Human vs machine towards neonatal pain assessment: A comprehensive analysis of the facial features extracted by health professionals, parents, and convolutional neural networks.

Neonates are not able to verbally communicate pain, hindering the correct identification of this phenomenon. Several clinical scales have been proposed to assess pain, mainly using the facial features of the neonate, but a better comprehension of these features is yet required, since several related works have shown the subjectivity of these scales. Meanwhile, computational methods have been implemented to automate neonatal pain assessment and, although performing accurately, these methods still lack the interpretability of the corresponding decision-making processes. To address this issue, we propose in this work a facial feature extraction framework to gather information and investigate the human and machine neonatal pain assessments, comparing the visual attention of the facial features perceived by health-professionals and parents of neonates with the most relevant ones extracted by eXplainable Artificial Intelligence (XAI) methods, considering the VGG-Face and N-CNN deep learning architectures. Our experimental results show that the information extracted by the computational methods are clinically relevant to neonatal pain assessment, but yet do not agree with the facial visual attention of health-professionals and parents, suggesting that humans and machines can learn from each other to improve their decision-making processes. We believe that these findings might advance our understanding of how humans and machines code and decode neonatal facial responses to pain, enabling further improvements in clinical scales widely used in practical situations and in face-based automatic pain assessment tools as well.

Pediatricians' focus of sight at pain assessment during a neonatal heel puncture / Foco do olhar do pediatra na avaliação da dor neonatal durante uma punção de calcanhar

ABSTRACT Objective: To evaluate the focus of pediatricians' gaze during the heel prick of neonates. Methods: Prospective study in which pediatricians wearing eye tracker glasses evaluated neonatal pain before/after a heel prtick. Pediatricians scored the pain they perceived in the neonate in a verbal analogue numerical scale (0=no pain; 10=maximum pain). The outcomes measured were number and time of visual fixations in upper face, lower face, and hands, in two 10-second periods, before (pre) and after the puncture (post). These outcomes were compared between the periods, and according to pediatricians' pain perception: absent/mild (score: 0-5) and moderate/intense (score: 6-10). Results: 24 pediatricians (31 years old, 92% female) evaluated 24 neonates. The median score attributed to neonatal pain during the heel prick was 7.0 (Interquartile range: 5-8). Compared to pre-, in the post-periods, more pediatricians fixed their gaze on the lower face (63 vs. 92%; p=0.036) and the number of visual fixations was greater on the lower face (2.0 vs. 5.0; p=0.018). There was no difference in the number and time of visual fixations according to the intensity of pain. Conclusions: At bedside, pediatricians change their focus of attention on the neonatal face after a painful procedure, focusing mainly on the lower part of the face.

RESUMO Objetivo: Avaliar o foco do olhar do pediatra durante a punção do calcanhar de neonatos. Métodos: Estudo prospectivo no qual pediatras, utilizando óculos de rastreamento visual, avaliaram a dor neonatal antes/depois de uma punção de calcanhar. Os pediatras pontuaram a dor de acordo com a sua percepção por meio de uma escala analógica verbal (0=sem dor; 10=dor máxima). Os desfechos analisados foram o número e o tempo das fixações visuais na face superior, face inferior e mãos, em dois períodos de 10 segundos, antes (PRÉ) e depois da punção (PÓS). Os resultados foram comparados entre os períodos e segundo a percepção da dor do pediatra: ausente/leve (escore: 0-5) e moderada/grave (escore: 6-10). Resultados: Vinte e quatro pediatras (31 anos, 92% sexo feminino) avaliaram 24 neonatos. A mediana do escore atribuído à dor do recém-nascido durante a punção do calcanhar foi 7,0 (intervalo interquartil: 5-8). Comparado ao período PRÉ, no período PÓS, o maior número de pediatras fixou o olhar na face inferior (63 vs. 92%; p=0,036) e o número de fixações visuais foi maior na face inferior (2,0 vs. 5,0; p=0,018). Não houve diferença no número e no tempo das fixações visuais de acordo com a intensidade da dor. Conclusões: À beira do leito, os pediatras mudam seu foco de atenção visual na face do recém-nascido após um procedimento doloroso, focando o olhar principalmente na parte inferior da face.

Pediatricians' focus of sight at pain assessment during a neonatal heel puncture.

OBJECTIVE: To evaluate the focus of pediatricians' gaze during the heel prick of neonates. METHODS: Prospective study in which pediatricians wearing eye tracker glasses evaluated neonatal pain before/after a heel prtick. Pediatricians scored the pain they perceived in the neonate in a verbal analogue numerical scale (0=no pain; 10=maximum pain). The outcomes measured were number and time of visual fixations in upper face, lower face, and hands, in two 10-second periods, before (pre) and after the puncture (post). These outcomes were compared between the periods, and according to pediatricians' pain perception: absent/mild (score: 0-5) and moderate/intense (score: 6-10). RESULTS: 24 pediatricians (31 years old, 92% female) evaluated 24 neonates. The median score attributed to neonatal pain during the heel prick was 7.0 (Interquartile range: 5-8). Compared to pre-, in the post-periods, more pediatricians fixed their gaze on the lower face (63 vs. 92%; p=0.036) and the number of visual fixations was greater on the lower face (2.0 vs. 5.0; p=0.018). There was no difference in the number and time of visual fixations according to the intensity of pain. CONCLUSIONS: At bedside, pediatricians change their focus of attention on the neonatal face after a painful procedure, focusing mainly on the lower part of the face.

Underreporting of unfavorable outcomes of congenital syphilis on the Notifiable Health Conditions Information System in the state of São Paulo, Brazil, 2007-2018.

OBJECTIVE: to describe the frequency of underreporting of unfavorable outcomes of congenital syphilis in the state of São Paulo, Brazil, 2007-2018. METHODS: this was a descriptive study of cases of abortion, fetal and non-fetal deaths due to congenital syphilis reported on the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN), and those of congenital syphilis registered in any line in the Death Certificate, on the Mortality Information System (Sistema de Informações sobre Mortalidade - SIM), by means of probabilistic and deterministic linkage. RESULTS: of the 27,713 cases of congenital syphilis reported, 1,320 progressed to death (871 fetal deaths, 449 infant deaths) and were matched to the SIM; 355 deaths (259 fetal deaths, 96 infant deaths) were not included on SINAN; there was an increase in unfavorable outcomes,11.4% for infant deaths due to congenital syphilis, 3.0% for fetal deaths and 1.9% for abortions. CONCLUSION: the use of different relationship techniques proved to be adequate to identify the frequency of underreporting of unfavorable outcomes of congenital syphilis in the state of São Paulo.

The burden of inappropriate birth weight on neonatal survival in term newborns: a population-based study in a middle-income setting.

Introduction: Premature birth, perinatal asphyxia, and infections are the main causes of neonatal death. Growth deviations at birth also affect neonatal survival according to week of gestation at birth, particularly in developing countries. The purpose of this study was to verify the association between inappropriate birth weight and neonatal death in term live births. Methods: This is an observational follow-up study with all term live births from 2004 to 2013 in Sao Paulo State, Brazil. Data were retrieved with the deterministic linkage of death and birth certificates. The definition of very small for gestational age (VSGA) and very large for gestational age (VLGA) used the 10th percentile of 37 weeks and the 90th percentile of 41 weeks + 6 days, respectively, based on the Intergrowth-21st. We measured the outcome in terms of time to death and the status of each subject (death or censorship) in the neonatal period (0-27 days). Survival functions were calculated using the Kaplan-Meier method stratified according to the adequacy of birth weight into three groups (normal, very small, or very large). We used multivariate Cox regression to adjust for proportional hazard ratios (HRs). Results: The neonatal death rate during the study period was 12.03/10,000 live births. We found 1.8% newborns with VSGA and 2.7% with VLGA. The adjusted analysis showed a significant increase in mortality risk for VSGA infants (HR = 4.25; 95% CI: 3.89-4.65), independent of sex, 1-min Apgar score, and five maternal factors. Discussion: The risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction. The development of strategies to control the factors that determine fetal growth restriction through planned and structured prenatal care can substantially reduce the risk of neonatal death in full-term live births, especially in developing countries such as Brazil.

What Facial Features Does the Pediatrician Look to Decide That a Newborn Is Feeling Pain?

OBJECTIVE: The study aimed to analyze the gaze fixation of pediatricians during the decision process regarding the presence/absence of pain in pictures of newborn infants. STUDY DESIGN: Experimental study, involving 38 pediatricians (92% females, 34.6 ± 9.0 years, 22 neonatologists) who evaluated 20 pictures (two pictures of each newborn: one at rest and one during a painful procedure), presented in random order for each participant. The Tobii-TX300 equipment tracked eye movements in four areas of interest of each picture (AOI): mouth, eyes, forehead, and nasolabial furrow. Pediatricians evaluated the intensity of pain with a verbal analogue score from 0 to 10 (0 = no pain; 10 = maximum pain). The number of pictures in which pediatricians fixed their gaze, the number of gaze fixations, and the total and average time of gaze fixations were compared among the AOI by analysis of variance (ANOVA). The visual-tracking parameters of the pictures' evaluations were also compared by ANOVA according to the pediatricians' perception of pain presence: moderate/severe (score = 6-10), mild (score = 3-5), and absent (score = 0-2). The association between the total time of gaze fixations in the AOI and pain perception was assessed by logistic regression. RESULTS: In the 20 newborn pictures, the mean number of gaze fixations was greater in the mouth, eyes, and forehead than in the nasolabial furrow. Also, the average total time of gaze fixations was greater in the mouth and forehead than in the nasolabial furrow. Controlling for the time of gaze fixation in the AOI, each additional second in the time of gaze fixation in the mouth (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.08-1.46) and forehead (OR: 1.16; 95% CI: 1.02-1.33) was associated with an increase in the chance of moderate/severe pain presence in the neonatal facial picture. CONCLUSION: When challenged to say whether pain is present in pictures of newborn infants' faces, pediatricians fix their gaze preferably in the mouth. The longer duration of gaze fixation in the mouth and forehead is associated with an increase perception that moderate/severe pain is present. KEY POINTS: · Neonatal pain assessment is intrinsically subjective.. · Visual tracking identifies the focus of attention of individuals.. · Adults' gaze in neonates' mouth and forehead is associated with pain perception..

Subnotificação de desfechos desfavoráveis da sífilis congênita no Sistema de Informação de Agravos de Notificação no estado de São Paulo, 2007-2018 / Subnotificación de resultados desfavorables de sífilis congénita en el Sistema de Información de Enfermedades de Declaración Obligatoria en el estado de São Paulo, Brasil, 2007-2018 / Underreporting of unfavorable outcomes of congenital syphilis on the Notifiable Health Conditions Information System in the state of São Paulo, Brazil, 2007-2018

Objective: to describe the frequency of underreporting of unfavorable outcomes of congenital syphilis in the state of São Paulo, Brazil, 2007-2018. Methods: this was a descriptive study of cases of abortion, fetal and non-fetal deaths due to congenital syphilis reported on the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN), and those of congenital syphilis registered in any line in the Death Certificate, on the Mortality Information System (Sistema de Informações sobre Mortalidade - SIM), by means of probabilistic and deterministic linkage. Results: of the 27,713 cases of congenital syphilis reported, 1,320 progressed to death (871 fetal deaths, 449 infant deaths) and were matched to the SIM; 355 deaths (259 fetal deaths, 96 infant deaths) were not included on SINAN; there was an increase in unfavorable outcomes,11.4% for infant deaths due to congenital syphilis, 3.0% for fetal deaths and 1.9% for abortions. Conclusion: the use of different relationship techniques proved to be adequate to identify the frequency of underreporting of unfavorable outcomes of congenital syphilis in the state of São Paulo.

Objetivo: describir la frecuencia de la subnotificación de resultados desfavorables por sífilis congénita en el estado de São Paulo, de 2007 a 2018. Métodos: estudio descriptivo de los casos de aborto espontáneo, muertes fetales y no fetales por sífilis congénita notificados en la Información Sistema de Enfermedades de Declaración Obligatoria (Sinan), y las registradas con sífilis congénita en el Sistema de Información de Mortalidad (SIM) mediante relaciones probabilísticas y determinísticas. Resultados: de los 27.713 casos de sífilis congénita, fallecieron 1.320 (871 fetales, 449 infantiles) y se emparejaron con SIM; 355 muertes (259 fetales, 96 infantiles) no se incluyeron en Sinan. Hubo un aumento en los resultados desfavorables: 11,4% muertes infantiles por sífilis congénita; 3,0% muertes fetales y 1,9% abortos. Conclusión: el uso de diferentes técnicas de vinculación demostró ser adecuado para identificar la frecuencia de subregistro de resultados desfavorables de sífilis congénita en el estado de São Paulo.

Objetivo: descrever a frequência de subnotificação de desfechos desfavoráveis da sífilis congênita no estado de São Paulo, Brasil, 2007-2018. Métodos: estudo descritivo dos casos de aborto, óbitos fetais e não fetais por sífilis congênita notificados no Sistema de Informação de Agravos de Notificação (Sinan), e daqueles registrados com sífilis congênita, em qualquer linha da Declaração de Óbito, no Sistema de Informações sobre Mortalidade (SIM), mediante relacionamentos probabilístico e determinístico. Resultados: dos 27.713 casos de sífilis congênita notificados, 1.320 evoluíram para óbito (871 fetais, 449 infantis) e foram pareados com o SIM; 355 óbitos (259 fetais, 96 infantis) não constavam no Sinan; ocorreu incremento de desfechos desfavoráveis, de 11,4% para óbitos infantis por sífilis congênita, 3,0% para óbitos fetais e 1,9% para abortos. Conclusão: o emprego de diferentes técnicas de relacionamento mostrou-se adequado para identificar a frequência da subnotificação dos desfechos desfavoráveis da sífilis congênita no estado de São Paulo.

Looking at neonatal facial features of pain: do health and non-health professionals differ?

Abstract Objective: To analyze the regions that trigger the attention of adults' gaze when assessing pain in newborn infants' pictures and to verify if there are differences between health and non-health professionals. Method: Experimental study with 84 health professionals and 59 non-health professionals, who evaluated two images of 10 neonates, one at rest and the other during a painful procedure. Each image was shown for 7 seconds on a computer screen, while eye movements were tracked by the Tobii TX300 EyeTracker. After evaluating each image, participants gave a score from 0 (absent pain) to 10 (maximum pain), according to their perception of neonatal pain. For each image, the number and total time of gaze fixations in the forehead, eyes, nasolabial furrow, and mouth were studied. Comparisons between both groups of adults were made by an intraclass correlation coefficient, Student's t-test, and Bland Altman graphic. Results: Health professionals (93% female; 34 ± 9 years old), compared to non-health professionals (64% female; 35 ± 11 years old), gave lower scores for images at rest (0.81 ± 0.50 vs. 1.59 ± 0.76; p = 0.010), with no difference for those obtained during the painful procedure (6.98 ± 1.08 vs. 6.73 ± 0.82). There was a strong or almost perfect correlation for the number of fixations in the mouth, eyes, forehead, and for the total fixation time in the eyes and forehead. Conclusions: Adults, irrespective of their profession, showed a homogeneous gaze pattern when evaluating pictures of neonates at rest or during a painful procedures.

Clusters of preterm live births and respiratory distress syndrome-associated neonatal deaths: spatial distribution and cooccurrence patterns.

BACKGROUND: Prematurity and respiratory distress syndrome (RDS) are strongly associated. RDS continues to be an important contributor to neonatal mortality in low- and middle-income countries. This study aimed to identify clusters of preterm live births and RDS-associated neonatal deaths, and their cooccurrence pattern in São Paulo State, Brazil, between 2004 and 2015.  METHODS: Population-based study of all live births with gestational age ≥ 22 weeks, birthweight ≥ 400 g, without congenital anomalies from mothers living in São Paulo State, Brazil, during 2004-2015. RDS-associated neonatal mortality was defined as deaths < 28 days with ICD-10 codes P22.0 or P28.0. RDS-associated neonatal mortality and preterm live births rates per municipality were submitted to first- and second-order spatial analysis before and after smoothing using local Bayes estimates. Spearman test was applied to identify the correlation pattern between both rates. RESULTS: Six hundred forty-five thousand two hundred seventy-six preterm live births and 11,078 RDS-associated neonatal deaths in São Paulo State, Brazil, during the study period were analyzed. After smoothing, a non-random spatial distribution of preterm live births rate (I = 0.78; p = 0.001) and RDS-associated neonatal mortality rate (I = 0.73; p = 0.001) was identified. LISA maps confirmed clusters for both, with a negative correlation (r = -0.24; p = 0.0000). Clusters of high RDS-associated neonatal mortality rates overlapping with clusters of low preterm live births rates were detected. CONCLUSIONS: Asymmetric cluster distribution of preterm live births and RDS-associated neonatal deaths may be helpful to indicate areas for perinatal healthcare improvement.

Looking at neonatal facial features of pain: do health and non-health professionals differ?

OBJECTIVE: To analyze the regions that trigger the attention of adults' gaze when assessing pain in newborn infants' pictures and to verify if there are differences between health and non-health professionals. METHOD: Experimental study with 84 health professionals and 59 non-health professionals, who evaluated two images of 10 neonates, one at rest and the other during a painful procedure. Each image was shown for 7 seconds on a computer screen, while eye movements were tracked by the Tobii TX300 EyeTracker. After evaluating each image, participants gave a score from 0 (absent pain) to 10 (maximum pain), according to their perception of neonatal pain. For each image, the number and total time of gaze fixations in the forehead, eyes, nasolabial furrow, and mouth were studied. Comparisons between both groups of adults were made by an intraclass correlation coefficient, Student's t-test, and Bland Altman graphic. RESULTS: Health professionals (93% female; 34 ± 9 years old), compared to non-health professionals (64% female; 35 ± 11 years old), gave lower scores for images at rest (0.81 ± 0.50 vs. 1.59 ± 0.76; p = 0.010), with no difference for those obtained during the painful procedure (6.98 ± 1.08 vs. 6.73 ± 0.82). There was a strong or almost perfect correlation for the number of fixations in the mouth, eyes, forehead, and for the total fixation time in the eyes and forehead. CONCLUSIONS: Adults, irrespective of their profession, showed a homogeneous gaze pattern when evaluating pictures of neonates at rest or during a painful procedures.

Identification of pain in neonates: the adults' visual perception of neonatal facial features.

OBJECTIVE: To verify the visual attention of adults when assessing neonatal pain. STUDY DESIGN: 143 adults (59% health professionals) evaluated 20 pictures (2 pictures of 10 neonates' faces: at rest; during a painful procedure). Tobii-TX300 tracked the participants' eyes movement. For each picture, adults scored pain intensity (0 = no pain; 10 = maximum). Latent classes analysis was applied by cognitive diagnosis models-GDINA with two attributes (knowledge of pain presence/absence). Variables associated with belonging to the class of adults that correctly identified pictures of newborns with/without pain were identified by logistic regression. RESULTS: To identify neonatal pain, adults look at the mouth, eyes, and forehead in facial pictures. The latent class analysis identified four classes of adults: those that identify painful/painless neonates (YY-Class; n = 80); only painful neonates (n = 28); only painless neonates (n = 34) and none (n = 1). Being a health professional (OR: 2.29; 95% CI: 1.16-4.51), and each look at the nasolabial furrow (2.07; 1.19-3.62) increased the chance of belonging to the YY-class. CONCLUSIONS: Being a health professional and the visual fixation at the nasolabial furrow helped to identify the presence/absence of neonatal pain.

Evaluation of usability of a neonatal health information system according to the user's perception / Avaliação da usabilidade de um sistema de informação em saúde neonatal segundo a percepção do usuário

ABSTRACT Objective: To measure the level of satisfaction regarding the usability of a neonatal health information system and identify if demographic factors can influence the usability of a health information system. Methods: A cross-sectional, exploratory study was carried out with a convenience sample of 50 users of the Brazilian Neonatal Research Network. The instrument chosen for the usability evaluation was the System Usability Scale between February and March 2017. The statistical analysis of the collected variables was carried out in order to describe the sample, to quantify the level of satisfaction of the users and to identify the variables associated with the level of satisfaction. Results: The female gender represented 75% of the sample. The mean age was 52.8 years; 58% had a doctoral degree, average time of graduation was 17 years, with area of practice in medicine (neonatology), with intermediate knowledge in computer science (74%) and mean system use time of 52 months. Regarding usability, 94% rated the system as "good", "excellent" or "better than imaginable". The usability of the system was not associated with age, gender, education, profession, area of practice, knowledge in computer science and time of system use. Conclusion: The level of satisfaction of the computerized health system user was considered good. No demographic factors were associated with the satisfaction of the users.

RESUMO Objetivo: Mensurar o grau de satisfação de profissionais de saúde quanto à usabilidade de um sistema de informação em saúde neonatal e identificar os fatores que podem influenciar na satisfação do usuário frente à usabilidade. Métodos: Estudo transversal e exploratório realizado com 50 profissionais de saúde integrantes dos centros da Rede Brasileira de Pesquisas Neonatais. Para avaliação da usabilidade foi utilizado o instrumento System Usability Scale entre fevereiro e março de 2017. Realizou-se a análise estatística descritiva e inferencial das variáveis coletadas, com a finalidade de descrever a amostra, quantificar o grau de satisfação dos usuários e identificar as variáveis associadas ao grau de satisfação do usuário em relação à usabilidade. Resultados: Da população avaliada, 75% era do sexo feminino, com idade média 52,8 anos, 58% com pós-graduação (doutorado); tempo médio da última formação de 17 anos; área de atuação em medicina (neonatologia), grau intermediário de conhecimento em informática e tempo de utilização média do sistema de 52 meses. Quanto à usabilidade, 94% avaliaram o sistema como "bom", "excelente" ou "melhor impossível". A usabilidade do sistema não foi associada a idade, sexo, escolaridade, profissão, área de atuação, nível de conhecimento em informática e tempo de uso do sistema. Conclusões: O grau de satisfação do usuário do sistema informatizado de saúde foi considerado bom. Não foram identificados fatores demográficos que influenciassem sua avaliação.

EVALUATION OF USABILITY OF A NEONATAL HEALTH INFORMATION SYSTEM ACCORDING TO THE USER'S PERCEPTION.

OBJECTIVE: To measure the level of satisfaction regarding the usability of a neonatal health information system and identify if demographic factors can influence the usability of a health information system. METHODS: A cross-sectional, exploratory study was carried out with a convenience sample of 50 users of the Brazilian Neonatal Research Network. The instrument chosen for the usability evaluation was the System Usability Scale between February and March 2017. The statistical analysis of the collected variables was carried out in order to describe the sample, to quantify the level of satisfaction of the users and to identify the variables associated with the level of satisfaction. RESULTS: The female gender represented 75% of the sample. The mean age was 52.8 years; 58% had a doctoral degree, average time of graduation was 17 years, with area of practice in medicine (neonatology), with intermediate knowledge in computer science (74%) and mean system use time of 52 months. Regarding usability, 94% rated the system as "good", "excellent" or "better than imaginable". The usability of the system was not associated with age, gender, education, profession, area of practice, knowledge in computer science and time of system use. CONCLUSION: The level of satisfaction of the computerized health system user was considered good. No demographic factors were associated with the satisfaction of the users.

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period? / Procedimentos dolorosos e analgesia em UTI Neonatal: o que mudou na opinião e na prática profissional em dez anos?

ABSTRACT OBJECTIVE: To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011. METHODS: This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture, tracheal intubation, mechanical ventilation, and postoperative period using a 10-cm visual analogic scale (VAS; pain >3 cm). RESULTS: For lumbar puncture, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for lumbar puncture in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for mechanical ventilation, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during mechanical ventilation. For the first three post-operative days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries. CONCLUSIONS: Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

RESUMO OBJETIVO: Confrontar o uso de analgesia versus a percepção de neonatologistas quanto ao emprego de analgésicos para procedimentos dolorosos em 2001, 2006 e 2011. MÉTODOS: Coorte prospectiva de todos recém-nascidos internados em quatro unidades universitárias. Avaliou-se a frequência do emprego de analgésicos para procedimentos dolorosos por um mês dos anos de estudo. Dos 202 neonatologistas atuantes nas unidades nos três períodos, 188 assinalaram em escala analógica visual de 10 cm (dor >3 cm) a intensidade da dor sentida pelo recém-nascido na punção lombar, intubação traqueal, ventilação mecânica e no pós-operatório. RESULTADOS: Para punção lombar, 12%, 43% e 36% foram feitas com analgesia em 2001, 2006 e 2011 e 40-50% dos neonatologistas referiam indicar analgésicos na punção lombar nos três períodos. Na intubação, 30% foram feitas sob analgesia nos três períodos e 35% (2001), 55% (2006) e 73% (2011) dos médicos diziam indicar analgésicos. Quanto à ventilação mecânica, 45-64% dos ventilados-dia estavam sob analgesia nos três períodos e 56% (2001), 57% (2006) e 26% (2011) dos neonatologistas diziam usar analgésicos. Dos pacientes-dia nos três primeiros dias de pós-operatório, 37% (2001), 78% (2006) e 89% (2011) receberam alguma dose de analgésico. Mais de 90% dos médicos referiam usar analgesia para essa situação. CONCLUSÕES: Entre 2001 e 2011, ocorreu aumento no uso de analgésicos para procedimentos dolorosos nas unidades neonatais e uma percepção mais acentuada por parte dos médicos de que o recém-nascido sente dor, mas o lapso entre a prática clínica e a percepção médica quanto à presença de dor persistiu.

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period?

OBJECTIVE: To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011. METHODS: This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture, tracheal intubation, mechanical ventilation, and postoperative period using a 10-cm visual analogic scale (VAS; pain >3cm). RESULTS: For lumbar puncture, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for lumbar puncture in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for mechanical ventilation, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during mechanical ventilation. For the first three post-operative days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries. CONCLUSIONS: Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

Reconhecimento da dor no recém-nascido por alunos de medicina, residentes de pediatria e neonatologia / Identification of pain in neonates by medical students, residents in pediatrics and neonatology

JUSTIFICATIVA E OBJETIVOS: O aprendizado a respeito do fenômeno doloroso durante a formação médica molda a prática clínica futura. O objetivo deste estudo foi avaliar a percepção e o conhecimento dos alunos de graduação em Medicina, residentes de Pediatria e de Neonatologia a respeito da dor no recém-nascido (RN). MÉTODO: Estudo transversal com 180 alunos do 1º ao 6º anos de Medicina, 42 residentes de Pediatria e 20 de Neonatologia, no período de 2009 e 2010. Foram aplicadas 12 questões teóricas sobre dor no RN. Os entrevistados examinaram 3 fotos: prematuro em ventilação mecânica, a termo recebendo injeção e pré-termo submetido à aspiração traqueal, e assinalaram em escala analógica visual a intensidade da dor. Cada aluno examinou 2 painéis de 8 fotos da face de dois RN a termo, sendo 1 foto por painel com mímica facial de dor presente; e o aluno apontava a foto do RN com dor. Na análise estatística empregaram-se os testes Qui-quadrado e ANOVA. RESULTADOS: Nas questões teóricas, o número médio de acertos se elevou de 9 nos alunos do 1º e 2º anos do curso de Medicina, para 11 nos residentes em Neonatologia. Nos painéis 1 e 2, menos de 75% dos entrevistados reconheceram a face de dor, sem diferenças entre alunos e residentes. Não houve diferenças entre alunos e residentes quanto aos escores assinalados para as duas fotos do prematuro. Para o RN a termo recebendo injeção, os residentes em Pediatria (p = 0,008) e Neonatologia (p = 0,036) atribuíram mais dor do que os alunos do 3º e 4º anos do curso médico. CONCLUSÃO: Os alunos do curso de medicina e residentes não diferiram quanto ao reconhecimento da presença de dor em recém-nascidos.

BACKGROUND AND OBJECTIVES: Learning about the painful phenomenon during medical qualification shapes future clinical practice. This study aimed at evaluating the perception and understanding of pain in neonates (NN) by medical students, residents in Pediatrics and Neonatology. METHOD: Cross-sectional study with 180 students from the 1st to the 6th year of Medicine, 42 residents in Pediatrics and 20 residents in Neonatology, from 2009 to 2010. Twelve theoretical questions about NN pain were applied. Respondents examined 3 photos: premature under mechanical ventilation, term baby receiving injection and pre-term baby submitted to tracheal aspiration, and scored pain intensity in the visual analog scale. Each student examined 2 panels with 8 photos of the face of 2 term NN, being one photo per panel with facial mimic of pain; and the student would point the photo of the NN with pain. Chi-square and ANOVA were used for statistical analysis. RESULTS: Mean number of right answers for theoretical questions has increased from 9 among students of the 1st and 2nd year of the medical course, to 11 for residents in Neonatology. Less than 75% of respondents have identified the painful face in panels 1 and 2, with no difference between students and residents. There has been no difference between students and residents in scores for the two premature photos. For the term NN receiving injection, residents in Pediatrics (p = 0.008) and Neonatology (p = 0.036) have scored more pain than students of the 3rd and 4th year of the Medical course. CONCLUSION: Medical course students and residents were no different in identifying pain in neonates.

Multidimensional pain assessment of preterm newborns at the 1st, 3rd and 7th days of life.

CONTEXT AND OBJECTIVE: It is challenge to assess and treat pain in premature infants. The objective of this study was to compare the multidimensional pain assessment of preterm neonates subjected to an acute pain stimulus at 24 hours, 72 hours and seven days of life. DESIGN AND SETTING: Prospective cohort study, at Universidade Federal de São Paulo. METHODS: Eleven neonates with gestational age less than 37 weeks that needed venepuncture for blood collection were studied. The exclusion criteria were Apgar score < 7 at five minutes, presence of any central nervous system abnormality, and discharge or death before seven days of life. Venepuncture was performed in the dorsum of the hand, and the heart rate, oxygen saturation and pain scales [Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP)] were assessed at 24 hours, 72 hours and 7 days of life. NFCS and NIPS were evaluated prior to procedure (Tpre), during venepuncture (T0), and two (T2) and five (T5) minutes after needle withdrawal. Heart rate, O2 saturation and PIPP were measured at Tpre and T0. Mean values were compared by repeated-measurement analysis of variance. RESULTS: The pain parameters did not differ at 24 hours, 72 hours and 7 days of life: heart rate (p = 0.22), oxygen saturation (p = 0.69), NFCS (p = 0.40), NIPS (p = 0.32) and PIPP (p = 0.56). CONCLUSION: Homogeneous pain scores were observed following venepuncture in premature infants during their first week of life.

Multidimensional pain assessment of preterm newborns at the 1st, 3rd and 7th days of life

CONTEXT AND OBJECTIVE: It is challenge to assess and treat pain in premature infants. The objective of this study was to compare the multidimensional pain assessment of preterm neonates subjected to an acute pain stimulus at 24 hours, 72 hours and seven days of life. DESIGN AND SETTING: Prospective cohort study, at Universidade Federal de São Paulo. METHODS: Eleven neonates with gestational age less than 37 weeks that needed venepuncture for blood collection were studied. The exclusion criteria were Apgar score < 7 at five minutes, presence of any central nervous system abnormality, and discharge or death before seven days of life. Venepuncture was performed in the dorsum of the hand, and the heart rate, oxygen saturation and pain scales [Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP)] were assessed at 24 hours, 72 hours and 7 days of life. NFCS and NIPS were evaluated prior to procedure (Tpre), during venepuncture (T0), and two (T2) and five (T5) minutes after needle withdrawal. Heart rate, O2 saturation and PIPP were measured at Tpre and T0. Mean values were compared by repeated-measurement analysis of variance. RESULTS: The pain parameters did not differ at 24 hours, 72 hours and 7 days of life: heart rate (p = 0.22), oxygen saturation (p = 0.69), NFCS (p = 0.40), NIPS (p = 0.32) and PIPP (p = 0.56). CONCLUSION: Homogeneous pain scores were observed following venepuncture in premature infants during their first week of life.

CONTEXTO E OBJETIVO: É um desafio avaliar e tratar a dor do bebê prematuro. O objetivo deste estudo foi comparar, diante de um mesmo estímulo doloroso agudo, as respostas multidimensionais à dor obtidas ao longo da primeira semana de vida de prematuros. TIPO DE ESTUDO E LOCAL: Coorte prospectiva, na Universidade Federal de São Paulo. MÉTODOS: Estudo de 11 neonatos com idade gestacional inferior a 37 semanas e necessidade de punção venosa para coleta de sangue, sendo excluídos aqueles com Apgar < 7 aos cinco minutos, alterações do sistema nervoso central e os que faleceram ou tiveram alta até sete dias de vida. A punção venosa foi feita no dorso da mão e avaliou-se a freqüência cardíaca, a saturação de oxigênio e as seguintes escalas de dor: NFCS (Neonatal Facial Coding System), NIPS (Neonatal Infant Pain Scale) e PIPP (Premature Infant Pain Profile) com 24, 72 horas e no sétimo dia de vida. A NFCS e a NIPS foram pontuadas antes da punção venosa (Tpré), durante (T0), dois (T2) e cinco (T5) minutos após. A freqüência cardíaca, a saturação de oxigênio e a PIPP foram analisadas em Tpré e T0. Compararam-se os valores médios das variáveis nos três momentos por análise de variância com medidas repetidas. RESULTADOS: Não houve diferenças no primeiro, terceiro e sétimo dias para freqüência cardíaca (p = 0,22), saturação de oxigênio (p = 0,69), NFCS (p = 0,40), NIPS (p = 0,32) e PIPP (p = 0,56). CONCLUSÃO: Houve homogeneidade da avaliação da dor causada por punção venosa em prematuros, ao longo da primeira semana de vida.