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- FROM THE AMERICAN ACADEMY OF PEDIATRICS:
American Academy of Pediatrics, Committee on Fetus and Newborn and Section on Surgery, Section on Anesthesiology and Pain Medicine, Canadian Paediatric Society, and Fetus and Newborn Committee
- Prevention and Management of Pain in the Neonate: An Update
Pediatrics 2006; 118: 2231-2241
[Abstract]
[Full text]
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eLetters published:
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Ketorolac and renal compromise in Neonates
- prabhakar devavaram
(3 November 2006)
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additional data on non-opioid analgesics in neonates
- karel allegaert, Gunnar Naulaers
(8 November 2006)
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Comment on “Prevention and Management of Pain in the Neonate: An Update”
- Roberto Bellu', Koert de Waal, Rinaldo Zanini
(22 November 2006)
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Additional information
- Cindy L Castaldi
(16 January 2008)
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Ketorolac and renal compromise in Neonates |
3 November 2006 |
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prabhakar devavaram, Anesthesiologist Children's Hospital, Boston
Send letter to journal:
Re: Ketorolac and renal compromise in Neonates
prabhakar.devavaram{at}childrens.harvard.edu prabhakar devavaram
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I read the policy statement on prevention and management of pain in
neonate with interest. I would like to make a comment on the subsection
;reducing pain from surgery.
The role of ketorolac in treating post-operative pain was discussed
and was not recommended for use as an adjuvant. However the possibility of
renal failure with its use was not raised . Since its introduction in 1992
there have been many reports of renal failure. Renal blood flow is
dependent on prostagladin , especially during stressful period as in
neonates in the postoperative course. Studies in premature neonates have
shown that glomerular filteration rate decreases by 20% with use of
ibuprofen (1). I would argue that that ketorolac and other nonsteroidal
anti-inflammatory drugs are contraindicated in the neonatal period.
1). Anderson BJ and Palmer GM . Receant pharmacological advances in
paediatric analgesics. Biomedicine and Pharmacotherapy 60(2006) 303 - 309.
Conflict of Interest:
None declared |
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additional data on non-opioid analgesics in neonates |
8 November 2006 |
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karel allegaert, MD, PhD University Hospital Gasthuisberg, Leuven, Belgium, Gunnar Naulaers
Send letter to journal:
Re: additional data on non-opioid analgesics in neonates
karel.allegaert{at}uz.kuleuven.ac.be karel allegaert, et al.
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Dear editor,
We read with great interest the review on pain treatment and
prevention of pain in neonates.
An integrated approach of neonatal analgesia starts with the systematic
evaluation of pain and should be followed by effective interventions,
mainly based on the appropriated (i.e. safe and effective) administration
of analgesics.
In contrast to the more potent opioids, data on the pharmacokinetics and
–dynamics of non-opioid analgesics in this specific population were still
rare.
We therefore evaluated various aspects of developmental pharmacology
of non-opioid analgesics (paracetamol, ibuprofen, acetylsalicyl acid) in
neonates. We first performed a single dose propacetamol study in preterm
and term neonates. Based on these preliminary findings, a repeated dose
administration scheme was developed and tested and maturational aspects
from preterm till teenage were documented (ref 1,2)
Although non-selective COX-inhibitors might be effective in the treatment
of postoperative or inflammatory pain syndromes in neonates, potential
efficacy should be balanced against the drugs’ safety profile. Neonatal
renal clearance strongly depends on glomerular filtration rate (GFR) and
GFR itself strongly depends on the vaso-dilatative of prostaglandins on
the afferent arterioli. We therefore evaluated the impact of the
administration of ibuprofen or acetylsalicylic acid on renal clearance in
preterm infants and hereby used amikacin clearance as a surrogate marker.
We hereby documented the negative effect of ibuprofen on glomerular
filtration rate in preterm infants up to 34 weeks and we were able to show
that ibuprofen and acetylsalicylic acid had an equal impact on the
glomerular filtration rate (ref 3)
We feel that the marked renal side effects should at least be
considered before non-selective COX-inhibitors are administered to treat
pain in neonates while the pharmacodynamics of intravenous paracetamol in
neonates should be further evaluated.
Ref:
1. Allegaert K, et al. Intravenous paracetamol (propacetamol)
pharmacokinetics in term and preterm neonates. Eur J Clin Pharmacol 2004.
2.Anderson B, et al. Paediatric intravenous paracetamol (propacetamol)
pharmacokinetics: a population analysis. Pediatr Anesth 2005.
3.Allegaert K, et al. Non-selective cyclo-oxygenase inhibitors and
glomerular filtration rate in preterm neonates Pediatr Nephrol 2005
Conflict of Interest:
None declared |
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Comment on “Prevention and Management of Pain in the Neonate: An Update” |
22 November 2006 |
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Roberto Bellu', Neonatologist Ospedale, Koert de Waal, Rinaldo Zanini
Send letter to journal:
Re: Comment on “Prevention and Management of Pain in the Neonate: An Update”
r.bellu{at}ospedale.lecco.it Roberto Bellu', et al.
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We read with interest the recent paper “Prevention and management of
pain in the neonate: an update” by the American Academy of Pediatrics'
Committee on Fetus and Newborn and Section on Surgery and by the Canadian
Paediatric Society's Fetus and Newborn Committee (1). When reading the
section “Prolonged mechanical ventilation” regarding the use of continuous
pain medication and sedatives in ventilated preterm neonates, we were
surprised that the authors did not cite our recent Cochrane review
“Opioids for neonates receiving mechanical ventilation” (2). However,
they did cite another systematic review by Aranda et al.(3), published in
June 2005, which concluded that “fentanyl seemed to result in increased
ventilator settings” and that “concern about adverse respiratory effects
…. and lack of a demonstrated long-term benefit suggest that their routine
use cannot be recommended at this time”. In our Cochrane review,
published in January 2005 (Issue 1), we concluded that there is
“insufficient evidence to support a recommendation for the routine use of
opioids”. Moreover, our meta-analysis found that opioids had no
significant effects on the duration of ventilation, but significantly
prolonged the time to reach full enteral feeding.
We wish to emphasize that referencing the results of two independent
systematic reviews would have added value to the statement of the
Committee. We therefore encourage the Committees, when writing statements
and recommendations, to perform comprehensive literature searches and to
include all the available systematic reviews.
1. American Academy of Pediatrics, Committee on Fetus and Newborn and
Section on Surgery, Canadian Paediatric Society and Fetus and Newborn
Committee. Prevention and Management of Pain in the Neonate: An Update.
Pediatrics 2006; 118; 2231-2241
2. Bellů R, de Waal KA, Zanini R. Opioids for neonates receiving
mechanical ventilation.
Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004212
3. Aranda JV, Carlo W, Hummel P, Thomas R, Lehr VT, Anand KJ.
Analgesia and sedation during mechanical ventilation in neonates. Clin
Ther. 2005;27:877–899
Conflict of Interest:
None declared |
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Additional information |
16 January 2008 |
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Cindy L Castaldi, RN LGH Womena dnd Babies Hosptial
Send letter to journal:
Re: Additional information
clcastal{at}lancastergeneral.org Cindy L Castaldi
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Has the complex issue on the use of medications for elective
intubation of neonates been furthur discussed? Is there additional
information?
Conflict of Interest:
None declared |
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