eLetters to:

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] [PDF]

eLetters published:

Ketorolac and renal compromise in Neonates

prabhakar devavaram   (3 November 2006)

additional data on non-opioid analgesics in neonates

karel allegaert, Gunnar Naulaers   (8 November 2006)

Comment on “Prevention and Management of Pain in the Neonate: An Update”

Roberto Bellu', Koert de Waal, Rinaldo Zanini   (22 November 2006)

Additional information

Cindy L Castaldi   (16 January 2008)

Ketorolac and renal compromise in Neonates 3 November 2006
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	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
additional data on non-opioid analgesics in neonates 8 November 2006
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.	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
Comment on “Prevention and Management of Pain in the Neonate: An Update” 22 November 2006
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.	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
Additional information 16 January 2008
Cindy L Castaldi, RN LGH Womena dnd Babies Hosptial Send letter to journal: Re: Additional information clcastal{at}lancastergeneral.org Cindy L Castaldi	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