Breastfeeding May Reduce Pain In Preterm Infants

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Poorly managed pain in the neonatal intensive care unit has serious short- and long-term consequences, causing physiological and behavioral instability in preterm infants and long-term changes in their pain sensitivity, stress arousal systems, and developing brains. In a study published in the November issue of PAIN®, researchers report that breastfeeding during minor procedures mitigated pain in preterm neonates with mature breastfeeding behaviors.

Currently, pain associated with minor procedures such as pricking for blood tests is managed with interventions such as skin-to-skin contact, pacifiers, and sweet tastes, but these produce only modest and/or inconsistent relief. In normal term-born infants, breastfeeding during painful procedures has been shown to reduce pain response by 80-90% and has no serious side effects, but this approach had not previously been tested in preterm infants. One concern is that preterm infants might come to associate breastfeeding with the painful procedure, jeopardizing their ability to feed effectively enough to adequately gain weight.

In a randomized clinical trial, investigators from the Child & Family Research Institute at BC Children's Hospital and The University of British Columbia in Vancouver, BC, conducted a study to learn if preterm infants would show lower pain scores when breastfed during blood collection. They also looked at whether breastfeeding during the painful procedure would have a negative impact on the development of breastfeeding skills, and whether infants who had more mature breastfeeding behaviors would have lower pain scores and heart rates during blood collection than less experienced feeders.

Fifty-seven infants born at 30 to 36 weeks gestational age were divided into two groups. One group was breastfed during blood collection. The other group was given a pacifier. During the procedure, their faces and hands were videotaped, their responses were scored using the Behavioral Indicators of Infant Pain, and their heart rates were measured. Breastfed babies were also scored according to the Premature Infant Breastfeeding Behaviors scale.

For the group as a whole, breastfeeding did not reduce either behavioral or physiological pain during blood collection. Nevertheless, no immediate adverse effects were found on breastfeeding skill development. "Our sample of infants was assessed early in their breastfeeding experience; none of our infants were fully established on breastfeeds," says lead investigator Liisa Holsti, PhD, Clinician Scientist at the Child & Family Research Institute; Assistant Professor, Department of Occupational Science and Occupational Therapy, University of British Columbia; and a Canada Research Chair in Neonatal Health and Development. "For infants whose breastfeeding skills are inconsistent, it is unlikely to mitigate pain effectively."

In the breastfed group, however, infants who were more advanced in their ability to feed did have significantly lower behavioral pain scores. Despite concerns that blood sampling during breastfeeding may be more difficult, the authors report that the time taken for the procedure in the breastfed group was significantly shorter, making blood collection more efficient.
"Finding creative ways to apply breastfeeding for pain mitigation in premature infants is important, because recent research suggests that sweetening agents used to reduce minor procedural pain may act as sedatives rather than analgesics, and they may have negative effects on development," says Professor Holsti. "Our findings support further research on the effects of breastfeeding for more mature feeders over repeated events to assess both the short- and long-term benefits of the treatment."

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Steroids Given to Preemies May Harm Brain Growth: Study

Steroids Given to Preemies May Harm Brain Growth: Study

By Jenifer Goodwin

Giving premature babies even low doses of steroids after birth interferes with development of the brain's cerebellum, which is important to motor skills, learning and behavior, new research finds.

For the study, researchers analyzed MRIs of 172 babies born very early (under 32 weeks' gestation) at two medical centers, the University of British Columbia and the University of California, San Francisco. Full term is considered 40 weeks' gestation.

Preemies are sometimes given steroids known as glucocorticoids after birth to improve lung function and to stabilize low blood pressure, both of which are common problems.
The study found that preemies given the steroids hydrocortisone or dexamethasone had on average a 10% smaller cerebellum than premature babies not given the drug. Most of the infants had their brains scanned shortly after birth and again at around what would have been full term.

"Their cerebellums were growing slower," said lead study author Dr. Emily Tam, an assistant professor of neurology and pediatrics at University of California, San Francisco. "And we know from other studies that a smaller cerebellum in preemies is associated with poorer outcomes."
Mothers-to-be who are at risk of preterm labor are also often given steroids (usually betamethasone) before the baby is born to speed up maturation of the lungs. Researchers did not see any connection between prebirth steroids and smaller cerebellums. More controversy surrounds their use in babies after birth.

The study is published in the Oct. 19 issue of Science Translational Medicine.
About 13% of babies are born prematurely each year in the United States, according to the study. Premature babies can have all sorts of difficulties. Some 5 to 10% of very preterm infants have cerebral palsy, and up to half have behavioral disorders or learning disabilities.
Prior research has found that high-dose steroids may interfere with cerebellum growth, Tam said. Previous research has also found that children given steroids right after birth are more prone to learning and behavioral problems, said Dr. Pierre Gressens, a professor of pediatric neurology at the Centre for the Developing Brain at Imperial College in London and a lab chief at INSERM in Paris.

The American Academy of Pediatrics recommends avoiding high-dose dexamethasone in babies after birth, according to background information in the study.
In practice, some hospitals never use steroids in premature babies, while others routinely give steroids, Gressens said. In the study, about 20% of the 172 babies had been given steroids post-birth, Tam said.

The new research suggests that steroids should be given after birth only with the utmost caution, carefully balancing potential risks and benefits, Gressens said.
"There are situations where steroids are useful for a short time for the lungs, but doctors have to remember there is a particular toxicity of this steroid," Gressens said.
Tam agreed that doctors should be very cautious in giving steroids to premature babies.
"Even a low dose of dexamethasone or hydrocortisone are associated with decreased brain development, which would make us need to be careful when using these drugs," she said.
"They are very effective drugs," she continued. "We wouldn't want to say don't use them entirely, because we don't have very good alternatives. But when you think about options, don't jump straight to the steroid. You always have to think about the risk and benefit balance. Now there's more risk they have to consider when they think about using this drug."
Tam and her colleagues plan to follow the children as they get older to see if the smaller cerebellums result in motor, learning or behavioral issues.

In a second study, also led by UCSF researchers and published in the same journal issue, researchers showed that a small molecule drug blocked the negative effects of steroids on the cerebellum in mice.
The drug worked by stimulating a pathway that's involved with growth of neurons, which is what steroids appear to hamper, Gressens said.
"If you give a small molecule which stimulates the pathway, in a way you reverse the toxicity of the steroid, and if you reverse the effect on growth, the cerebellum goes back to normal size," he said. "There is potential for application in humans, but it's still a long time from clinical applications, maybe 5 to 10 years."

Related articles

• Steroids Given to Preemies May Harm Brain Growth (nlm.nih.gov)

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