Clinics in perinatology
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Investigations in animal models of hypoxic-ischemic injury have not translated into clinical trials of success because of the complex pathology of hypoxic-ischemic brain injury in neonates, the difficulty in defining the onset and duration and severity of the injury, the underlying predisposing disorders of the mothers or the infant, the side effects of many of the investigational drugs precluded clinical use, and many of the investigational agents interfered with only one step of the cascade of events that lead to brain injury. It is possible that a combination of therapeutic agents, including those that affect different levels of the cascade to cell death, will have the greatest neuroprotective effects. Modest hypothermia postpones secondary energy failure and can prolong the window while pharmacotherapeutic agents can be used. It is possible that in the future, sequential administration of agents or strategies that are initiated in the intrapartum period and continued postnatally will be the optimum method for treating infants who are at highest risk for brain injury following acute hypoxic-ischemic asphyxia.
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Clinics in perinatology · Sep 2002
ReviewThe effects of analgesia in the vulnerable infant during the perinatal period.
Although our knowledge of pain and its management in the perinatal period has increased, little is known about the first hours and days of life when major physiologic transition events occur. Prematurity and critical illnesses further complicate analgesic use during this time. Increased morbidity and mortality have been shown in infants receiving placebo infusions after surgery compared with infants with analgesia, highlighting the negative consequences of pain in infants. ⋯ There are no longitudinal studies published investigating the pharmacokinetic properties of any analgesic more than once per infant. Polymorphisms of the genes encoding for the enzymes involved in the metabolism of analgesics or in genes involved in receptor expression may contribute to the large interindividual pharmacokinetic parameter variability. Polymorphism of the human mu opioid receptor has not yet satisfactorily explained pharmacodynamic variability.
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Clinics in perinatology · Sep 2002
ReviewEarly pain in preterm infants. A model of long-term effects.
There are multiple lines of evidence suggesting that in vulnerable prematurely born infants, repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Multiple factors cumulatively contribute to altered developmental trajectories in such infants. These include characteristics of the developing organism (low tactile threshold, sensitization, rapid brain development), characteristics intrinsic to the infant (gestation, illness severity), characteristics of the experience in the neonatal intensive care unit (pain exposure and cumulative stress), and characteristics of the caregivers within their family and social context. This article provides a model for examining long-term effects of pain in the newborn period embedded in a developmental context framework.
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Clinics in perinatology · Sep 2002
ReviewAre postoperative pain instruments useful for specific groups of vulnerable infants?
Based on the authors' review of the literature on pediatric postoperative pain assessment with special attention to groups of vulnerable infants, this article (1) reports on type of surgery and its relationship to postoperative pain intensity; (2) reviews the characteristics of existing postoperative pain instruments for neonates, infants, and toddlers; (3) discusses timing, duration, and who should assess postoperative pain; (4) reviews the specific literature on pain assessment in critically ill infants, including the extremely low birth weight and the cognitively and/or neurologically impaired infant, and (5) discusses the role of parents in postoperative pain assessment. Postoperative pain instruments are useful for specific groups of vulnerable infants, but it is important that in addition to the valuable scoring of pain, common sense is used and factors such as developmental stage, temperament and personality, number of previous painful experiences, anxiety, and environmental factors are taken into account.
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Clinics in perinatology · Sep 2002
ReviewOpioid analgesia for infants in the neonatal intensive care unit.
There is an ethical obligation to relieve the pain and suffering in newborn infants. Opioids have been demonstrated to blunt the physiologic effects of pain and may prevent some of the clinical consequences of unmanaged pain. There are sufficient data to recommend the clinical use of opioid analgesics for the treatment of pain in the neonate. ⋯ Adverse effects can be minimized by the use of various drug administration techniques and close monitoring. Further research is needed to determine how to optimize their effects. Data on the long-term effects of neonatal opioid exposure are warranted.