The impact of parental contact upon cortical noxious-related activity in human neonates

BACKGROUND: Neonates display strong behavioural, physiological and cortical responses to tissue-damaging procedures. Parental contact can successfully regulate general behavioural and physiological reactivity of the infant, but it is not known whether it can influence noxious-related activity in the brain. Brain activity is highly dependent upon maternal presence in animal models, and therefore this could be an important contextual factor in human infant pain-related brain activity. METHODS: Global topographic analysis was used to identify the presence and inter-group differences in noxious-related activity in three separate parental contexts. EEG was recorded during a clinically required heel lance in three age and sex-matched groups of neonates (a) while held by a parent in skin-to-skin (n = 9), (b) while held by a parent with clothing (n = 9) or (c) not held at all, but in individualized care (n = 9). RESULTS: The lance elicited a sequence of 4-5 event-related potentials (ERPs), including the noxious ERP (nERP), which was smallest for infants held skin-to-skin and largest for infants held with clothing (p=0.016). The nERP was then followed by additional and divergent long-latency ERPs (> 750 ms post-lance), not previously described, in each of the groups, suggesting the engagement of different higher level cortical processes depending on parental contact. CONCLUSIONS: These results show the importance of considering contextual factors in determining infant brain activity and reveal the powerful influence of parental contact upon noxious-related activity across the developing human brain. SIGNIFICANCE: This observational study found that the way in which the neonatal brain processes a noxious stimulus is altered by the type of contact the infant has with their mother. Specifically, being held in skin-to-skin reduces the magnitude of noxious-related cortical activity. This work has also shown that different neural mechanisms are engaged depending on the mother/infant context, suggesting maternal contact can change how a baby's brain processes a noxious stimulus

To look or not to look during vaccination: A pilot randomized trial

Background: Clinicians commonly advise patients to look away from the needle during vaccinations; however, this recommendation is not evidence based. Aim: The aim of this study was to determine whether looking at the needle versus looking away affects pain and fear during vaccinations in adults. Methods: This was a pilot randomized two-group parallel trial with university students receiving influenza vaccinations. Participants were stratified according to their initial needle-looking preference and randomly assigned to either look at versus away from the needle. Participants self-reported their pain and fear during vaccination. Results: Of the 184 subjects who agreed to participate, 160 were enrolled; 66% were female. A three-way analysis of variance (ANOVA; Looking allocation assignment × Looking preference × Sex) revealed a significant main effect of looking allocation assignment on fear (P = 0.025); those who were randomized to look had higher fear scores than those who were randomized to look away. There was also a significant main effect of looking preference on fear (P \u3c 0.001); those who preferred to look away had higher fear scores than those who preferred to look. There was no evidence of an effect of looking allocation assignment or looking preference on pain. There was a significant main effect of sex on fear and pain, with females reporting higher pain and fear scores than males (P = 0.017 and P = 0.001, respectively). There were no significant interactions. Conclusion: These preliminary findings suggest that advising individuals to look away from the needle reduces fear. A larger trial including more individuals and a different population is recommended to confirm the results

Procedural and physical interventions for vaccine injections systematic review of randomized controlled trials and quasi-randomized controlled trials

Background: This systematic review evaluated the effectiveness of physical and procedural interventions for reducing pain and related outcomes during vaccination. Design/Methods: Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Data were extracted according to procedure phase (preprocedure, acute, recovery, and combinations of these) and pooled using established methods. Results: A total of 31 studies were included. Acute infant distress was diminished during intramuscular injection without aspiration (n=313): standardized mean difference (SMD) -0.82 (95% confidence interval [CI]: -1.18, -0.46). Injecting the most painful vaccine last during vaccinations reduced acute infant distress (n=196): SMD -0.69 (95%CI: -0.98, -0.4). Simultaneous injections reduced acute infant distress compared with sequential injections (n=172): SMD -0.56 (95%CI: -0.87, -0.25). There was no benefit of simultaneous injections in children. Less infant distress during the acute and recovery phases combined occurred with vastus lateralis (vs. deltoid) injections (n=185): SMD -0.70 (95%CI: -1.00, -0.41). Skin-to-skin contact in neonates (n=736) reduced acute distress: SMD -0.65 (95% CI: -1.05, -0.25). Holding infants reduced acute distress after removal of the data from 1 methodologically diverse study (n=107): SMD -1.25 (95% CI: -2.05, -0.46). Holding after vaccination (n=417) reduced infant distress during the acute and recovery phases combined: SMD -0.65 (95% CI: -1.08, -0.22). Self-reported fear was reduced for children positioned upright (n=107): SMD -0.39 (95% CI: -0.77, -0.01). Non-nutritive sucking (n=186) reduced acute distress in infants: SMD -1.88 (95% CI: -2.57, -1.18). Manual tactile stimulation did not reduce pain across the lifespan. An external vibrating device and cold reduced pain in children (n=145): SMD -1.23 (95% CI: -1.58, -0.87). There was no benefit of warming the vaccine in adults. Muscle tension was beneficial in selected indices of fainting in adolescents and adults. Conclusions: Interventions with evidence of benefit in select populations include: no aspiration, injecting most painful vaccine last, simultaneous injections, vastus lateralis injection, positioning interventions, non-nutritive sucking, external vibrating device with cold, and muscle tension

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Attributions of pain to infants : a comparative analysis of parents, nurses and paediatricians

The limited ability of infants to communicate their pain and to moderate their pain experience places great importance on caregivers in accurately detecting when they are suffering. The goal of this investigation was to conduct a comparative analysis of the pain judgments of three major infant caregiver populations (parents, nurses and paediatricians) and the beliefs that each group held in regards to those judgments. This study finds theoretical grounding in the Sociocommunication Model of Infant Pain. In order to understand the role of beliefs in pain judgments, the current study controlled other variables postulated by Craig and colleagues to impact the communication between an infant in pain and his/her caregiver. Participants provided attributions of pain after viewing video clips of infants (from five different age groups) who had received a routine immunization injection. Between caregiver group differences and differences across the pain attributions to different infant ages were examined. Parents attributed greater pain than paediatricians, while nurses did not differ from either group. A systematic age bias in pain attributions was also found, in that younger infants were attributed significantly less pain. Finally, several secondary findings contributed to a clearer understanding of both these findings. Using self-reported importance ratings as an indication, betweencaregiver group differences were found regarding how each sample made their pain attributions. As well, caregivers demonstrated different beliefs regarding the cognitive ability of infants of differing age groups. By elucidating infant pain attribution differences between caregivers and age groups, the current study helped determine possible factors responsible for the incidence of unrelieved infant pain.Arts, Faculty ofPsychology, Department ofGraduat

Assessing pain in infancy: The caregiver context

BACKGROUND: Pain is largely accepted as being influenced by social context. Unlike most other developmental stages throughout the lifespan, infancy is marked by complete dependence on the caregiver. The present paper discusses the primary importance of understanding the caregiver context when assessing infant pain expression

Chronic Pain in Hospitalized Infants: Health Professionals' Perspectives

Potentially significant numbers of infants hospitalized in Neonatal Intensive Care Units (NICUs) and Pediatric Intensive Care Units (PICUs) experience chronic pain. However, the phenomenon of chronic pain in infancy has neither been defined nor described adequately by researchers. To stimulate and focus further work in the area, the purpose of this study was to explore expert opinions on definitional and assessment parameters of infant chronic pain. Forty-five health care professionals, with a median of 17 years of clinical experience, were recruited from 4 tertiary-level, university-affiliated institutions. Individual (n=24) and group (n=21) interviews were conducted by trained interviewers. Qualitative data were analyzed using a standard descriptive method. Health care professionals were able to offer preliminary definitions of chronic pain in infants. The most contentious definitional issue was whether iatrogenically prolonged pain (pain induced and maintained by medical procedures) should be considered chronic pain. Possible indicators for chronic pain included inability to settle, social withdrawal, constant grimacing, tense body, hypo- or hyper-reactions to acute pain, and dysregulated sleep or feeding patterns. These indicators differed significantly from those traditionally used to measure acute pain