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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is no longer any doubt that sick new-born&#44; and in particular premature-born&#44; infants suffer immediate&#44; but also long-term negative effects as a result of the pain and stress they experience during their hospital stay&#46; It was first shown by Anand and Hickey<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> in the late the 1980s that the outcome after cardiac surgery performed on new-borns was much improved if an opioid was added to the traditional anaesthesia with muscle-relaxant and nitrous oxide alone&#46; This led to an awareness of the necessity to treat and prevent pain in new-borns in order to avoid medical complications&#44; and also to a great number of studies in the subject of neonatal pain&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">From this early research stems the knowledge of the acute consequences of untreated pain in new-born infants&#44; namely cardiorespiratory&#44; hormonal and metabolic changes&#44; which are increasing the risk of cerebral haemorrhage and postoperative morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Subsequent research in the following years also suggested that untreated neonatal pain could have long-term effects such as affected perception and processing of pain in these individuals&#44; both in toddler- and child-years but also later in life&#44; as adolescents and grown-ups&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> For instance&#44; boys who where circumcised showed more pain at vaccination 4&#8211;6 month later&#44; and preterm born adolescents had more &#8220;tender-points&#8221; and lower pain threshold than their full-term peers&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A recent review by Valeri et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> analysed 13 studies about long-term effects of neonatal pain&#46; In infants born extremely preterm&#44; greater numbers of painful procedures were associated with delayed postnatal growth&#44; poor early neurodevelopment&#44; high cortical activation&#44; and altered brain development&#46; In infants who were born very preterm&#44; greater numbers of neonatal painful experiences were associated with a poor quality of cognitive and motor development at 1 year of age and changes in cortical rhythmicity and cortical thickness in children at 7 years of age&#46; Also lower IQ at school age can be related to the number of painful procedures in infancy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It can be argued that it is not possible &#8211; or meaningful &#8211; to differentiate between the effects of pain and those of other stressors&#44; like the prematurity and illness them-selves&#44; or the separation from the mother&#46; This is true&#44; but the greatest impact of these recent studies is that they have quantified the amount of painful events the infant has been subjected to&#44; and linked a higher number of this to a more negative outcome&#46; They also clearly demonstrate&#44; by using new neuroimaging technologies like fMRI&#44; NIRS and DTI&#44; that changes in the brain can be seen both on the functional and the structural side&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">An important focus of the research has always been to find methods to prevent and alleviate the pain&#46; This can be done with environmental&#44; behavioural and pharmacological interventions&#44; in combination with adequate pain assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> International and regional&#47;national guidelines give the same message in this aspect&#58; as a base the neonates should be guaranteed an environment as stress-free as possible&#46; This means reducing the light&#44; the sound and the activity around the bed-space as much as possible&#46; Painful procedures should be performed only when absolutely necessary and the infant should be helped into a position where it can contain and regulate itself&#44; i&#46;e&#46; by being tucked&#44; having the opportunity so suck and be given sweet solution in the mouth before any painful procedure&#46; In addition to that&#44; pharmacologic treatment should be given whenever deemed necessary by pain assessment or by knowledge of how painful the procedure is&#46; It should be noted that sedative medication is not enough and may instead mask the ability to show pain signs&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Mechanical ventilation is a common and severe kind of stressor in neonatal care&#46; It includes both the placement of an endotracheal tube&#44; suctioning of mucus through and around that tube and often forcing the infant to breathe with an involuntary rate&#44; decided by the ventilator and not the infant itself&#46; It is therefore important to provide ventilated infants with sufficient pain- and stress-relief&#46; It has been suggested that a pre-emptive &#8220;umbrella&#8221; with opioid-infusion should be given to ventilated infants&#44; to reduce the risk of neurological sequel&#46; The large multi-centre NEOPAIN-trial&#44; however&#44; could not show this protecting effect&#46; Instead there was a slightly increased risk of intra-ventricular haemorrhage&#44; periventricular leucomalacia or neonatal death in the morphine-group&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Animal studies have demonstrated endotoxic effects of many analgesic drugs&#46; For the present being&#44; there is no rationale for recommending a general prescription of pre-emptive opioids for all ventilated infants&#46; Pharmacological treatment should be given on individual indications&#44; and the dose and duration should be re-evaluated on a regular base&#46; Instead extra effort should be made to provide environmental and behavioural support and to perform scheduled pain assessments on infants receiving mechanical ventilation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite this knowledge of the negative impact both of pain and of excessive analgesic use&#44; several studies have shown that we perform many painful procedures every day in our neonatal intensive care units&#44; often without sufficient pain relief&#46; In the recent French EPPIPAIN-study the infants experienced on average 75 painful procedures during their NICU-stay&#44; whereof almost 80&#37; without specific analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The same situation is seen in other epidemiological studies from countries around the world&#46; Things have been better over the last decades but we are still not there&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the light of this&#44; the NeoOpioid-project &#40;<a href="http://www.neoopioid.eu/">www&#46;neoopioid&#46;eu</a>&#41; started&#44; with the support of the European Commissions 7th framework programme for research&#44; and coordinated by Karolinska Institutet&#44; Stockholm&#44; Sweden&#46; A substantial part of NeoOpioid was the EUROPAIN-study which was conducted with an observational&#44; longitudinal and prospective design &#40;<a href="http://www.europainsurvey.eu/">www&#46;europainsurvey&#46;eu</a>&#41;&#46; EUROPAIN collected data on over 6000 infants in 18 European countries&#44; with the opportunity for countries and regions to do their own designated studies as part of the larger project&#46; This was done in Spain by Alejandro Avila et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a>&#44; and the results from an almost total-investigation of Spanish NICUS are presented in this volume of Anales de Pediatria&#46; The findings showed that almost half of the infants admitted to intensive care received sedative and&#47;or analgesic medication&#46; It was also obvious that there was significant variability between Spanish neonatal units in relation to the guidelines for sedation and analgesia&#46; Though a much higher proportion is preferred&#44; the results are similar to those from other studies&#46; The findings can therefore serve as a base for developing national Spanish guidelines in accordance with international guidelines<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> and state-of-the-art knowledge about pain and its effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> With this in mind&#44; the present study must be seen as good &#8211; but not perfect &#8211; news for Spanish neonates&#46; It also opens up for future collaborative research within the EUROPAIN-network&#46; With Europe as a base&#44; large trials and epidemiological studies can be performed&#44; with better use of resources and faster accomplishment of goals for the study&#46;</p></span>"
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Editorial
Good news for Spanish neonates!
¡Buenas noticias para los neonatos españoles!
M. Eriksson
Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is no longer any doubt that sick new-born&#44; and in particular premature-born&#44; infants suffer immediate&#44; but also long-term negative effects as a result of the pain and stress they experience during their hospital stay&#46; It was first shown by Anand and Hickey<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> in the late the 1980s that the outcome after cardiac surgery performed on new-borns was much improved if an opioid was added to the traditional anaesthesia with muscle-relaxant and nitrous oxide alone&#46; This led to an awareness of the necessity to treat and prevent pain in new-borns in order to avoid medical complications&#44; and also to a great number of studies in the subject of neonatal pain&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">From this early research stems the knowledge of the acute consequences of untreated pain in new-born infants&#44; namely cardiorespiratory&#44; hormonal and metabolic changes&#44; which are increasing the risk of cerebral haemorrhage and postoperative morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Subsequent research in the following years also suggested that untreated neonatal pain could have long-term effects such as affected perception and processing of pain in these individuals&#44; both in toddler- and child-years but also later in life&#44; as adolescents and grown-ups&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> For instance&#44; boys who where circumcised showed more pain at vaccination 4&#8211;6 month later&#44; and preterm born adolescents had more &#8220;tender-points&#8221; and lower pain threshold than their full-term peers&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A recent review by Valeri et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> analysed 13 studies about long-term effects of neonatal pain&#46; In infants born extremely preterm&#44; greater numbers of painful procedures were associated with delayed postnatal growth&#44; poor early neurodevelopment&#44; high cortical activation&#44; and altered brain development&#46; In infants who were born very preterm&#44; greater numbers of neonatal painful experiences were associated with a poor quality of cognitive and motor development at 1 year of age and changes in cortical rhythmicity and cortical thickness in children at 7 years of age&#46; Also lower IQ at school age can be related to the number of painful procedures in infancy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It can be argued that it is not possible &#8211; or meaningful &#8211; to differentiate between the effects of pain and those of other stressors&#44; like the prematurity and illness them-selves&#44; or the separation from the mother&#46; This is true&#44; but the greatest impact of these recent studies is that they have quantified the amount of painful events the infant has been subjected to&#44; and linked a higher number of this to a more negative outcome&#46; They also clearly demonstrate&#44; by using new neuroimaging technologies like fMRI&#44; NIRS and DTI&#44; that changes in the brain can be seen both on the functional and the structural side&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">An important focus of the research has always been to find methods to prevent and alleviate the pain&#46; This can be done with environmental&#44; behavioural and pharmacological interventions&#44; in combination with adequate pain assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> International and regional&#47;national guidelines give the same message in this aspect&#58; as a base the neonates should be guaranteed an environment as stress-free as possible&#46; This means reducing the light&#44; the sound and the activity around the bed-space as much as possible&#46; Painful procedures should be performed only when absolutely necessary and the infant should be helped into a position where it can contain and regulate itself&#44; i&#46;e&#46; by being tucked&#44; having the opportunity so suck and be given sweet solution in the mouth before any painful procedure&#46; In addition to that&#44; pharmacologic treatment should be given whenever deemed necessary by pain assessment or by knowledge of how painful the procedure is&#46; It should be noted that sedative medication is not enough and may instead mask the ability to show pain signs&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Mechanical ventilation is a common and severe kind of stressor in neonatal care&#46; It includes both the placement of an endotracheal tube&#44; suctioning of mucus through and around that tube and often forcing the infant to breathe with an involuntary rate&#44; decided by the ventilator and not the infant itself&#46; It is therefore important to provide ventilated infants with sufficient pain- and stress-relief&#46; It has been suggested that a pre-emptive &#8220;umbrella&#8221; with opioid-infusion should be given to ventilated infants&#44; to reduce the risk of neurological sequel&#46; The large multi-centre NEOPAIN-trial&#44; however&#44; could not show this protecting effect&#46; Instead there was a slightly increased risk of intra-ventricular haemorrhage&#44; periventricular leucomalacia or neonatal death in the morphine-group&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Animal studies have demonstrated endotoxic effects of many analgesic drugs&#46; For the present being&#44; there is no rationale for recommending a general prescription of pre-emptive opioids for all ventilated infants&#46; Pharmacological treatment should be given on individual indications&#44; and the dose and duration should be re-evaluated on a regular base&#46; Instead extra effort should be made to provide environmental and behavioural support and to perform scheduled pain assessments on infants receiving mechanical ventilation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite this knowledge of the negative impact both of pain and of excessive analgesic use&#44; several studies have shown that we perform many painful procedures every day in our neonatal intensive care units&#44; often without sufficient pain relief&#46; In the recent French EPPIPAIN-study the infants experienced on average 75 painful procedures during their NICU-stay&#44; whereof almost 80&#37; without specific analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The same situation is seen in other epidemiological studies from countries around the world&#46; Things have been better over the last decades but we are still not there&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the light of this&#44; the NeoOpioid-project &#40;<a href="http://www.neoopioid.eu/">www&#46;neoopioid&#46;eu</a>&#41; started&#44; with the support of the European Commissions 7th framework programme for research&#44; and coordinated by Karolinska Institutet&#44; Stockholm&#44; Sweden&#46; A substantial part of NeoOpioid was the EUROPAIN-study which was conducted with an observational&#44; longitudinal and prospective design &#40;<a href="http://www.europainsurvey.eu/">www&#46;europainsurvey&#46;eu</a>&#41;&#46; EUROPAIN collected data on over 6000 infants in 18 European countries&#44; with the opportunity for countries and regions to do their own designated studies as part of the larger project&#46; This was done in Spain by Alejandro Avila et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a>&#44; and the results from an almost total-investigation of Spanish NICUS are presented in this volume of Anales de Pediatria&#46; The findings showed that almost half of the infants admitted to intensive care received sedative and&#47;or analgesic medication&#46; It was also obvious that there was significant variability between Spanish neonatal units in relation to the guidelines for sedation and analgesia&#46; Though a much higher proportion is preferred&#44; the results are similar to those from other studies&#46; The findings can therefore serve as a base for developing national Spanish guidelines in accordance with international guidelines<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> and state-of-the-art knowledge about pain and its effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> With this in mind&#44; the present study must be seen as good &#8211; but not perfect &#8211; news for Spanish neonates&#46; It also opens up for future collaborative research within the EUROPAIN-network&#46; With Europe as a base&#44; large trials and epidemiological studies can be performed&#44; with better use of resources and faster accomplishment of goals for the study&#46;</p></span>"
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ISSN: 23412879
Original language: English
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Idiomas
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