Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice?

Mechanical ventilation is an uncomfortable and potentially painful intervention. Opioids, such as morphine and fentanyl, are used for analgesia and sedation but there is uncertainty whether they reduce pain in mechanically ventilated infants. Moreover, there may be short-term and long-term adverse consequences such as respiratory depression leading to prolonged mechanical ventilation and detrimental long-term neurodevelopmental effects. Despite this, opioids are widely used, possibly due to a lack of alternatives.Dexmedetomidine, a highly selective alpha-2-adrenergic agonist with analgesic and sedative effects, currently approved for adults, has come into use in newborn infants. It provides analgesia and simulates natural sleep with maintenance of spontaneous breathing and upper airway tone. Although data on pharmacokinetics–pharmacodynamics in preterm infants are scant, observational studies report that using dexmedetomidine in conjunction with opioids/benzodiazepines or on its own can reduce the cumulative exposure to opioids/benzodiazepines. As it does not cause respiratory depression, dexmedetomidine could enable quicker weaning and extubation. Dexmedetomidine has also been suggested as an adjunct to therapeutic hypothermia in hypoxic ischaemic encephalopathy and others have used it during painful procedures and surgery. Dexmedetomidine infusion can cause bradycardia and hypotension although most report clinically insignificant effects.The increasing number of publications of observational studies and clinical use demonstrates that dexmedetomidine is being used in newborn infants but data on safety and efficacy are scant and not of high quality. Importantly, there are no data on long-term neurodevelopmental impact on preterm or term-born infants. The acceptance of dexmedetomidine in routine clinical practice must be preceded by clinical evidence. We need adequately powered and well-designed randomised controlled trials investigating whether dexmedetomidine alone or with opioids/benzodiazepines in infants on mechanical ventilation reduces the need for opioids/benzodiazepine and improves neurodevelopment at 24 months and later as compared with the use of opioids/benzodiazepines alone

Systemic effects of Optos versus indirect ophthalmoscopy for retinopathy of prematurity screening

Many regions of the world have a relative shortage of ophthalmologists trained and willing to screen for retinopathy of prematurity (ROP).1 As a result, many regions have turned to retinal imaging and telemedicine.2 Optos ultrawide-field retinal imaging (Optos PLC, Dunfermline, UK) has recently been used as a screening tool for ROP.3,4 However, there are no data available regarding the systemic effects or stress induced by a ROP screening examination with the Optos. In this prospective, randomized, crossover study, we determined the effects of Optos ultrawide-field screening examination on cardiorespiratory indices, as a measure of stress, and compared the stress response with that of conventional binocular indirect ophthalmoscopy (BIO) examination

Sedation and analgesia from prolonged pain and stress during mechanical ventilation in preterm infants: is dexmedetomidine an alternative to current practice?

Mechanical ventilation is an uncomfortable and potentially painful intervention. Opioids, such as morphine and fentanyl, are used for analgesia and sedation but there is uncertainty whether they reduce pain in mechanically ventilated infants. Moreover, there may be short-term and long-term adverse consequences such as respiratory depression leading to prolonged mechanical ventilation and detrimental long-term neurodevelopmental effects. Despite this, opioids are widely used, possibly due to a lack of alternatives.Dexmedetomidine, a highly selective alpha-2-adrenergic agonist with analgesic and sedative effects, currently approved for adults, has come into use in newborn infants. It provides analgesia and simulates natural sleep with maintenance of spontaneous breathing and upper airway tone. Although data on pharmacokinetics-pharmacodynamics in preterm infants are scant, observational studies report that using dexmedetomidine in conjunction with opioids/benzodiazepines or on its own can reduce the cumulative exposure to opioids/benzodiazepines. As it does not cause respiratory depression, dexmedetomidine could enable quicker weaning and extubation. Dexmedetomidine has also been suggested as an adjunct to therapeutic hypothermia in hypoxic ischaemic encephalopathy and others have used it during painful procedures and surgery. Dexmedetomidine infusion can cause bradycardia and hypotension although most report clinically insignificant effects.The increasing number of publications of observational studies and clinical use demonstrates that dexmedetomidine is being used in newborn infants but data on safety and efficacy are scant and not of high quality. Importantly, there are no data on long-term neurodevelopmental impact on preterm or term-born infants. The acceptance of dexmedetomidine in routine clinical practice must be preceded by clinical evidence. We need adequately powered and well-designed randomised controlled trials investigating whether dexmedetomidine alone or with opioids/benzodiazepines in infants on mechanical ventilation reduces the need for opioids/benzodiazepine and improves neurodevelopment at 24 months and later as compared with the use of opioids/benzodiazepines alone.</p

Episiotomy and Initiation of Human Milk Feeds: A Retrospective Observational Study

Objective: To investigate the association, in the United Kingdom, between having an episiotomy during childbirth and giving human milk by any modality as an infant's first feed. We also identified maternal demographic factors and perinatal experiences associated with increased chance of the infant's first feed being human milk. Study Design: Retrospective observational cohort study at two large maternity units within district general hospitals in the United Kingdom. Population: Mothers giving birth vaginally to singleton babies at ≥34 weeks and ≥1,800 g. Methods and Main Outcome Measures: Deidentified data from hospital records were analyzed. The odds ratio (OR) of a mother giving human milk for an infant's first feed after episiotomy versus no episiotomy was calculated using a chi-squared test. Logistic regression was used to investigate and then control for confounders known to affect breastfeeding. Results: A total of 13,906 women met the inclusion criteria (2,113 had had an episiotomy and 11,793 had not). Human milk was given as a first feed to 70% of infants in the study population. Women whose infants received their first feed as human milk were on average older, had lower body mass index, lived in an area of less socioeconomic deprivation, and had fewer previous births than those women who gave formula milk as the first feed to their infant. The occurrence of an episiotomy during delivery was not associated with a change in the odds of the infant receiving human milk for the first feed (OR: 1.12 [confidence interval, CI: 0.96-1.38]). Where a woman had skin-to-skin care with her infant straight after birth, the infant was more likely to receive human milk as a first feed (OR: 4.23 [CI: 3.59-4.98]). Conclusion: There is no link between episiotomy during delivery and the odds of a woman giving human milk as the first feed to her infant

Effects of implementation of a care bundle on rates of necrotising enterocolitis and own mother’s milk feeding in the East Midlands: protocol for a mixed methods impact and process evaluation study

Introduction: Prevention of necrotising enterocolitis (NEC) is vital for improving neonatal outcomes. Feeding own mother’s milk helps prevent NEC. Rates of own mother’s milk feeding in the East Midlands are lower than the national average and the incidence of NEC is higher. The East Midlands Neonatal Operational Delivery Network (EMNODN) has created a care bundle to improve these in babies born at <32 weeks’ gestation, the group at the highest risk of NEC. The bundle was introduced in September 2022 and embedded by December 2022. We will evaluate its effectiveness and conduct a process evaluation to understand barriers and facilitators to implementation. Methods and analysis: We will conduct a retrospective cohort study (workstream 1) using data from the National Neonatal Research Database (NNRD). We will identify infants receiving any own mother’s milk on day 14 and at discharge, and cases of severe NEC. We will aggregate outcomes by birth month and use interrupted time series analysis to estimate an incidence rate ratio for changes after the care bundle was embedded, relative to pre-implementation. We will model data from all other NNRD units and assess whether there are any concurrent changes to exclude confounding due to other events. We will apply the RE-AIM framework (workstream 2), supplemented by the Consolidated Framework for Implementation Research and Framework for Implementation Fidelity, to conduct a mixed methods evaluation in EMNODN units. We will triangulate data from several sources, including questionnaires and semistructured interviews with parents and healthcare professionals, and data from patient records. Ethics and dissemination: The study has approval from the South East Scotland Research Ethics Committee 01 and the Health Research Authority and Health and Care Research Wales (IRAS 323099). Results will be disseminated via scientific journals and conferences, to neonatal service commissioners and through public-facing infographics. Trial registration number: NCT05934123