitation

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Diagnosis and Management of Pediatric Diseases

A screenshot of some the most rapidly evolving fields in Neonatology and Pediatrics with articles reviewing some metabolic dysregulations as well as non-oncologic diseases that may occur in infancy, childhood, youth. The illustrative material with original photographs and drawings highlighting some pathogenetic concepts are keystones of this book

The Implementation Gap Between Evidence-Based Guidelines and Primary Care Providers\u27 Provision of Care for Adult Obese Individuals

Adult obesity has become a significant problem in the United States. To reduce health consequences and the rising cost of obesity, evidence-based guidelines to identify and treat obesity are available to primary care providers (PCPs). Despite literature supporting favorable outcomes by PCPs who address obesity at a patient\u27s visit, studies indicate obesity counseling is occurring infrequently, particularly in military primary care settings. Guided by the Diffusion of Innovations Theory, this research utilization project evaluated whether there is an implementation gap between use of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Clinical Practice Guideline for Screening and Management of Overweight and Obesity and military primary care providers’ provision of care for adult obese individuals. A retrospective review of electronic medical records was conducted at an Air Force military treatment facility and continued until 50 records were identified that met inclusion criteria (i.e., TRICARE beneficiaries age 19 and older with a body mass index (BMI) of 30 kg/m2 or greater). The rate of identification of adult obesity was 36%. Only 36% of individuals were offered diet and exercise counsel. Sixteen percent were offered behavioral counsel and 12% received a one-month follow-up appointment. No individuals eligible to receive pharmacologic and bariatric surgical treatment were offered these interventions. The overall composite score for obesity treatment was 0.22, indicating identification and treatment of obesity occurred an average of 22% of the time. Results of this research utilization project are consistent with other studies, suggesting the need to determine barriers and implement interventions that can assist PCPs in translating evidence to practice to reduce rates of adult obesity in the primary care setting

The role of simulation in neonatal and pediatric training and research

From a pediatric perspective, the two main types of simulation-based research are: studies that assess the efficacy of simulation as a training methodology and studies where simulation is used as an investigative methodology. Aim of the study. Overall, the aim of the research activity is to inquire the use of simulation as investigative methodology in pediatric and neonatal settings. Study design: Previously, we investigated the current use of simulation in pediatric fellowships in Italy in order to understand the state of the art and the expectations of pediatric residents with regard to simulationbased training and research. Furthermore, we developed suitable simulated scenarios for pediatric training and research. As second step, we evaluated technical (TS) and non-technical (NTS) skills in a sample of Italian pediatric residents using a neonatal resuscitation scenario; Finally, we aimed to evaluate the accuracy of NeoTapAS in reliably determining HR from auscultation in a high-fidelity simulated newborn resuscitation scenario. Results and future perspectives: Firstly, we highlighted that an extremely high percentage of pediatric italian residents spent less than 5 hours/year in simulation-based education. Secondly, the mean compliance to last ILCOR recommendations about neonatal resuscitation was 59 % and a very low compliance (< 30%) was observed for a number of important technical items. Finally, NeoTapAS showed a good accuracy in estimating HR and it could be an important resource for neonatologists in delivery room resuscitation As future perspective, we designed a new simulation-based multi-center research (\u201cSimarrest \u201d) in collaboration with University of Padua in order to identify gaps about in-hospital pediatric cardiac arrest management in a standardized setting

Management of hypertension in pregnancy — prevention, diagnosis, treatment and long-term prognosis. A position statement of the Polish Society of Hypertension, Polish Cardiac Society and Polish Society of Gynaecologists and Obstetricians

ADDITIONAL INFORMATION This article has been co‑published in Kardiologia Polska (doi:10.33963/KP.14904), Arterial Hypertension (doi:10.5603/AH.a2019.0011), and Ginekologia Polska (doi:10.5603/GP.2019.0074). The articles in Kardiologia Polska, Arterial Hypertension, and Ginekologia Polska are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Any citation can be used when citing this article