Fundus Examination in Pediatric Patients Using Indirect Ophthalmoscopy

The goal of this chapter is to provide the clinician with an understanding of binocular indirect ophthalmoscopy (BIO) and helpful clinical techniques for success in examining the fundus of the pediatric patient, including scleral depression. The challenging technique to examine the premature infant at risk for retinopathy of prematurity will be explained in detail, including the standard classification of the disease with photos depicting the different location and stages of disease. BIO with the addition of scleral indentation helps the clinician diagnose and locate lesions that may otherwise go undetected, such as retinal holes, tears, or vitreoretinal adhesions. Complete examination of the fundus of a child is no less important than of any other patient who seeks eye care but often requires efficiency and precision (as well as many human arms). Time is a rate limiting aspect when examining children so preparation and experience will lead to success.

Lateral Kangaroo Care in Hemodynamic Stability of Extremely Preterm Infants: Protocol Study for a Non-Inferiority Randomized Controlled Trial CANGULAT

Introduction: This study aims to assess the efficacy of the modified kangaroo care lateral position on the thermal stability of preterm neonates versus conventional kangaroo care prone position. Material and methods: A non-inferiority randomized parallel clinical trial. Kangaroo care will be performed in a lateral position for the experimental group and in a prone position for the control group preterm. The study will take place at the neonatal intensive care unit (NICU) of a University Hospital. The participants will be extremely premature infants (under 28 weeks of gestational age) along the first five days of life, hemodynamically stable, with mother or father willing to do kangaroo care and give their written consent to participate in the study. The sample size calculated was 35 participants in each group. When the premature infant is hemodynamically stable and one of the parents stays in the NICU, the patient will be randomized into two groups: an experimental group or a control group. The primary outcome is premature infant axillary temperature. Neonatal pain level and intraventricular hemorrhage are secondary outcomes. Discussion: There is no scientific evidence on modified kangaroo care lateral position. Furthermore, there is little evidence of increased intraventricular hemorrhage association with the lateral head position necessary in conventional or prone kangaroo care in extremely premature newborns. Kangaroo care is a priority intervention in neonatal units increasing the time of use more and more, making postural changes necessary to optimize comfort and minimize risks with kangaroo care lateral position as an alternative to conventional prone position kangaroo care. Meanwhile, it is essential to ensure that the conventional kangaroo care prone position, which requires the head to lay sideways, is a safe position in terms of preventing intraventricular hemorrhage in the first five days of life of children under 28 weeks of gestational age. Trial registration at clinicaltrials.gov: NCT03990116.

Inborn Errors of Immunity in the Premature Infant: Challenges in Recognition and Diagnosis

Due to heightened awareness and advanced genetic tools, inborn errors of immunity (IEI) are increasingly recognized in children. However, diagnosing of IEI in premature infants is challenging and, subsequently, reports of IEI in premature infants remain rare. This review focuses on how common disorders of prematurity, such as sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia, can clinically overlap with presenting signs of IEI. We present four recent cases from a single neonatal intensive care unit that highlight diagnostic dilemmas facing neonatologists and clinical immunologists when considering IEI in preterm infants. Finally, we present a conceptual framework for when to consider IEI in premature infants and a guide to initial workup of premature infants suspected of having IEI.

Effects of oral stimulation with breast milk in preterm infants oral feeding: a randomized clinical trial

Objectives This study was performed to evaluate the effect of oral stimulation with breast milk for preterm infants. Methods A total of 68 subjects form neonatal intensive care unit were randomly assigned into control group (n=20), premature infant oral motor intervention (PIOMI) group (n=25) and premature infant oral motor intervention with breast milk (BM-PIOMI) group (n=23). Results BM-PIOMI group had significant shorter initiation of oral feeding (IOF) time compared to PIOMI group (2.95 days, 95% CI [0.42–5.48]) or control group (9.79 days, 95% CI [7.07–12.51]). BM-PIOMI group had significant sooner transition time from IOF to full oral feeding (FOF) compared to control group (6.68 days, 95% CI [2.2–11.16]), but not to PIOMI group (2.09 days, 95% CI [−2.07 to 6.25]). Length of hospital stay (LOS) did not show statistical different between three groups (control 38.85 ± 14.40 vs. PIOMI 38.48 ± 11.76 vs. BM-PIOMI 38.04 ± 12.2). Growth mixture model identified improvement in non-nutritive sucking (NNS) score in BM-PIOMI group compared to control and PIOMI group (0.8293, p<0.0001, and 0.8296, p<0.0001, respectively). Conclusions Oral stimulation with breast milk can better promotes the oral feeding process of premature infants than the simple oral stimulation, by shorten IOF time and improve early NNS score, but does not shorten transition time from IOF to FOF and LOS. Trial registration The trial identification number is ChiCTR1800019134 (Chinese Clinical Trial Registry http://www.who.int/ictrp/network/chictr2/en/)

THE EFFECTIVENESS OF ORAL SUCROSE ON PAIN DURING INVASIVE PROCEDURES IN PREMATURE INFANTS: SCOPING REVIEW

Introduction: Nowadays premature births continue to be common, it caused the infant necessitating treatment. Invasive procedures, such as the placement of an peripheral intravenous catheters or the drawing of blood, should be carried out while the baby is being cared for. Some intervention needed, sucrose is one approach to make invasive procedure less painful. This study aims to determine the effectiveness of oral sucrose in reducing the pain of invasive procedures in premature infants. Method: This study is a scoping review, and 11 articles were selected from Proquest, ScienceDirect, Willy Online, PubMed, and EBSCO (CINAHL) databases. Results: In eight of the articles, giving oral sucrose two minutes before the invasive procedure was effective in reducing pain, while sucrose was not effective in reducing pain in infants in the other three of the articles, during or after procedures. Conclusion: According to these studies, giving oral sucrose to premature infant before invasive procedure is significant reducing the pain during invasive procedure.

Manejo não-farmacológico da dor em neonatos internados em Unidades de Terapia Intensiva: atualidades

Introdução: Inerente à maioria dos procedimentos realizados em Unidade de Terapia Intensiva Neonatal, a dor é um fenômeno que precisa ser correta e precocemente avaliado e tratado para que não prejudique o desenvolvimento do bebê a longo prazo. A sua terapêutica não-farmacológica age no bloqueio da transmissão do estímulo nociceptivo ao tálamo e na ativação de vias inibitórias descendentes, sendo uma importante e diversa aliada no controle da dor. Metodologia: Trata-se de uma Revisão Integrativa de Literatura feita com pesquisa inicial das bases de dados Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO) e Medical Literature Analysis and Retrieval Sistem (Medline). Foi utilizado o termo de busca “Intensive Care Units, Neonatal AND Pain management”. Incluiu-se publicações de 2017 a 2021 e excluiu-se artigos revisão, metanálises e relatos de casos. Não houve duplicações. Excluiu-se, ainda, os artigos cujo título ou resumo corroboravam com o propósito desta revisão. Organizou-se os 18 artigos filtrados pelos critérios de exclusão e, a leitura de todo seu conteúdo, resgatou-se 14 artigos que compõem os resultados dessa revisão. Resultados e Discussão: Todos os artigos resgatados são randomizações e a maioria delas foi publicada no ano de 2020. Observou-se que a punção de calcanhar é um procedimento doloroso e avaliado na maioria dos ensaios clínicos, inclusive com aplicação da escala Premature Infant Pain Profile (PIPP), para os estudos com pré-termos. Ainda, constatou-se que sacarose oral a 24% foi a intervenção mais comparada a outras e que se mostrou inferior ou equiparável ao método canguru e a ingesta de leite materno para o controle da dor em neonatos internos em UTI. Conclusão: esta revisão pontuou a eficácia clínica de intervenções de diferentes naturezas evidenciadas nos estudos resgatados. O olfato, a audição, o paladar e o tato têm sido potenciais campos de intervenção para o controle analgésico ou distração da dor em neonatos submetidos a procedimentos dolorosos de rotina. Destaca-se que o método canguru, a ingesta de leite materno e o seu odor, bem como o som do batimento cardíaco materno têm mostrado resultados positivos, seguros e reproduzíveis, inclusive em comparação com o uso de sacarose oral a 24%. Ressalta-se que novos ensaios clínicos e metanálises são imprescindíveis para o fortalecimento das conclusões desse estudo.