Efficacy and safety of 'Second Adjuvant' therapy with BRAF/MEK inhibitors after local therapy for recurrent melanoma following adjuvant PD-1 based immunotherapy.

BACKGROUND: Anti-PD-1 antibodies and BRAK/MEK inhibitors (BRAF/MEKi) reduce the risk of recurrence for patients with resected stage III melanoma. BRAFV600-mutated (BRAFmut) melanoma patients who recur with isolated disease following adjuvant therapy may be suitable for 'second adjuvant' treatment after local therapy. We sought to examine the efficacy and safety of 'second adjuvant' BRAF/MEKi. PATIENTS AND METHODS: Patients with BRAFmut melanoma treated with adjuvant PD-1 based immunotherapy who recurred, underwent definitive local therapy and were then treated with adjuvant BRAF/MEKi were identified retrospectively from 13 centres (second adjuvant group). Demographics, disease and treatment characteristics and outcome data were examined. Outcomes were compared to BRAFmut patients who did not receive 'second adjuvant' therapy (no second adjuvant group). RESULTS: 73 patients were included; 61 who received 'second adjuvant' therapy and 12 who did not. Most initially recurred on PD-1 therapy (66%). There were no differences in characteristics between groups. 92% of second adjuvant group received dabrafenib and trametinib and median duration of therapy was 11.8 months (0.4, 34.5). 72% required dose adjustments, 23% had grade 3 + toxicity and 38% permanently discontinued drug due to toxicity. After median 26.1 months (1.9, 56.3) follow-up, recurrence-free survival (RFS) was improved in second adjuvant group versus no second adjuvant group (median 30.8 vs 4 months, HR 0.35; p = 0.014), largely driven by a delay in early recurrence, with no difference in overall survival (p = 0.59). CONCLUSION: This is the first study examining outcomes of 'second adjuvant' targeted therapy for melanoma, after failure of adjuvant PD-1 based immunotherapy. Data suggest a short-term improvement in RFS, but at the cost of toxicity. Alternative strategies and more data on sequencing adjuvant therapies are required to improve outcomes.

Out-of-pocket costs for families and people living with cerebral palsy in Australia.

The most recent cost estimates of cerebral palsy (CP) in Australia did not include out-of-pocket costs for families. This study aimed to: 1) describe and estimate out-of-pocket costs for people with CP and their families by age and gross motor function classification system (GMFCS) level; 2) measure financial distress. A cross-sectional quantitative survey design was used with qualitative approaches to analyse open-ended questions. A CP-specific out-of-pocket costs survey was co-designed with people with lived experience. Adults with CP and carers were recruited from Australian population-based CP Registers and via social media. Sociodemographic variables were analysed descriptively and median (IQR) expenses for health, assistive technology, personal care, housing, occupation, transport, leisure, respite and holidays, by age (0-6; 7-17; 18 years +) and gross motor function [GMFCS level I-II vs III-V] were calculated. The In Charge Financial Distress/Financial Wellbeing Scale measured financial distress. Regression analyses were conducted to investigate costs and financial distress. Additional out-of-pocket costs itemised in open-ended questions were charted. Comments were thematically analysed using the framework approach. 271 surveys were completed for children 0-6 years (n = 47), children/adolescents 7-17 years (n = 124) and adults (n = 100). 94% of participants had out-of-pocket costs associated with CP, with an overall annual median of $4,460 Australian dollars (IQR $11,955). After controlling for income, private insurance and disability funding, the GMFCS III-V group had costs two times higher than the GMFCS I-II group (2.01; 95% CI 1.15-3.51). Age was not significantly associated with costs. 36% of participants had high to overwhelming financial distress; this was not associated with age or GMFCS level after controlling for financial factors. Families had several additional disability costs. Open-ended responses revealed experiences of financial concern were influenced by funding scheme experiences, reduced income, uncertainty, access to support networks and an inability to afford CP-related costs. Cost estimates and financial distress indicators should inform policy, funding and clinical decisions when planning interventions to support people with CP and their families.

Risk of Developmental Coordination Disorder in 8- and 9-Year-Olds Following Newborn Cardiac and Non-Cardiac Surgery.

PURPOSE: To investigate the risk of developmental coordination disorder (DCD) and motor impairment for children aged 8 to 9 years following newborn surgery. METHODS: Prospective longitudinal cohort study. Motor proficiency and risk of DCD were assessed using the Movement Assessment Battery for Children (second edition) for children born 37 weeks of gestation and older who had undergone newborn cardiac surgery (CS) or non-cardiac surgery (NCS). RESULTS: Children who had undergone CS were 3.0 times more likely than controls and 1.7 times more likely than children who had undergone NCS to score below the 15th centile on MABC-2 and have increased risk of DCD. Children who had undergone CS were 1.9 times more likely than controls and 1.4 times more likely than children who had undergone NCS to score below the fifth centile on MABC-2. CONCLUSION: The surgical population should be considered at an increased risk of DCD.

Proportion of Infant Neurodevelopment Trials Reporting a Null Finding: A Systematic Review.

CONTEXT: Discovering new interventions to improve neurodevelopmental outcomes is a priority; however, clinical trials are challenging and methodological issues may impact the interpretation of intervention efficacy. OBJECTIVES: Characterize the proportion of infant neurodevelopment trials reporting a null finding and identify features that may contribute to a null result. DATA SOURCES: The Cochrane library, Medline, Embase, and CINAHL databases. STUDY SELECTION: Randomized controlled trials recruiting infants aged <6 months comparing any "infant-directed" intervention against standard care, placebo, or another intervention. Neurodevelopment assessed as the primary outcome between 12 months and 10 years of age using a defined list of tools. DATA EXTRACTION: Two reviewers independently extracted data and assessed quality of included studies. RESULTS: Of n = 1283 records screened, 21 studies (from 20 reports) were included. Of 18 superiority studies, >70% reported a null finding. Features were identified that may have contributed to the high proportion of null findings, including selection and timing of the primary outcome measure, anticipated effect size, sample size and power, and statistical analysis methodology and rigor. LIMITATIONS: Publication bias against null studies means the proportion of null findings is likely underestimated. Studies assessing neurodevelopment as a secondary or within a composite outcome were excluded. CONCLUSIONS: This review identified a high proportion of infant neurodevelopmental trials that produced a null finding and detected several methodological and design considerations which may have contributed. We make several recommendations for future trials, including more sophisticated approaches to trial design, outcome assessment, and analysis.

Neurodevelopmental outcomes in neonatal extracorporeal membrane oxygenation survivors: An institutional perspective.

AIM: To describe the neurodevelopmental outcomes following extracorporeal membrane oxygenation (ECMO) in early infancy. METHODS: Thirty-seven patients who had survived following ECMO support from 2008 to 2018 had their neurodevelopmental outcomes assessed and analysed using the Bayley Scales of Infant and Toddler Development. Developmental outcome was defined as impairment in any of the developmental domains of motor function, cognition and language with mild impairment being 1-2 standard deviations below the test mean, moderate being 2-3 standard deviations below and severe being greater than 3 standard deviations below. RESULTS: Of these 37 patients, the median age at admission to Paediatric Intensive Care Unit was 0.4 months (interquartile range 2.8 months) with all of the study patients having an underlying diagnosis of congenital cardiac disease and 37/40 (92.5%) ECMO runs occurring in the immediate post-operative period. Of the 29 patients who had had follow-up at 12 months of age or older, 3 (10.3%) had severe impairment, 4 (13.8%) had moderate impairment, 12 (41.3%) had mild impairment and 10 (34.5%) had no impairment. Gross motor function was most significantly impacted in 18/29 (62.1%) patients, of which 7/18 (38.9%) had severe impairment. This was followed by impairment of receptive language in 8/29 (27.6%) patients and expressive language in 6/29 (20.1%) patients. CONCLUSIONS: One in four infants undergoing ECMO treatment in early infancy has moderate to severe neurodevelopmental impairment. Gross motor and language are the most affected developmental domains.

Non-gynaecological Applications of Menstrual-derived Stem Cells: A Systematic Review.

Menstrual-derived Stem Cells (MenSC) are a potential novel source of mesenchymal stem cells. There is an increased interest in investigating the therapeutic potential of MenSC due to the various advantages they exhibit, when compared to other types of stem cells. MenSC are obtained non-invasively from menstrual blood. Thus, collection of MenSC is simple, reproducible and can be carried out periodically, with minimal complications. MenSC are present in abundance, are highly proliferative, exhibit a low immunogenicity and lack ethical issues. MenSC have shown the ability to differentiate into several lineages. The therapeutic potential of MenSC in non-gynaecological applications has been investigated in wound healing, neurological, musculo-skeletal, cardiovascular, respiratory, and liver disorders, as well as in diabetes and cancer. Human clinical trials are limited. To date, therapeutic efficacy and safety have been reported in patients with Avian influenza A subtype H7N9, COVID-19, congestive heart failure, multiple sclerosis and Duchene muscular dystrophy. However, further clinical trials in humans should be conducted, to study the long-term therapeutic effects of these stem cells in various diseases and to further explore their mechanism of action. This systematic review focuses on the application of MenSC in non-gynaecological diseases.

The long-term burden of congenital cytomegalovirus: Hospitalisation and mortality in a population-based matched cohort study.

AIM: Congenital cytomegalovirus (cCMV) infection can result in considerable morbidity and mortality. However, the impact of cCMV on health system utilisation beyond infancy is poorly defined. Here we sought to describe the burden of cCMV health service use and mortality using linked population-based datasets. METHODS: The design was a matched cohort study using record-linked administrative datasets. Participants included all children aged 0-15 years identified through the New South Wales (NSW), Australia, Admitted Patient Data Collection who were hospitalised with an admission code for cCMV infection between 2001 and 2011. Participants were then matched by age, sex and birth postcode quintile using Socio-Economic Indexes for Area, to children randomly selected from the NSW Perinatal Data Collection, excluding those with central nervous system infections or cerebral palsy. We calculated rate ratios (RR) for hospital admissions adjusted for preterm birth, the median length of stay, cost weights of admission and odds ratio (OR) for deaths. RESULTS: There were 130 children with cCMV matched to 2672 children. Neonates (aged <1 month) with cCMV had twice the rate of admissions (RR 2.4 95%CI 2.0, 2.8) and children aged ≥ 5yr to < 15yrs with cCMV almost eight times the rate of admissions (RR 7.8 95%CI 5.1, 11.5). Children with cCMV had significantly higher cost weights of admissions and an increased risk of mortality (OR 18.4 95%CI 7.8, 43.6). CONCLUSION: Throughout childhood, children with cCMV had higher rates of hospital admissions, higher admission cost weights and an increased risk of mortality compared with matched peers without cCMV.

Education can improve clinician confidence in information sharing and willingness to refer to stem cell clinical trials for cerebral palsy.

To progress stem cell therapies for cerebral palsy, clinicians need to openly engage with patients about emerging evidence and be willing to refer to relevant clinical trials, if and when appropriate. To assess whether education can change clinicians' confidence in information sharing and willingness to refer to relevant clinical trials, an online questionnaire was distributed at a scientific conference before and after a professional workshop on cell therapies for cerebral palsy. Of the 42 participants who completed the survey, 26 self-identified as clinicians. Of these, 81% had had patients ask about stem cells, yet in the pre-workshop questionnaire indicated they were not confident answering questions about cell therapies. Clinicians were most commonly asked about stem cell treatments provided by private clinics, stem cell research and current evidence. Post-workshop, knowledge and confidence regarding stem cells, as well as likelihood to refer to clinical trials using therapies with a strong evidence base (eg, umbilical cord blood/placental cells), significantly increased (p<0.001). This study highlights that by offering resources and education, clinician confidence and willingness to refer to cell therapy trials can improve; this may help drive the stem cell research landscape and support patient decision-making.

Outcome of Community-Based Early Intervention and Rehabilitation for Children with Cerebral Palsy in Rural Bangladesh: A Quasi-Experimental Study.

We evaluated the outcome of a community-based early intervention and habilitation for children with cerebral palsy (CP) in Bangladesh. Children registered on the Bangladesh CP Register (BCPR) were recruited in two groups for this study: Group A received a comprehensive six-month long community-based caregiver-led intervention program at the "Shishu Shorgo" (Bengali title, which translates to 'Children's Heaven') Early Intervention and Rehabilitation Centres developed to support participants from the BCPR. Group B received standard care. A quasi-experimental study was conducted. Data were obtained at baseline, at the end of the program (i.e., 6 months), and at a 12-month follow-up. Outcome measures for children included gross motor functional measure (GMFM-66), Communication Function Classification System (CFCS), and Viking Speech Scale (VSS) and, for adult caregivers, the depression, anxiety, and stress scale (DASS 21). Between October 2016 and March 2017, 156 children with CP were recruited (77 in Group A and 79 in Group B). The total score of GMFM-66, CFCS level, and VSS level significantly improved statistically in Group A (p < 0.05 for all) and deteriorated in Group B (p < 0.001, p = 0.095, p = 0.232). The intervention showed promising outcomes particularly for children with CP under five years of age. There is a need for caregiver-led community-based programs for children with CP in LMICs.

Depression, anxiety and stress among caregivers of adolescents with cerebral palsy in rural Bangladesh.

PURPOSE: Prior studies indicate high risk of mental health problems among caregivers of adolescents with cerebral palsy although limited consideration is given to caregivers in low- and middle-income countries. This study aimed to compare the burden of depression, anxiety and stress among caregivers of adolescents with cerebral palsy to caregivers of adolescents without disability in rural Bangladesh; and to identify factors unique to low- and middle-income countries that predict caregiver's mental health. METHODS: Observational study comparing caregivers of adolescents with cerebral palsy identified through the Bangladesh Cerebral Palsy Register and caregivers of adolescents without disability from neighboring dwellings. Caregiver mental health was assessed using the Depression, Anxiety and Stress Scale-21, adolescent mental health using the Strengths and Difficulties Questionnaire and adolescent health-related quality of life using Kidscreen-27. Hierarchical multivariable regression analysis was performed. RESULTS: Participants were 154 caregivers of adolescents with cerebral palsy and 173 caregivers of adolescents without disability, matched on adolescent age and sex. Caregivers of adolescents with cerebral palsy reported significantly higher risk of depression and stress than caregivers of adolescents without disability (Effect Size 0.1 to 0.2, p < 0.05) although no difference on anxiety. Caregiver age, adolescent mental health, household overcrowding and adolescent hearing impairment were significant predictors of depression, anxiety and/or stress (0.1 to 2.2, p < 0.05). CONCLUSIONS: Caregivers of adolescents with cerebral palsy in rural Bangladesh are at high risk of depression and stress. Initiatives to improve caregiver mental health are required; we recommend initiatives address adolescent mental health problems and include poverty reduction measures to improve social and economic capital. Improved understanding of the factors predicting caregiver depression, anxiety and stress unique to low and middle-income countries are necessary to guide policies and public health infrastructure development.Implications for rehabilitationCaregivers of adolescents with cerebral palsy in rural Bangladesh are at significantly higher risk of depression and stress than caregivers of adolescents without disability.We recommend interventions to improve caregiver mental health give specific consideration to older caregivers, those whose adolescent report mental health problems, families living in crowded households, and/or whose child has hearing impairment.We recommend interventions include poverty reduction measures to improve social and economic capital and target both caregivers and adolescents with CP to enhance long term outcomes.

Skincare practices in extremely premature infants: A survey of tertiary neonatal intensive care units from Australia and New Zealand.

AIM: To investigate skincare practices in the first 2 weeks of life in extremely premature infants across tertiary neonatal intensive care units (NICUs). METHODS: A web-based secure survey invite was emailed to the medical directors of tertiary NICUs. The survey included questions on various aspects of skincare practices in the first 2 weeks of life in extremely premature infants (born before 28 weeks gestation). The person most familiar with local skincare practices was asked to complete the survey and only one response per unit was requested. We performed a descriptive analysis. RESULTS: We received responses from 30 out of 32 NICUs (response rate 93%). Twenty-five NICUs (89%) reported offering resuscitation and intensive care to infants born at ≥23 weeks gestation. All NICUs reported occurrences of skin breakdown, including medical adhesive-related skin injury (30%), abrasion/friction-associated skin injury (46%), perineal skin breakdown (55%), pressure site injury (47%) and diaper dermatitis (60%). A high level of consensus (≥75%) was observed for certain practices, such as the use of polyethylene occlusive plastic wraps at birth and aqueous chlorhexidine solution for sterile procedures, but a low level of consensus (<25%) was observed for many other practices, including the skin risk assessment tool used. CONCLUSIONS: Skin injuries in extremely premature infants are common and skincare practices vary considerably amongst NICUs. Clinical practice improvement projects and further clinical research will help improve consistency amongst NICUs. Further research is needed to assist the development of evidence-based guidelines and benchmarking for skincare practices in these vulnerable infants.

Influence of patterns of neonatal transfers on breastfeeding outcomes.

AIM: To investigate/evaluate the impact of hospital transfers on breastfeeding outcomes for infants requiring neonatal intensive care and to explore approaches to supporting lactation and breastfeeding. METHODS: A national study of two cohorts of infants admitted to the nine neonatal intensive care units (NICUs) in New South Wales (NSW) Australia using data sourced from a prospectively collected NICUS data collection. RESULTS: A total of 7829 infants were admitted to the nine NICUs in NSW for two 18-month cohorts (2012/2013 and 2015/2016) and were included in the study. These infants experienced 17 238 transfers to 107 different hospitals during the study period. Multiple transfers and low gestational age were independently associated with lower breastfeeding rates at hospital discharge across both cohorts. Extremely preterm infants and those with the greatest number of hospital transfers are least likely to be breastfed at time of discharge. Breastfeeding rates remained unchanged over time. The level of lactation support varied across NICUs. CONCLUSION: This study highlights the challenges of establishing and maintaining breastfeeding for infants requiring intensive care who have had multiple hospital transfers for continuing or specialist care. There is wide variation in lactation support across facilities. The importance of a consistent approach, education programmes and the provision of appropriate lactation support is emphasised.

Cerebral Oxygenation and Perfusion when Positioning Preterm Infants: Clinical Implications.

OBJECTIVES: To evaluate cerebral tissue oxygenation (cTOI) and cerebral perfusion in preterm infants in supine vs prone positions. STUDY DESIGN: Sixty preterm infants, born before 32 weeks of gestation, were enrolled; 30 had bronchopulmonary dysplasia (BPD, defined as the need for respiratory support and/or supplemental oxygen at 36 weeks of postmenstrual age). Cerebral perfusion, cTOI, and polysomnography were measured in both the supine and prone position with the initial position being randomized. Infants with a major intraventricular hemorrhage or major congenital abnormality were excluded. RESULTS: Cerebral perfusion was unaffected by position or BPD status. In the BPD group, the mean cTOI was higher in the prone position compared with the supine position by a difference of 3.27% (P = .03; 95% CI 6.28-0.25) with no difference seen in the no-BPD group. For the BPD group, the burden of cerebral hypoxemia (cumulative time spent with cTOI <55%) was significantly lower in the prone position (23%) compared with the supine position (29%) (P < .001). In those without BPD, position had no effect on cTOI. CONCLUSIONS: In preterm infants with BPD, the prone position improved cerebral oxygenation and reduced cerebral hypoxemia. These findings may have implications for positioning practices. Further research will establish the impact of position on short- and long-term developmental outcomes.

Positive perception of stem cells for neurological conditions: results from an Australian public forum.

Background: Stem cells offer great hope and promise as a potential treatment for human diseases. The aim of this study was to gain insight into the public perception of stem cells for neurological conditions. Materials & methods: A paper-based questionnaire was administered to all attendees of a free, public stem cell forum. Results: Of 203 respondents, >95% believe that stem cells have the potential to treat neurological conditions. There was also high support (92%) for the use of embryonic/fetally derived cells, and 67% of respondents indicated a high likelihood to participate in a clinical trial of stem cell treatment(s), indicating overall support for research and translation. Conclusion: Our data demonstrates a positive perception of stem cell treatments for neurological conditions in our cohort.

Feasibility of modifying the hospital environment to reduce the length of amnesia after traumatic brain injury: a pilot randomized controlled trial.

BACKGROUND: Reorientation programmes have been an important component of neurotrauma rehabilitation for adults who suffer from post-traumatic amnesia (PTA) after traumatic brain injury (TBI); however, research testing the efficacy of acute programmes is limited. OBJECTIVE: This study aimed to determine if it is feasible to provide a standardized environmental reorientation programme to adults suffering from PTA after TBI in an acute care hospital setting, and whether it is likely to be beneficial. METHODS: We conducted a randomized controlled trial with concealed allocation and intention-to-treat analysis. A total of 40 participants suffering from PTA after TBI were included. The control group received usual care; the experimental group received usual care plus a standardized orientation programme inclusive of environmental cues. The primary outcome measure was time to emergence from PTA measured by the Westmead PTA Scale, assessed daily from hospital admission or on regaining consciousness. RESULTS: Adherence to the orientation programme was high, and there were no study-related adverse responses to the environmental orientation programme. Although there were no statistically significant between-group differences in time to emergence, the median time to emergence was shorter for those who received the standardized reorientation programme (9.0 (6.4-11.6) versus 13.0 (4.5-21.5) days). Multivariate analysis showed that the Glasgow Coma Scale (GCS) at scene (P = 0.041) and GCS at arrival at hospital (P = 0.0001) were significant factors contributing to the longer length of PTA. CONCLUSION: Providing an orientation programme in acute care is feasible for adults suffering from PTA after TBI. A future efficacy trial would require 216 participants to detect a between-group difference of 5 days with an alpha of 0.05 and a power of 80%.

Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care.

OBJECTIVE: The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT). MATERIALS AND METHODS: A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011). RESULTS: Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P<0.001) for the Physiological Pain Measures factor, whereas Behavioral Pain Measures frequency was higher at term than at preterm (χ2(3)=8.1, P<0.043). A similar pattern was observed for postmenstrual age at assessment categories: Behavioral Pain Measures (χ2(3)=41.8, P<0.001) Physiological Pain Measures (χ2(3)=46.1, P<0.001). The 2-factor correlated model performed better at explaining the observed variances: (χ2(13)=41.6, P<0.001) compared with rival models. DISCUSSION: The PAT assesses both Behavioral Pain and Physiological Pain Measures, and these dimensions need to be considered separately when assessing pain in infants in the neonatal intensive care unit. Behavioral item scores may be insufficient for detecting pain in premature infants if used alone.

Stakeholder consensus for decision making in eye-gaze control technology for children, adolescents and adults with cerebral palsy service provision: findings from a Delphi study.

BACKGROUND: Limited research exists to guide clinical decisions about trialling, selecting, implementing and evaluating eye-gaze control technology. This paper reports on the outcomes of a Delphi study that was conducted to build international stakeholder consensus to inform decision making about trialling and implementing eye-gaze control technology with people with cerebral palsy. METHODS: A three-round online Delphi survey was conducted. In Round 1, 126 stakeholders responded to questions identified through an international stakeholder Advisory Panel and systematic reviews. In Round 2, 63 respondents rated the importance of 200 statements generated by in Round 1. In Round 3, 41 respondents rated the importance of the 105 highest ranked statements retained from Round 2. RESULTS: Stakeholders achieved consensus on 94 of the original 200 statements. These statements related to person factors, support networks, the environment, and technical aspects to consider during assessment, trial, implementation and follow-up. Findings reinforced the importance of an individualised approach and that information gathered from the user, their support network and professionals are central when measuring outcomes. Information required to support an application for funding was obtained. CONCLUSION: This Delphi study has identified issues which are unique to eye-gaze control technology and will enhance its implementation with people with cerebral palsy.

The effects of education levels of developmental care in Australia: Perceptions and challenges.

BACKGROUND: Developmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention. AIMS AND OBJECTIVES: The objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care. DESIGN: This involves a cross-sectional survey design. METHODS: An online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys. RESULTS: Differences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2-1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9-6.2] and [OR: 2.1, 95% CI: 0.6-7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3-9.9) than metropolitan respondents. CONCLUSION: The application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.

Trajectories of post-surgical pain in infants admitted to neonatal intensive care.

BACKGROUND: The aim of this study was (a) to statistically identify distinct trajectories of pain following surgery in infants less than 6 months of age, and (b) to compare these trajectories to descriptions of chronic pain in infants in the neonatal intensive care unit (NICU). METHODS: This was a retrospective medical record review of infants admitted to a NICU between 2008 and 2018 following surgery. All infants who underwent one major procedure to the abdomen or thorax and returned to the NICU following surgery were included. Pain was assessed regularly using a validated Pain Assessment Tool. Group-based trajectory analysis was used to determine the trajectory of recovery from pain following surgery. RESULTS: A total of 726 infants were included in the study. A two-group trajectory model, defined as typical and atypical pain trajectories, was selected. The typical group (n = 467) consisted of infants who had significantly fewer days (1.5 ± 2.3 vs 5.3 ± 5.5, p < .001) and recorded instances of pain (2.0 ± 3.4 vs 9.7 ± 10.5, p < .001) compared to infants in the atypical group (n = 259). The incidence of iatrogenic neonatal abstinence syndrome was greater in the atypical than the typical group (11% vs 5%, p = .001). CONCLUSIONS: This study has revealed two distinct pain trajectories in infants after surgery. While recovery from pain occurs within days in the typical group, the atypical group demonstrates pain for a significantly longer period, often weeks and months following surgery. This latter group adheres closely to current descriptions of chronic pain in infants.