Comparative heel stick study showed that newborn infants who had undergone repeated painful procedures showed increased short-term pain responses.

AIM: We evaluated the short-term effect of repeated pain exposure on the pain responses of newborn infants using different pain assessment methods, as this area had been under-researched. METHODS: We compared 20 term, large for gestational age infants and 40 term, appropriate for gestational age controls. All had undergone a heel stick for a newborn screening test just before discharge, but the larger babies had also undergone at least other five painful stimuli prior to that. A pulse oximeter and a skin conductance algesimeter (SCA) were connected to the babies during the heel prick, and video recordings were made. Crying time, the Neonatal Infant Pain Scale (NIPS), heart rate, peripheral oxygen saturation (SpO2 ) and SCA measurements were compared within and between the groups. RESULTS: After the heel prick, the crying time (p = 0.021) and NIPS (p = 0.013) scores were significantly higher in the study group and the SpO2 levels were significantly lower (p = 0.009), but the heart rate (p = 0.981) was not significantly different between the groups. SCA measurements did not differ significantly between the groups. CONCLUSION: Babies who received more painful stimuli during the first few days of life showed greater pain responses during a subsequent heel prick.

Noise levels in neonatal intensive care unit and use of sound absorbing panel in the isolette.

OBJECTIVE: The purposes of this study were to measure the noise level of a busy neonatal intensive care unit (NICU) and to determine the effect of sound absorbing panel (SAP) on the level of noise inside the isolette. METHODS: The sound pressure levels (SPL) of background noise, baby crying, alarms and closing of isolette's door/portholes were measured by a 2235-Brüel&Kjaer Sound Level Meter. Readings were repeated after applying SAP (3D pyramidal shaped open cell polyurethane foam) to the three lateral walls and ceiling of the isolette. RESULTS: The median SPL of background noise inside the NICU was 56dBA and it decreased to 47dBA inside the isolette. The median SPL of monitor alarms and baby crying inside the isolette were not different than SPL measured under radiant warmer (p>0.05). With SAP, the median SPL of temperature alarm inside the isolette decreased significantly from 82 to 72dBA, monitor alarm from 64 to 56dBA, porthole closing from 81 to 74dBA, and isolette door closing from 80 to 68dBA (p<0.01). There was a significant reduction in the noise produced by baby crying when SAP was used in the isolette (79dBA vs 69dBA, respectively) (p<0.0001). There was also significant attenuation effect of panel on the environmental noise. CONCLUSIONS: The noise level in our NICU is significantly above the universally recommended levels. Being inside the isolette protects infants from noise sources produced outside the isolette. However, very high noises are produced inside the isolette as well. Sound absorbing panel can be a simple solution and it attenuated the noise levels inside the isolette.

FISH detection of chimerism in pediatric hematopoietic stem cell transplantation.

Allogeneic hematopoietic stem cell transplantation (HSCT) is a well-established curative therapy for various malignant and non-malignant diseases. Successful outcome after allogeneic HSCT has been associated with donor chimerism (DC). However, the detection of residual host cells or mixed hemopoietic chimerism (MC) has indicated that donor chimerism is not obligatory following HSCT. More recently, fluorescence in situ hybridization (FISH) analysis has been applied to engraftment studies for the identification of polymorphic or sex chromosomes. In this study, chimerism status was evaluated in 48 sex-mismatched HSCT pediatric patients (17 women/31 men, mean age: 9.02 +/- 3.95 years, range: 2-19) by FISH and the effect of DC or MC on outcome and long-term disease-free survival was documented. The stem cell source was bone marrow in all cases. All of the donors were human leucocyte antigen-identical siblings. FISH was performed on 156 specimens between days +13 and +1878. Donor chimerism was found in 47.9% (23/48) and MC was found in 52.1% (25/48) of the patients. Fifteen of 48 (31.25%) patients died, of whom 12 (80%) were MC and three patients (20%) were DC. The difference in chimerism status (MC or DC) was statistically significant between those patients who died and those still alive (chi(2) = 6.813; P = 0.009).

Cost-effectiveness of cefepime + netilmicin or ceftazidime + amikacin or meropenem monotherapy in febrile neutropenic children with malignancy in Turkey.

Infection remains the major cause of morbidity and mortality in immunocompromised children with malignancy. In addition, the economic impact of antibiotic treatment should always be evaluated, especially in developing countries. In our center between January 1998 and January 1999, 73 children with hematological malignancies [acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML)]; 9 children with solid tumors (rhabdomyosarcoma, neuroblastoma) had 87 febrile neutropenic episodes (related to chemotherapy). These children were randomized prospectively into three treatment groups. The first group (n: 28) received cefepime plus netilmicin, while the second group (n: 29) was treated with ceftazidime plus amikacin and the third (n: 30) with meropenem as monotherapy. The aim of the study was to compare the success rates and cost of fourth generation cephalosporin plus aminoglycoside and monotherapy of meropenem with ceftazidime plus amikacin, which is the standard therapy for febrile neutropenia. Microbiologically documented infections were 29.9%, clinically documented infections were 9.2% and 60.9% of the febrile neutropenic episodes were considered to be FUO. Gram-positive microorganisms were the most commonly isolated agents from blood cultures [MRSA (Methicillin Resistant Staphylococcus aureus) in 6 patients and MSSA (Methicillin Sensitive Staphylococcus aureus) in 4 patients]. The success rates were 78.5%, 79.3% and 73.3 % for the 1st, 2nd and 3rd groups respectively. In 4 patients (4.5%) fever responded only to amphotericin-B therapy. There was no statistically significant difference between the three treatment regimens with respect to efficacy, safety and tolerance (chi2 test, p>0.05), but while the third and fourth generation cephalosporins + aminoglycosides were comparable for cost, the monotherapy regimen was the most expensive. The main determining factors for the choice of treatment of febrile neutropenic children, especially in a developing country, are cost, presence of indwelling catheter and the bacterial flora of the unit, as well as efficacy.

Comparison of sucrose, expressed breast milk, and breast-feeding on the neonatal response to heel prick.

Newborns endure many heel pricks and other uncomfortable procedures during their first hospital stay. The aim of this study was to investigate the effectiveness of breast-feeding in reducing pain in newborns undergoing heel prick tests. One hundred thirty healthy term infants requiring a heel prick blood sampling for the Guthrie test were studied. Infants were randomly allocated to 1 of the following treatment groups: group 1, 25% sucrose (n = 35); group 2, breast milk (n = 33); group 3, sterile water (n = 34); and group 4, breast-feeding (n = 28). The median values of crying and recovery time and percent change in heart rate at 1, 2, and 3 minutes were recorded. A behavioral pain scale was applied according to the infant body coding system. The median crying time was 36, 62, 52, and 51 seconds in groups 1, 2, 3, and 4, respectively (P =.002). Similarly, there was a significant overall difference among groups for the duration of recovery time (P =.006) and the percent change in heart rate at 1 (P =.03), 2 (P =.01), and 3 (P =.009) minutes favoring the sucrose group. But when we compared the groups, the significance remained for the sucrose versus breast milk (P =.007) and water (P =.001) groups for the recovery time and sucrose versus all other groups for the percent change in heart rate at 3 minutes. The infant body coding system showed that babies in the sucrose group had significantly lower scores followed by the breast-fed and breast milk groups (P =.0001). Our study revealed that 25% sucrose is superior to breast-feeding in pain relief, which is reflected mainly in crying time and behavioral variables. The behavioral effects of breast-feeding did not provide any additional benefit.

Comparison of oral glucose and sucrose solutions on pain response in neonates.

In this study, we aimed to compare the analgesic effect of 30% sucrose and 10% and 30% glucose in a group of healthy term newborns. A total of 113 infants whose heels were pricked for the guthrie test were included in the study. The babies were randomized into 4 groups, receiving 2 ml of 30% sucrose, 10% glucose, 30% glucose, or distilled water. Response to pain was assessed by mean crying time, recovery time, maximum heart rate, and percent change in heart rate at 1, 2, and 3 minutes. Mean crying times were 60, 102, 95, and 105 seconds in the sucrose, 10% glucose, 30% glucose, and placebo groups, respectively (P =.02). Although mean recovery time was shorter in the sucrose group (102 seconds), there was neither a significant difference between the groups (10% glucose, 121 seconds; 30% glucose, 109 seconds; control group, 132 seconds [P =.09]), Nor was there a difference in maximum heart rate and percent change in heart rate at 1, 2, and 3 minutes after heel prick (P =.14, P =.05, P =.53 For the first, second, and third minutes, respectively ). However, a statistically borderline difference existed at the end of 2 minutes favoring sucrose (P =.05). We conclude that 30% sucrose is superior to 10% and 30% glucose solutions in relieving pain, showing its primary effect in crying time. As glucose solutions are readily available in neonatal intensive care units and easier to use in routine practice, further trials are needed to evaluate the antinociceptive effect of glucose when combined with other nonpharmacologic methods.

Could Parvovirus B19 Induce a Rejection After Bone Marrow Transplantation in a Patient with Diamond-Blackfan Anemia?

A four year-old-girl with Diamond-Blackfan anemia (DBA) that was resistant to corticosteroid treatment and transfusion dependent underwent (bone marrow transplantation) BMT from HLA identical sibling. The patient was conditioned with busulfan and cyclophosphamide and achieved complete marrow engraftment and mixed chimerism in DNA analysis. For the following 13 months she was not transfusion dependent and had a 100% Karnofsky score. But on the 14th month she had anemia ollowing fever, rash and enteritis. Parvovirus B19 IgM seropositivity confirmed Parvovirus infection. Although intravenous immunoglobulin was administered, bone marrow morphology and DNA analysis revealed rejection. Although mixed chimerism detected shortly after the BMT procedure might raise the possibility of an ongoing slow graft rejection during the relatively stable remission period, we think that parvovirus B19 had also contributed rejection.

Comparison of sucrose and human milk on pain response in newborns.

UNLABELLED: The aim of this study was to compare the analgesic effect of 2 ml 25% sucrose and human milk in a group of healthy term newborns. Healthy infants (n = 102) were randomly allocated to receive one of three solutions (sucrose, human milk, sterile water) 2 min prior to taking a heel prick blood sample. The median values of crying time, recovery time and percentage change in heart rate at 1, 2 and 3 min were recorded in response to the heel prick. Median crying times were 36, 52, and 62 s in the sucrose, placebo and human milk groups, respectively (P = 0.0009). In the sucrose group, there was a significant reduction in crying time compared to human milk and placebo groups. Similarly, the median recovery time in the sucrose group (72 s) was shorter than that in the human milk (112 s) and placebo groups (124 s) (P = 0.004). The percentage change in heart rate at 1, 2 and 3 min was also significantly lower in the sucrose group (P = 0.008, P = 0.01, P = 0.002 at 1, 2, and 3 min respectively). CONCLUSION: The orosensorial antinociceptive effect of human milk is not as effective as an analgesic as a 25% sucrose solution.

Transcutaneous measurement of hyperbilirubinaemia: comparison of the Minolta jaundice meter and the Ingram icterometer.

The effectiveness of two different non-invasive transcutaneous bilirubin measurement devices was compared with serum bilirubin levels in 96 healthy newborns. Transcutaneous measurements were obtained with the Minolta Air Shields jaundice meter and the Ingram icterometer and serum bilirubin levels were determined by a direct spectrophotometric method (Bilitron 444). A linear correlation existed between serum bilirubin values and the readings on both the Minolta jaundice meter (r = 0.83) and the Ingram icterometer (r = 0.78). The Kappa coefficient was 0.66. the sensitivity, specificity and positive and negative predictive values were 100%, 56%, 33% and 100% for the Minolta jaundice meter and 100%, 48%, 29% and 100% for the Ingram icterometer, respectively. The high sensitivity and negative predictive value of both devices render them suitable for screening neonatal hyperbilirubinaemia. However, because of its low cost, the Ingram icterometer is preferable to the more complex and expensive Minolta jaundice meter, especially in countries with a high birth rate, such as Turkey.

Evaluation of chimerism with DNA polymorphisms in bone marrow transplantation.

Evaluation of chimeric status following allogenic BMT is an important tool for monitoring the replacement of host cells with donor cells and for determining the risk of relapse. Polymorphic DNA sequences can be used as powerful markers in identification of donor/recipient genotype differences, even between close relatives. Polymerase chain reaction (PCR) amplification of three variable number of tandem repeat (VNTR) loci and five single-locus polymorphisms (SLP) was used to identify chimerism in 40 recipient-donor pairs. Mixed chimerism was present in 11 patients, and complete chimerism in 29. This PCR method is a rapid and sensitive assay to detect engraftment and evaluate relapse potential, and thus is very useful in the clinical management of BMT patients.

Neonatal intracranial hemorrhage due to rupture of arteriovenous malformation.

Two cases of neonatal intracerebral hemorrhage secondary to rupture of arteriovenous malformation are reported and the pertinent literature is reviewed. Despite the limited number of cases, review of the literature and our results demonstrate that the outcome of surgical removal of an arteriovenous malformation in the neonatal period is not as poor as was previously believed.