Beliefs about pain among professionals working with children with significant neurologic impairment.
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Adult↗
Biomedical subjects
T F Oberlander
Publications and source records attributed to T F Oberlander.
Relations between behavioral and cardiac autonomic reactivity to acute pain in preterm neonates.
OBJECTIVE: The purpose of this study was to assess relations and concordance between behavioral and physiologic reactivity to pain in preterm neonates at 32 weeks postconceptional age as a function of gestational age at birth. SETTING: Level III neonatal intensive care unit. DESIGN/PATIENTS: The study group comprised 136 preterm neonates (mean [range] birthweight, 1,020 g [445-1,500 g]: gestational age at birth, 28 weeks [23-32 weeks]) separated into three groups according to gestational age at birth as follows: 23 to 26 weeks (n = 48), 27 to 29 weeks (n = 52), and 30 to 32 weeks (n = 36). OUTCOME MEASURES: Reactivity to routine blood collection at 32 weeks postconceptional age was assessed using bedside-recorded behavioral and autonomic measures. Coders who were blinded to the study design scored behavioral responses (facial activity using the Neonatal Facial Coding System, sleep/waking state, and finger splay). Autonomic reactivity was assessed by change in heart rate and spectral analysis of heart rate variability (change in low-frequency and high-frequency power, and the ratio of low-frequency to high-frequency power during blood collection). RESULTS: Facial activity and state correlated moderately with change in heart rate across gestational age groups (r = 0.41-0.62). Facial activity and state did not correlate significantly with change in low-frequency and high-frequency power, or the ratio of low-frequency to high-frequency power (r = 0.00-0.31). Finger splay did not correlate with any autonomic recording (r = 0.03-0.41). Concordance between established biobehavioral measures of pain revealed individual differences. Although some neonates showed high behavioral but low physiologic reactivity, other neonates displayed the opposite reaction; however, the majority displayed concordant reactions. CONCLUSIONS: The study findings confirm the value of measuring domains independently, especially in neonates born at a very young gestational age.
Acute Disease↗
Demographic and therapeutic determinants of pain reactivity in very low birth weight neonates at 32 Weeks' postconceptional Age.
BACKGROUND: Management of pain in very low birth weight infants is limited by a lack of empiric knowledge about the multiple determinants of biobehavioral reactivity in infants receiving neonatal intensive care. OBJECTIVE: To examine relationship of early neonatal factors and previous medication exposure to subsequent biobehavioral reactivity to acute pain of blood collection. DESIGN: Prospective cohort study. Methods. One hundred thirty-six very low birth weight (</=1500 g) infants who underwent heel lance for blood collection at 32 weeks' postconceptional age formed the study sample, after excluding those with significant cerebral lesions (periventricular leukomalacia or cerebral parenchymal infarction [grade 4 intraventricular hemorrhage]) on cranial ultrasound. Pain reactions were assessed using the Neonatal Facial Coding System, infant state, and spectral analysis of change in heart rate variability from baseline to reaction to invasive stimulation. Factor analysis was used to provide an empirical basis for deriving summary pain scores, one factor was primarily behavioral and the other primarily autonomic. RESULTS: A normal reaction to procedural pain is characterized by facial grimacing and heightened cardiac sympathetic activity. The most significant factors associated with altered behavioral and autonomic pain reactivity at 32 weeks' postconceptional age were a greater number of previous invasive procedures since birth and gestational age (GA) at birth, both of which were related to a dampened response. After controlling for these variables, exogenous steroid exposure made an independent contribution to both the behavioral and autonomic pain scores, also in the direction of dampening the response. Conversely, previous exposure to morphine was associated with "normalized" (ie, increased) rather than diminished responses. In addition, higher mean heart rate at baseline was associated with lower GA at birth and longer time on mechanical ventilation. CONCLUSION: Early pain exposure at very low GA may alter the autonomic substrate, resulting in infants who are in a perpetual state of stress. The results of this study suggest that the judicious use of analgesia may ameliorate these effects on later pain reactivity. However, although early morphine exposure may "normalize" subsequent pain reaction, this study did not examine its effects on neurodevelopment.
Blood Specimen Collection↗
Prenatal and breast milk morphine exposure following maternal intrathecal morphine treatment.
A case of an infant who had morphine exposure during and following pregnancy while her mother was treated with intrathecal (i.t.) morphine is presented along with a review of the relevant literature. Successful maternal pain management was achieved during pregnancy and while breastfeeding. Minimal maternal serum and breast milk levels in the first 7 postpartum weeks were found. Also, infant sleep and arousal behavior and general development at 2 and 7 months were unremarkable, illustrating the possible safe and efficacious use of i.t. morphine during and following pregnancy. Further work is required to understand opioid pharmacology during breastfeeding, which will be used to develop an empirical approach to breastfeeding and morphine use.
Adult↗
Biobehavioral pain responses in former extremely low birth weight infants at four months' corrected age.
OBJECTIVE: To compare biobehavioral responses to acute pain at 4 months' corrected age between former extremely low birth weight (ELBW) infants and term-born controls. METHODOLOGY: Measures of facial behavioral and cardiac autonomic reactivity in 21 former ELBW infants (mean birth weight = 763 g) were compared with term-born infants (n = 24) during baseline, lance, and recovery periods of a finger-lance blood collection. Further, painful procedures experienced during neonatal care were quantified in both groups. RESULTS: Overall, behavioral and cardiac autonomic responses to the lance were similar between groups. However, the ELBW group seemed to have a less intense parasympathetic withdrawal in the lance period and a more sustained sympathetic response during recovery than the control group. Further, in the recovery period, two behavioral patterns (early recovery and a late recovery) were apparent among the ELBW group. CONCLUSIONS: Biobehavioral pain responses were similar overall between both groups of infants. Subtle differences were observed in cardiac autonomic responses during the lance period and in behavioral recovery among ELBW infants. Whether these findings represent a long-term effect of early pain experience or a developmental lag in pain response remains unclear. The lack of an overall difference runs counter to previously reported findings of reduced behavioral response in former ELBW infants. biobehavioral pain response, premature infants, repetitive pain, heart rate variability.
Blood Specimen Collection↗
Biobehavioral responses to acute pain in adolescents with a significant neurologic impairment.
OBJECTIVE: To further understand acute pain response in children with a significant neurologic impairment (SNI), we undertook a descriptive hypothesis-generating study of the response to a routine vaccine among adolescents with SNI. DESIGN: Within-subject crossover design. SETTING: Tertiary care facility for children and adolescents with SNI. PATIENTS: Eight adolescents (mean age = 15 years). INTERVENTIONS: Mock and real vaccine injections. OUTCOME MEASURES: Quantitative measures of heart rate, videotaped facial action, Child Facial Coding System (CFCS), and Facial Action Coding System (FACS); observer ratings visual analog scale (VAS) were obtained before, during, and after a mock injection and routine annual influenza vaccine injection presented in a counterbalanced order. RESULTS: VAS scores were significantly higher during the injection phase than during the other time periods; however, there were no significant differences across study time periods when using the other outcome measures. CONCLUSIONS: Although the dampened behavioral and physiologic reactions to an acute noxious stimulus were similar to those of previous work with developmentally delayed children and frail elderly, it remains unclear what underlies the apparent reduced pain response in this setting. These findings have potentially important implications for the daily care of individuals with significant neurologic impairment and illustrate the compelling need tor further study of the unique character of the pain experience in this setting.
Acute Disease↗
Pain in children with significant neurological impairment.
The pain experience in the child with a significant neurological impairment is complex and confusing, and it raises many questions about the very nature of pain itself. Early work in this field suggests that the pain experience may be blunted. The neurological impairment associated with conditions such as cerebral palsy may alter the neurological system and hence the ability to comprehend and communicate pain; there is no evidence to date that this reflects true pain insensitivity or indifference. From recent work, the emerging body of evidence supports a relationship between the pain system and the motor, sensory, and autonomic systems and demonstrates how alterations to these systems may have a profound and unique impact on the pain experience. Beyond the altered neurological substrate, communication disabilities and social/environmental factors also seem to alter the pain experience. Establishing a clear pain history, including baseline information of child-specific patterns of behaviors and ongoing comparative use of this information over time, can provide clinically meaningful measures. Pain management should be directed at the underlying sources of pain and should include the analgesic ladder for everyday pain, opioids for acute/procedural pain (+/- benzodiazepine adjuvants), and antispasticity medications for high tone. With appropriate monitoring, demand and regional analgesic techniques can provide effective and safe postoperative pain control. The lack of basic and clinical knowledge in this field, however, adds another challenge to the clinician.
Analgesics↗
The developmental character of cardiac autonomic responses to an acute noxious event in 4- and 8-month-old healthy infants.
Heart rate (HR) has been widely studied as a measure of an individual's response to painful stimuli. It remains unclear whether changes in mean HR or the variability of HR are specifically related to the noxious stimulus (i.e. pain). Neither is it well understood how such changes reflect underlying neurologic control mechanisms that produce these responses, or how these mechanisms change during the first year of life. To study the changes in cardiac autonomic modulation that occur with acute pain and with age during early infancy, the relationship between respiratory activity and short-term variations of HR (i.e. respiratory sinus arrhythmia) was quantified in a longitudinal study of term born healthy infants who underwent a finger lance blood collection at 4 months of age (n = 24) and again at 8 months of age (n = 20). Quantitative respiratory activity and HR were obtained during baseline, lance, and recovery periods. Time and frequency domain analyses from 2.2-min epochs of data yielded mean values, spectral measures of low (0.04-0.15 Hz) and high (0.15-0.80 Hz) frequency power (LF and HF), and the LF/HF ratio. To determine sympathetic and parasympathetic cardiac activity, the transfer relation between respiration and HR was used. At both 4 and 8 months, mean HR increased significantly with the noxious event (p > 0.01). There were age-related differences in the pattern of LF, HF, and LF/HF ratio changes. Although these parameters all decreased (p > 0.01) at 4 months, LF and LF/HF increased at 8 months and at 8 months HF remained stable in response to the noxious stimulus. Transfer gain changes with the lance demonstrated a change from predominant vagal baseline to a sympathetic condition at both ages. The primary finding of this study is that a response to an acute noxious stimulus appears to produce an increase in respiratory-related sympathetic HR control and a significant decrease in respiratory-related parasympathetic control at both 4 and 8 months. Furthermore, with increasing age, the sympathetic and parasympathetic changes appear to be less intense, but more sustained.
Aging↗
Halothane and cardiac autonomic control in infants: assessment with quantitative respiratory sinus arrhythmia.
In comparison to adults, infants undergoing halothane anesthesia have an increased incidence of clinically significant episodes of bradycardia, hypotension, and cardiac arrest. To examine potential cardiac autonomic regulatory mechanisms that may account for these observations, the relationship between respiratory activity and short-term variations of heart rate was quantified in 10 healthy term nonpremedicated infants (28.4 +/- 0.6 wk old) undergoing elective surgery with halothane and low caudal anesthesia. Quantitative respiratory activity, heart rate, and cuff blood pressure data were obtained during the preoperative awake period, and at three depths of halothane--1, 1.3, and 2.0 mean alveolar concentration (MAC). Time and frequency domain analyses were performed on two 2.2-min epochs of data from each condition to yield mean values, spectral measures of low (0.02-0.15 Hz) and high (0.15-0.80 Hz) frequency power (LF and HF), and the LF/HF ratio. The sympathetic (As) and parasympathetic (Ap) components of respiratory sinus arrhythmia were quantified using the transfer relations between respiration and heart rate to derive gain factors Ax and Ap, respectively. Mean heart rate, blood pressure, and respiratory activity all decreased with halothane exposure (p < 0.01), but did not differ by halothane dose. Similarly, LF, HF, LF/HF, and respiratory powers all decreased with halothane, but not between doses. When the effects of respiratory activity on heart rate were accounted for, As decreased at 1.3 and 2.0 MAC only, but Ap remained unchanged. Decreased LF and HF power suggests that halothane altered both sympathetic and parasympathetic heart rate control; however, when the ratio between LF and HF and the quantitative effects of respiration are accounted for, halothane appears to cause a reduction in respiratory related sympathetic heart rate control, without a significant change in parasympathetic control.
Anesthetics, Inhalation↗
Infants tolerate spinal anesthesia with minimal overall autonomic changes: analysis of heart rate variability in former premature infants undergoing hernia repair.
Unlike adults, neonates tolerate high thoracic spinal anesthesia with minimal changes in heart rate (HR) and arterial blood pressure. To examine the potential autonomic regulatory mechanisms which may account for these findings, the relation between short-term heart rate variability (HRV) and respiratory activity was analyzed in a group of eight ASA grade II former premature infants undergoing high thoracic spinal anesthesia for inguinal hernia repairs. Quantitative measures of sympathetic (As) and parasympathetic (Ap) modulation of HR were derived. HR, arterial blood pressure, and a calibrated respiratory signal were recorded during 4.4-min stable epochs in eight subjects 1) preoperatively, 2) postincision after high thoracic spinal anesthesia, and 3) during an active sleep state in the postoperative period. Power spectral analysis of HRV and respiratory power yielded measures of low-frequency power (LFP: 0.02-0.15 Hz) and high-frequency power (HFP: 0.15-0.8 Hz). Transfer function analysis between respiratory activity and HR were used to quantify As and Ap. All subjects had successful high thoracic spinal anesthesia with highest levels ranging from C7-T4. Mean HR, blood pressure, and respiratory power did not change significantly with high thoracic spinal anesthesia. LFP and HFP both decreased significantly, whereas the LFP/HFP ratio remained stable. Group mean As and Ap both decreased, but the changes were not significant. Despite overall cardiovascular stability, HRV decreased with high thoracic spinal anesthesia, but the balance between LFP and HFP remained stable, suggesting that the reflex response to high thoracic spinal anesthesia was predominantly diminished parasympathetic modulation of cardiac function. The expected decrease in HR and blood pressure from the sympatholysis which results from high thoracic spinal anesthesia were apparently offset by withdrawal of cardiac vagal activity.
Anesthesia, Spinal↗
Time and frequency domain methods for heart rate variability analysis: a methodological comparison.
The purpose of this paper is to analytically evaluate and compare two of the most common methods for measuring respiration-related heart rate fluctuations: linear detrended heart rate power spectral analysis and the Porges technique of filtered variance. Low-frequency power was removed from instantaneous 4-Hz R-R interval signals using either a first-order linear (linear/spectral technique) or a third-order polynomial (MPF-var technique). The signals were band-pass filtered and analyzed in both the time and frequency domains. Although in most cases the two techniques yielded substantially similar results, the MPF-var technique resulted in signal amplification at a few specific frequencies. The frequency range and effect to amplification of the MPF-var technique were dependent upon the polynomial size, sampling frequency, and frequency content of the signal.
Algorithms↗
Effects of intra-oral sucrose on crying, mouthing and hand-mouth contact in newborn and six-week-old infants.
To determine whether a single intra-oral administration of sucrose would calm infants and elicit mouthing and hand-mouth contact, crying newborn and six-week-old infants were given sucrose solution before one feed and sterile water before another in a cross-over trial. Six-week-old infants were also given sucrose and water after feeding. For the newborn infants, the calming effect was rapid, substantial and lasted for at least four minutes. Mouthing and hand-mouth contact increased, but for shorter durations. For the six-week-old infants, sucrose calmed for one minute only before feeding, but had no effects on mouthing or hand-mouth contact. The results imply that intra-oral sucrose has acute age-related effects on crying and suckling-feeding behaviour mediated by a pre-absorptive mechanism. Sucrose may tap a functional system for reducing distress related to feeding and/or regulation of infant state.
Administration, Oral↗
Advice seeking and appropriate use of a pediatric emergency department.
OBJECTIVES: To determine whether seeking advice prior to an unscheduled visit to a pediatric emergency department (PED) influences appropriate use of this setting for minor illnesses. DESIGN: Cross-sectional questionnaire survey. SETTING: The medical emergency department of the Montreal (Quebec) Children's Hospital, a major referral and urban teaching hospital. PARTICIPANTS: Four hundred eighty-nine of 562 consecutive parents visiting the PED over two periods, one in February and the other in July 1989. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Parents of children between 0 and 18 years of age visiting the PED were asked whether they had previously sought advice from family, friends, or a physician. Other factors possibly related to the decision to seek care were also measured. Appropriateness was rated, blind to discharge diagnosis, by two pediatricians using a structured series of questions incorporating the child's age, time of the visit, clinical state, and problem at presentation. Thirty-four percent of visits among respondents were judged appropriate. In bivariate analysis, appropriate visits occurred significantly more often when a parent spoke to both a physician and a nonphysician (47%) prior to visiting the PED than when no advice was sought (29%; P < .05). In multivariate analysis, having a regular physician and being one of two children also contributed to appropriateness. CONCLUSIONS: Appropriate use of the PED was positively influenced by seeking prior advice from both a physician and family member, having a regular physician, and having prior child care experience.
Adolescent↗
Recurrent abdominal pain during childhood.
RAP offers a complex and often confusing array of symptoms and diagnostic possibilities. This may be due to its unique age of presentation, its inherent somatic and cognitive developmental issues, or the physiology of abdominal pain itself. A careful examination of the historic and physical findings should produce a therapeutic plan that addresses somatic, psychological, and environmental aspects of the child. This process will avoid overly simplistic and premature misdiagnosis or potentially unnecessary investigations that convey a sense of disinterest, haste, and disbelief in the problem. The successful management of RAP lies in the recognition that serious underlying disease frequently is not present and that time usually is on our side. It is the process of continued and thoughtful evaluation and reassurance over time that counts.
Abdominal Pain↗
Short-term effects of feed composition on sleeping and crying in newborns.
To determine whether the composition of feedings would affect newborn behavior independently of the act of feeding itself, 53 two- to three-day-old normal newborns were randomly assigned to receive an extra feeding of water, carbohydrate (lactose), or balanced formula 3 hours after their usual early morning feeding. Previous studies in adult humans and animals, and a single study in human newborns, have indicated that more sleep might be expected following the carbohydrate feed compared with the water and balanced-formula feeds because of recruitment of centrally mediated serotonergic systems. Behavioral effects were assessed for 40 minutes postfeeding by direct observation of the newborn's states (quiet, active, and indeterminate sleep; drowsiness; non-cry wakefulness; and fret/cry). Feed composition did affect behavior, and the effects were fairly specific to particular newborn states. Non-cry wakefulness and drowsiness were unrelated to the presence or type of nutrients, but they tended to occur soon after the meal in all groups. Crying was increased in water-fed newborns relative to both carbohydrate- and formula-fed newborns. Sleeping showed specific patterns of change in all three groups. Sleep duration was increased in the balanced-formula group compared with the water group throughout the observation period. Contrary to the prediction, sleeping duration in carbohydrate-fed newborns never exceeded that of formula-fed newborns; rather, it resembled that of water-fed newborns early in the postprandial period, but formula-fed newborns later. These effects could not easily be explained by potential confounding factors such as handling, volume ingested, caloric intake, or plasma glucose concentration.(ABSTRACT TRUNCATED AT 250 WORDS)
Crying↗
Pain management of junctional epidermolysis bullosa in an 11-year-Old boy.
Epidermolysis bullosa is a group of hereditary blistering disorders for which there is no definitive therapy. Wound care is an important component of management. Regular dressing changes are required to protect blistered and eroded skin, and to prevent secondary infection and sepsis. These dressing changes can be very painful for patients with extensive erosions. We report our experience of pain management in an 11-year-old boy with severe junctional epidermolysis bullosa. Amitryptiline and cognitive behavioral techniques were effective in relieving chronic pain and discomfort. Oral midazolam 0.33 mg/kg administered 20 minutes prior to baths and dressing changes substantially improved his tolerance of wound care.
Amitriptyline↗