Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants

Abstract

Procedural pain in the neonatal intensive care unit triggers a cascade of physiological, behavioral and hormonal disruptions which may contribute to altered neurodevelopment in infants born very preterm, who undergo prolonged hospitalization at a time of physiological immaturity and rapid brain development. The aim of this study was to examine relationships between cumulative procedural pain (number of skin-breaking procedures from birth to term, adjusted for early illness severity and overall intravenous morphine exposure), and later cognitive, motor abilities and behavior in very preterm infants at 8 and 18 months corrected chronological age (CCA), and further, to evaluate the extent to which parenting factors modulate these relationships over time. Participants were N = 211 infants (n = 137 born preterm ≤32 weeks gestational age [GA] and n = 74 full-term controls) followed prospectively since birth. Infants with significant neonatal brain injury (periventricular leucomalacia, grade 3 or 4 intraventricular hemorrhage) and/or major sensori-neural impairments, were excluded. Poorer cognition and motor function were associated with higher number of skin-breaking procedures, independent of early illness severity, overall intravenous morphine, and exposure to postnatal steroids. The number of skin-breaking procedures as a marker of neonatal pain was closely related to days on mechanical ventilation. In general, greater overall exposure to intravenous morphine was associated with poorer motor development at 8 months, but not at 18 months CCA, however, specific protocols for morphine administration were not evaluated. Lower parenting stress modulated effects of neonatal pain, only on cognitive outcome at 18 months.

Score for Neonatal Acute Physiology–II and Neonatal Pain Predict Corticospinal Tract Development in Premature Newborns

“…Chronic lung disease was diagnosed if the infant required oxygen after 36 weeks postmenstrual age. Similar to our previous work [22,27], we operationalized neonatal procedural pain as the total number of skin-breaking procedures (e.g., heel lance, intramuscular injection, chest tube insertion, central line insertion) from birth to hospital discharge or term-equivalent age, adjusted for cumulative morphine exposure. Cumulative morphine exposure was calculated from the average daily dose of intravenous and oral morphine (equivalence calculated), adjusted for daily weight, and multiplied by the number of days on morphine from birth to term-equivalent age.…”

“…These risk factors include antenatal exposures, such as pregnancy-induced hypertension [6], gestational diabetes [7], and intrauterine inflammation [8][9][10], as well as male sex [11][12][13]. Putative perinatal and post-natal risk factors include early illness severity as measured by the Score of Neonatal Acute Physiology-Version II (SNAP-II) [14,15], infection [9,16,17], necrotizing enterocolitis [16,17], patent ductus arteriosus [18], chronic lung disease [18][19][20][21], and neonatal procedural pain [22]. We hypothesized that these ante-, peri-and postnatal comorbidities, rather than gestational age at birth, would predict poorer microstructural development in the corticospinal tract, as evidenced by higher mean diffusivity and lower fractional anisotropy in this motor pathway [23,24].…”

A Intervenção Motora Como Fator De Prevenção De Atrasos No Desenvolvimento Motor E Cognitivo De Bebês Durante O Período De Internação Hospitalar

“…Ainda, os procedimentos dolorosos dentro do hospital afetam o desenvolvimento cognitivo e motor de bebês de 8 a 18 meses (n=211). Funções cognitiva e motora são mais baixas com maior número de procedimentos dolorosos, independentemente da gravidade da doença da criança (GRUNAU et al, 2009). Tais resultados, somados ao resultado do grupo controle do presente estudo, demonstram o ambiente hospitalar e as práticas a que o bebê precisa ser submetido em uma internação como possível causa para atrasos no desenvolvimento.…”

Stress : Clinical and Developmental Aspects of Salivary Cortisol in Infants

“…It is well known that long-term elevation of cortisol levels is associated with various health problems including diabetes, hypertension, depression, behavioral problems, and cognitive impairment (memory, learning and concentration deficiencies) [51,[104][105][106][107][108][109][110][111]. To adequately aid these fragile but otherwise normal infants with both individualized care for the child and support to the caregiver, further investigations and advances are critical.…”