Rectal Paracetamol in Newborn Infants after Assisted Vaginal Delivery May Increase Pain Response

Tinner, Eva Maria; Hoesli, Irène; Jost, Kerstin; Schöbi, Nina; Megged, Yvonne Ulrich; Burkhardt, Tilo; Krafft, Alexander; Bucher, Hans Ulrich; Surbek, Daniel; Nelle, Mathias; Bührer, Christoph

doi:10.1016/j.jpeds.2012.06.020

Cited by 22 publications

(16 citation statements)

References 38 publications

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“…In most trials, pain scores were higher in the placebo group than in the paracetamol group, but the inability to pool data prevented any further comparisons. In one study, pain scores and crying time, when compared during heel lance performed 2 days after administration of the study drugs, were significantly increased after rectal paracetamol, as compared to placebo controls (crying time mean difference 19 s longer for paracetamol group vs placebo group, 95% CI 14 to 24 s) 1. In contrast, an opioid-sparing efficacy was demonstrated for infants allocated to intravenous paracetamol, as compared to placebo, after major non-cardiac surgery (mean difference in total amount of morphine −157 μg/kg for paracetamol group vs placebo group, 95% CI −27 to −288) 2…”

Section: Resultsmentioning

confidence: 99%

“…In other age groups, paracetamol is hardly ever considered for the pre-emptive treatment of pain originating from short procedures but is used to alleviate ongoing subacute pain. Infants born by vacuum or forceps (presumably causing some lasting headache) had similar subacute pain scores after rectal paracetamol (2×20–25 mg/kg) or placebo,1 but the effect of paracetamol may have been obscured by vasopressin-mediated perinatal analgesia 4. However, intravenous paracetamol (30 mg/kg/day) reduced morphine requirements after major surgery 2.…”

Section: Commentarymentioning

confidence: 99%

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In newborns, oral or rectal paracetamol fails to reduce procedural pain, whereas intravenous paracetamol reduces morphine requirements after major surgery

Bührer

2016

Evid Based Med

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Section: Resultsmentioning

confidence: 99%

Section: Commentarymentioning

confidence: 99%

In newborns, oral or rectal paracetamol fails to reduce procedural pain, whereas intravenous paracetamol reduces morphine requirements after major surgery

Bührer

2016

Evid Based Med

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“…Tinner et al described a possible increase of pain response, based on the neonatal pain and discomfort scale, in term and near term neonates who received rectal paracetamol soon after an assisted vaginal delivery [16].…”

Section: Discussionmentioning

confidence: 99%

Pain Treatment of Newborns: Paracetamol Rectal Versus Intravenous Administration, A Randomised Open Clinical Trial

Arc¹,

Jm²,

Jcg³

et al. 2015

J Neonatal Biol

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Early recognition and treatment of pain is of great importance in the neonatal period. Moreover, exposure to pain without effective treatment of pain in this period might influence not only early but also later development [1,2]. Paracetamol is the most frequent prescribed medicine for pain treatment excluding neonates. In the neonatal intensive care unit (NICU) neonates are frequently exposed to painful procedures but most medication used for pain are opioids (morphine and fentanyl). These opioids can have severe adverse effects in premature neonates (depression of breathing, hypotension, urine retention) [3]. On the other hand a clear description of the exposure of rectal paracetamol in preterm and term neonates is lacking [4,5]. In addition, the administration, of rectal paracetamol has limitations such as administration problems, loss of paracetamol suppository with defecation and immaturity of the porta-rectal system especially in preterms leading to a variable absorption. Moreover, in some clinical conditions rectal administration of paracetamol is contraindicated such as necrotising enterocolitis (NEC) and severe thrombocytopenia (< 50×10 9 /l).Taken the adverse effects of opioids and limitations of rectal administration of paracetamol into account it is important to realize that (preterm) newborns has to be treated with medication characterized by good analgesic but less adverse effects or limitations in administration such as intravenous paracetamol. Currently rectal paracetamol is being used in preterm and terme neonates. We know that the effectiveness of rectal paracetamol can be variable in neonates [6,7]. Intravenous paracetamol being used in (preterm) neonates is not common. Improved understanding of the pharmacokinetics (PK) and pharmacodynamics (PD) of paracetamol will contribute to a safer, more effective and predictive analgesic dosing regimen for premature and term neonates. We think it is essential to estimate the effectiveness of intravenous paracetamol compared to rectal paracetamol, based on the hypothesis that intravenous paracetamol is well tolerated, less variable and therefore more reliable in preterm neonates compared to rectal paracetamol.In the present study we used the paracetamol dosing regimen for optimal dosing exposure according to the Dutch guidelines and the described literature [8-10] The rectal and intravenous (iv) dosing is based on the post menstrual age (PMA) and weight in (preterm) neonates during a period of pain. AbstractBackground and aim: Early recognition and treatment of pain is of great importance in the neonatal period.

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“…Data on the impact of paracetamol to take care of minor to moderate pain syndromes in (pre)term neonates were quantified and reported following a "minor" surgery (one study, circumcision of 44 neonates) or following a birth-associated tissue damage [assisted vaginal delivery, bruising, three studies, 264 (pre)term neonates] in a randomized, placebo-controlled setting. In addition, there is also a retrospective analysis on the impact of intravenous paracetamol (prophylactic, for patent ductus arteriosus closure) on glucose 33% consumption and additional analgesics prescribed compared to a historical cohort (449 neonates) in a single (Innsbruck, Austria) NICU ( Table 2) (53)(54)(55)(56)(57).…”

Section: Paracetamol and Minor To Moderate Pain Syndromes In Neonatesmentioning

confidence: 99%

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

Allegaert

2020

Front. Pediatr.

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Effective and safe pain relief in neonates matters. This is not only because of ethical constraints or human empathy, but even more because pain treatment is an important and crucial part of contemporary medical, paramedical, and nursing care to improve the outcome in neonatal intensive care graduates. Paracetamol (acetaminophen) is likely one of the pharmacological tools to attain this, with data on prescription practices suggesting that paracetamol is somehow the "rising star" in neonatal pain management. Besides very rare topical clinical scenarios like peripartal asphyxia and subsequent whole body hypothermia or the use of cardiorespiratory support devices, data on paracetamol pharmacokinetics and metabolism were reported throughout neonatal age or weight ranges, and we have summarized these data. In this review, we subsequently aimed to provide the reader with the currently available observations on the use of paracetamol as analgesic for different pain syndromes (major surgery, minor surgery or trauma, and procedural pain), with focus on the limitations of paracetamol when prescribed for neonatal procedural pain management. We hereby intentionally will not discuss other indications (patent ductus arteriosus and fever) for paracetamol administration in neonates. Based on the available evidence, paracetamol has opioid-sparing effects for major pain syndromes, is effective to treat minor to moderate pain syndromes, but fails for effective procedural pain management in neonates. This efficacy failure for procedural pain management should stimulate us to continue to search for more effective interventions, including non-pharmacological interventions and preventive strategies. Furthermore, there are also upcoming association type of epidemiological studies on the relation between exposure to analgesics-including paracetamol-and the negative short-or long-term outcome characteristics (neuro-behavioral, atopy, and fertility). Consequently and in addition to the search for effective alternatives to prevent or treat pain, studies on long-term outcome following paracetamol exposure are needed to inform all stakeholders on the full effect-side effect balance of the different strategies to treat pain.

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Rectal Paracetamol in Newborn Infants after Assisted Vaginal Delivery May Increase Pain Response

Cited by 22 publications

References 38 publications

In newborns, oral or rectal paracetamol fails to reduce procedural pain, whereas intravenous paracetamol reduces morphine requirements after major surgery

In newborns, oral or rectal paracetamol fails to reduce procedural pain, whereas intravenous paracetamol reduces morphine requirements after major surgery

Pain Treatment of Newborns: Paracetamol Rectal Versus Intravenous Administration, A Randomised Open Clinical Trial

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

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