Auszug
Wann beim menschlichen Fetus die Schmerzempfindung einsetzt und wie Schmerz von ihm empfunden wird, ist nicht endgültig geklärt (Wolf 1997). Korrekterweise sollte man besser über Nozizeption als über Schmerzempfindung sprechen: „Schmerz“ ist definitionsgemäß mit dem Erleben starker Emotionen verbunden (Anand u. Hickey 1987); solche werden einem Fetus üblicherweise nicht zugestanden. Auf die feinsinnige Unterscheidung zwischen Nozizeption und Schmerzempfindung (Anand u. Hickey 1987) wollen wir — wie in der einschlägigen Literatur durchaus üblich — in diesem Beitrag jedoch verzichten, insbesondere, weil ein Großteil der Schmerzauswirkungen offenbar nicht an Schmerzempfindung geknüpft ist (s. unten; Marsh et al. 1997).
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Literatur
Acharya AB, Annamali S, Taub NA, Field D (2004) Oral sucrose analgesia for preterm infant venepuncture. Arch Dis Child Fetal Neonatal Ed, 89: F17–18
Acharya AB, Bustani PC, Phillips JD, Taub NA, Beattle RM (1998) Randomised controlled trial of eutectic mixture of local anaesthetics cream for venepuncture in healthy preterm infants. Arch Dis Child Fetal Neonatal Ed, 78: 138–142
Allegaert K, Rayyan M, Anderson BJ (2006) Impact of ibuprofen administration on renal drug clearance in the first weeks of life. Methods Find Exp Clin Pharmacol, 28(8): 519–522
Allegaert K, Vanhole C, de Hoon J, Guignard JP, Tibboel D, Devlieger H, van Overmeire B (2005) Nonselective cyclooxygenase inhibitors and glomerular filtration rate in preterm neonates. Pediatr Nephrol, 20(11): 1557–1561
American Academiy of Pediatrics, Canadian Paediatric Society (2000) Prevention and management of pain and stress in the neonate. Pediatrics, 105: 454–461
Anand KJ (2000) Effects of perinatal pain and stress. Prog Brain Res, 122: 117–129
Anand KJ, Hall RW, Desai N, Shephard B, Bergqvist LL, Young TE, Boyle EM, Carbajal R, Bhutani VK, Moore MB, Kronsberg SS, Barton BA, Neopain Trial Investigators Group (2004a) Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Lancet, 363(9422): 1673–1682
Anand KJ, International Evidence-Based Group for Neonatal Pain (2001) Consensus Statement for the Prevention and management of Pain in the Newborn. Arch Pediatr Adolesc, 155(Feb): 173–180
Anand KJ, Hall RW, Desai N, Shephard B, Bergqvist LL, Young TE, Boyle EM, Carbajal R, Bhutani VK, Moore MB, Kronsberg SS, Barton BA, Neopain Trial Investigators Group (2004b) Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Lancet, 363: 1673–1682
Anand KJ, Hickey PR (1987) Pain and its effects in the human neonate and fetus. N Engl J Med, 817: 1321–1329
Anand KJ, Hickey PR (1992) Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med, 326: 1–9
Anand KJ, McIntosh N, Lagercrantz H, Pelausa E, Young TE, Vasa R (1999) Analgesia and sedation in preterm neonates who require ventilatory support. Arch Pediatr Adolesc Med, 153: 331–338
Anderson BJ, Palmer GM (2006) Recent pharmacological advances in paediatric analgesics. Biomed Pharmacother, 60(7): 303–309
Anderson BJ, van Lingen RA, Hansen TG, Lin YC, Holford NH (2002) Acetaminophen developmental pharmacokinetics in premature neonates and infants: a pooled population analysis. Anesthesiology, 96(6): 1336–1345
Andrews K, Fitzgerald M (1997) Biological barriers to paediatric pain management. Clin J Pain, 13: 138–143
Aranda J V, Carlo W, Hummel P, Thomas R, Lehr VT, Anand KJ (2005) Analgesia and sedation during mechanical ventilation in neonates. Clin Ter, 27(6): 877–899
Axelin A, Salanterä S, Lehtonen L (2006) ’Facilitated tucking by parents’ in pain management of preterm infants — a randomized crossover trial. Early Hum Dev, 82(4): 241–247
Barr RG (1998) Reflections on measuring pain in infants: dissociation in responsive systems and „honest signalling“. Arch Dis Child Fetal Neonatal Ed, 79: F152–156
Bauer K, Ketteler J, Hellwich M, Laurenz M, Versmold H (2004) Oral glucose before venepuncture relieves neonates of pain, but stress is still evidenced by increase in oxygen consumption, energy expenditure, and heart rate.Pediatr Res, 55: 695–700
Bauer K, Versmold H (1999) Analgesie bei Früh-und Neugeborenen. Pädiatrische Praxis, 57: 169–178
Baumgartner R, Fauchère JC, Bucher HU (2000) Künstliche Süßstoffe reduzieren die Schmerzreaktion beim Guthrie Test. Z Geburtshilf Neonatol, 204: 1–1
Bellieni CV, Buonocore G, Nenci A, Franci N, Cordelli DM, Bagnoli F (2001) Sensorial saturation; an effective analgesic tool for heel-prick in preterm infants. Biol Neonate, 80: 15–18
Bellù R, de Waal KA, Zanini R (2008) Opioids for neonates receiving mechanical ventilation. Cochrane Database Syst Rev, 23(1): CD004212
Bhandari V, Bergqvist LL, Kronsberg SS, Barton BA, Anand KJ, Neopain Trial Investigators Group (2005) Morphine administration and short-term pulmonary outcomes among ventilated preterm infants. Pediatrics, 116(2): 352–359
Blass EM, Watt LB (1999) Suckling-and sucrose-induced analgesia in human newborns. Pain, 83: 611–623
Boyle EM, Freer Y, Khan-Orakzai Z, Watkinson M, Wright E, Ainsworth JR, McIntosh N (2006) Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed, 91(3): F166–168
Brent AS (2000) The management of pain in the emergency department. Pediatr Clin North Am, 47: 651–679
Calobrisi S D, Drolet BA, Esterly NB (1998) Petechial eruption after the application of EMLA cream. Pediatrics, 101: 471–473
Carbajal R, Chauvet X, Couderc S, Olivier-Martin M (1999) Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates. Br Med J, 19: 1393–1397
Chay PC, Duffy BJ, Walker JS (1992) Pharmacokinetic-pharmacodynamic relationship of morphine in neonates. Clin Pharmacol Ther, 51: 334–342
Cignacco E, Hamers JP, Stoffel L, van Lingen RA, Gessler P, McDougall J, Nelle M (2007) The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systematic literature review. Eur J Pain, 11(2): 139–152
Curtis SJ, Jou H, Ali S, Vandermeer B, Klassen T (2007) A randomized controlled trial of sucrose and/or pacifier as analgesia for infants receiving venipuncture in a pediatric emergency department. British Medical Journal Pediatrics, 7: 27
Derbyshire SW, Furedi A (1996) „Fetal pain“ is a misnomer. Br Med J, 313: 795
Dickenson A, Rahman W (1999) Mechanisms of chronic pain and the developing nervous system. In P. J. McGrath, G. A. Finley (Hrsg.), Chronic and recurrent pain in children and adolescents (S. 5–39) Seattle: IASP Press
Dripps, RD., Eckenhoff, J. E., Vandam, L. D. (1982) Introduction to anesthesia. The principles of safe practice. Philadelphia: Saunders. Eriksson M, Finnström O (2004) Can daily repeated doses of orally administered glucose induce tolerance when given for neonatal pain relief? Acta Paediatr, 93: 246–249
Evans JC, McCartney EM, Lawhon G, Galloway J (2005) Longitudinal comparison of preterm pain responses to repeated heelsticks. Paediatr Nurs, 31(3): 216–221
Field T (1982) Alleviating stress in newborn infants in the intensive care unit. Clin Perinatol, 17: 1–9
Fitzgerald M, Beggs S (2001) The neurobiology of pain: Developmental aspects. Neuroscientist, 7: 246–257
Franck LS, Miaskowski C (1997) Measurement of neonatal responses to painful stimuli: A research review. J Pain Symptom Manage, 14: 343–378
Franck LS, Miaskowski C (1998) The use of intravenous opioids to provide analgesia in critically ill, premature neonates: A research critique. J Pain Symptom Manage, 15: 41–69
Gibbins S, Stevens B, Beyene J, Chan PC, Bagg M, Asztalos E (2008a) Pain behaviours in Extremely Low Gestational Age infants. Early Hum Dev, 84(7): 451–458
Gibbins S, Stevens B, McGrath PJ, Yamada J, Beyene J, Breau L, Camfield C, Finley A, Franck L, Johnston C, Howlett A, McKeever P, O’Brien K, Ohlsson A (2008b) Comparison of pain responses in infants of different gestational ages. Neonatology, 93(1): 10–18
Gorski PA, Huntington L, Lewkowicz DJ (1990) Handling preterm infants in hospitals. Clin Perinatol, 17: 103–112
Grabska J, Walden P, Lerer T, Kelly C, Hussain N, Donovan T, Herson V (2005) Can oral sucrose reduce the pain and distress associated with screening for retinopathy of prematurity? J Perinatol, 25(1): 33–35
Gray L, Watt L, Blass EM (2000) Skin-to-skin contact is analgesic in healthy newborns. Pediatrics, 105 No. 1 Jan 2000: e14
Grunau RE, Oberlandr T, Holsti L, Whilfield MF (1998) Bedside application of the Neonatal Facial Coding System in pain assessment of premature neonates. Pain, 76: 277–286
Guinsburg RG, Kopelman BI, Anand KJS, de Almeida MFB, Peres CA, Miyoshi MH (1998) Physiological, hormonal, and behavioral responses to a single fentanyl dose in intubated and ventilated preterm neonates. J Pediatr, 132: 954–959
Hall RW, Boyle E, Young T (2007) Do ventilated neonates require pain management. Semin Perinatol, 31(5): 289–297
Hall RW, Kronsberg SS, Barton BA, Kaiser JR, Anand KJ, Neopain Trial Investigators Group (2005) Morphine, hypotension, and adverse outcomes among preterm neonates: who’s to blame? Secondary results from the NEOPAIN trial. Pediatrics, 115(5): 1351–1359
Hartley R, Quinn M, Green M, Levene MI (1993) Morphine glucuronidation in premature neonates. Br J Clin Pharmacol, 35: 314–317
Holliday MA, Pinckert TL, Kiernan SC, Kunos I, Angelus P, Keszler M (1999) Dorsal penile nerve block vs topical placebo for circumcision in low-birth-weight neonates. Archives of Pediatrics, Adolescent Medicine, 153: 476–480
Holsti L, Grunau RE (2007) Initial validation of the Behavioral Indicators of Infant Pain (BIIP) Pain, 132(3): 264–272
Holsti L, Grunau RE, Oberlander TF, Osiovich H (2008) Is it painful or not? Discriminant validity of the Behavioral Indicators of Infant Pain (BIIP) scale. Clin J Pain, 24(1): 83–88
Holsti L, Grunau RE, Oberlander TF, Whifield MF (2004) Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit. Pediatrics, 114(1): 65–72
Holsti L, Grunau RE, Oberlander TF, Whifield MF (2005) Prior pain induces heightened motor responses during clustered care in preterm infants in the NICU. Early Hum Dev, 81(3): 293–302
Holsti L, Grunau RE, Whifield MF, Oberlander TF, Lindh V (2006) Behavioral responses to pain are heightened after clustered care in preterm infants born between 30 and 32 weeks gestational age. Clin J Pain, 22(9): 757–764
Isbister GK, Bucens IK, Whyte IM (2001) Paracetamol overdose in a preterm neonate. Arch Dis Child, 85: F70–F72
Jain S, Kumar P, McMillan DD (2006) Prior leg massage decreases pain responses to heel stick in preterm babies. J Paediatr Child Health, 42(9): 505–508
Johnston CC, Collinge JM, Henderson SJ, Anand KJS (1997a) A cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units. Clin J Pain, 13: 308–312
Johnston CC, Sherrard A, Stevens B, Franck L, Stremler R, Jack A (1999a) Do cry features reflect pain intensity in preterm neonates? A preliminary study. Biol Neonate, 76: 120–124
Johnston CC, Stremler R, Horton L, Friedman A (1999b) Effect of repeated doses of sucrose during heel stick procedures in preterm neonates. Biol Neonate, 75: 60–66
Johnston CC, Stremler RL, Stevens B, Horton LJ (1997b) Effectiveness of oral sucrose and simulated rocking on pain response in preterm neonates. Pain, 72: 193–199
Kart T, Chirstrup LL, Rasmussen M (1997a) Recommended use of morphine in neonates, infants and children based on a literature review. Pharmacokinetics Pediatric Anaesthesia, 7(1): 5–11
Kart T, Christrup LL, Rasmussen M (1997b) Recommended use of morphine in neonates, infants and children based on a literature review, pt 2: Clinical use. Paediatr Anaesth, 7: 93–101
Kennedy KA, Tyson JE (1999) Narcotic analgesia for ventilated newborns: Are placebo-controlled trials ethical and necessary? J Pediatr, 134: 127–129
Lago P, Benini F, Agosto C, Zacchello F (1998) Randomised controlled trial of low dose fentanyl infusion in preterm infants with hyaline membrane disease. Arch Dis Child Fetal Neonatal Ed, 79: F194–197
Larsson B A (1999) Pain management in neonates. Acta Paediatr, 88: 1301–1310
Larsson BA, Tannfeldt G, Lagercrantz H, Olsson GL (1998a) Alleviation of the pain of venepuncture in neonates. Acta Paediatr, 87: 774–779
Larsson BA, Tannfeldt G, Lagercrantz H, Olsson GL (1998b) Venipuncture is more effective and less painful than heel lancing for blood tests in neonates. Pediatrics, 101: 882–886
Lee TC, Charles BG, Harte GJ, Gray PH, Steer PA, Flenady VJ (1999) Population pharmacokinetic modeling in very premature infants receiving midazolam during mechanical ventilation. Anesthesiology, 90: 151–157
Lewindon PJ, Harkness L, Lewindon N (1998) Randomised controlled trial of sucrose by mouth for the relief of infant crying after immunisation. Arch Dis Child, 78: 453–456
Lloyd-Thomas AR (1997) Paediatric pain management — the next step? Paediatr Anaesth, 7: 487–493
Lloyd-Thomas AR, Fitzgerald M (1996) Reflex responses do not necessarily signify pain. Br Med J, 313: 797–798
Ludington-Hoe SM, Hosseini R, Torowicz DL (2005) Skin-toskin contact (Kangaroo Care) analgesia for preterm infant heel stick. AACN Clin Issues, 16(3): 373–387
Lynn A, Nespeca MK, Bratton SL, Strauss SG, Shenn DD (1998) Clearance of morphine in postoperative infants during intravenous infusion: The influence of age and surgery. Anesth Analg, 86: 958–963
MacGregor R, Evans E, Sugden D, Gaussen T, Levene M (1998) Outcome at 5-6 years of prematurely born children who received morphine as neonates. Arch Dis Child Fetal Neonatal Ed, 79: F40–43
Marsh DF, Hatch DJ, Fitzgerald M (1997) Opioid systems and the newborn. Br J Anaesth, 79: 787–795
Maxwell LG, Yaster M (1999) Analgesia for neonatal circumcision. No more studies, just do it. Arch Pediatr Adolesc Med, 153: 444–445
McIntosh N (1997) Pain in the newborn, a possible new starting point. Eur J Pediatr 156: 173–177
Oberlander TF, Grunau RE, Whitfield MF, Fitzgerald C, Pitfield S., Saul JP (2000) Biobehavioral pain responses in former extremely low birth weight infants at four months’ corrected age. www.pediatrics.org, #e6,107
Örs R, Özek E, Baysoy G, Cebeci D, Bilgen H, Türküner M, Basaran M (1999) Comparison of sucrose and human milk on pain response in newborns. Eur J Pediatr, 158: 63–66
Pasternak GW, Zhang A, Tecott L (1980) Developmental differences between high and low affinity binding sites: their relationship to analgesia and respiratory depression. Life Sci, 27: 1185–1190
Playfor SD, Thomas DA, Choonara I, Jarvis A (2000) Quality of sedation during mechanical ventilation. Paediatr Anaesth, 10: 195–199
Pokela M L (1994) Pain relief can reduce hypoxemia in distressed neonates during routine treatment procedures. Pediatrics, 93: 379–383
Polander DM, Berde CB (1993) Postoperative pain management. In C. J. Coté, J. F. Ryan, I. D. Todres, N. G. Goudsouzian (Hrsg.), A practice of anesthesia for infants and children (S 451–467) Philadelphia: Saunders
Porter FL, Wolf CM, Gold J, Lotsoff D, Miller JP (1997) Pain and pain management in newborn infants: A survey of physicians and nurses. Pediatrics, 100: 626–632
Porter FL, Wolf CM, Miller JP (2000) Procedural pain in newborn infants: The influence of intensity and development, http://www.pediatrics.org, #e13
Quinn MW, Wild J, Dean HG, Hartley R, Rushforth JA, Puntis JWL, Levene MI (1993) Randomised double-blind controlled trial of effect of morphine on catecholamine concentrations in ventilated preterm babies. Lancet, 342: 324–327
Ramenghi LA, Evans DJ, Levene MI (1999) „Sucrose analgesia“: absorptive mechanism or taste perception? Arch Dis Child Fetal Neonatal Ed, 80: F146–147
Rogers AJ, Greenwald MH, Deguzman MA, Kelley ME, Simon HK (2006) A randomized, controlled trial of sucrose analgesia in infants younger than 90 days of age who require bladder catheterization in the pediatric emergency department. Acad Emerg Med, 13(6): 617–622
Rush R, Rush S, Ighani F, Anderson B, Irwin M, Naqvi M (2005) The effects of comfort care on the pain response in preterm infants undergoing screening for retinopathy of prematurity. Retina, 25(1): 59–62
Saarenmaa E, Huttunen P, Leppäluoto J, Meretojy O, Fellmann V (1999) Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth. J Pediatr, 134: 144–150
Schuster A, Lenard HG (1990) Pain in newborns and prematures: Current practice and knowledge. Brain Dev, 12: 459–465
Shah PS, Aliwalas L, Shah V (2007) Breastfeeding or breastmilk to alleviate procedural pain in neonates: a systematic review. Breastfeed Med, 2(2): 74–82
Shah, V., Ohlsson, A. Venepuncture vs. heel lance for blood sampling in term neonates. The Cochrane Library, Oxford, Issue 3 (update software), 2001.
Shah V, Ohlsson A (2007) Venepuncture versus heel lance for blood sampling in term neonates. Cochrane Database Syst Rev, 17(4)
Shah V, Taddio A, Ohlsson A (1998) Randomised controlled trial of paracetamol for heel prick pain in neonates. Arch Dis Child Fetal Neonatal Ed, 79: F209–211
Sharma P K, Garg SK, Narang A (2003) Pharmakinetics of oral ibuprofen in premature infants. J Clin Pharmacol, 43: 968–973
Simons SH, Roofthooft DW, van Dijk M, van Lingen RA, Duivenvoorden HJ, Van den Anker JN, Tibboel D (2006) Morphine in ventilated neonates: its effects on arterial blood pressure. Arch Dis Child Fetal Neonatal Ed, 91(1): F46–51
Simons SH, van Dijk M, van Lingen RA, Roofthooft D, Duivenvoorden HJ, Jongeneel N, Bunkers C, Smink E, Anand KJ, Van den Anker JN, Tibboel D (2003) Routine morphine infusion in preterm newborns who received ventilatory support: a randomized controlled trial. JAMA, 290(18): 2419–2427
Skogsdal Y, Eriksson M, Schollin J (1997) Analgesia in newborns given oral glucose. Acta Paediatr, 86: 217–220
Stevens B, Johnston C, Franck L, Petryshen P, Jack A, Foster G (1999) The efficacy of developmentally sensitive interventions and sucrose for relieving procedural pain in very low birth weight neonates. Nurs Res, 48: 35–43
Stevens B, Ohlsson A (2000) Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2, CD001069
Stevens B, Taddio A, Ohlsson A, Einarson T (1997) The efficacy of sucrose for relieving procedural pain in neonates — a systematic review and meta-analysis. Acta Paediatr, 86: 837–842
Stevens B, Yamada J, Beyene J, Gibbins S, Petryshen P, Stinson J, Narciso J (2005) Consistent management of repeated procedural pain with sucrose in preterm neonates: Is it effective and safe for repeated use over time? Clin J Pain, 21(6): 543–548
Stevens B, Yamada J, Ohlsson A (2004) Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev, 3: CD001069
Suresh S, Anand KJ (2001) Opioid tolerance in neonates: a state-of-the-art review. Paediatr Anaesth, 11: 511–521
Taddio A, Katz J, Ilersich AL, Koren G (1997) Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 349: 599–603
Tobias JD, Rasmussen GE (1994) Pain management and sedation in the pediatric intensive care unit. Pediatr Clin North Am, 41: 1269–1292
Upadhyay A, Aggarwal R, Narayan S, Joshi M, Paul VK, Deorari AK (2004) Analgesic effect of expressed breast milk in procedural pain in term neonates: a randomized, placebo-controlled, double-blind trial. Acta Paediatr, 93: 518–522
Van Howe RS (1997) Neonatal circumcision. Lancet, 349: 1257
van Lingen RA, Deinum HT, Quak CME, Okken A, Tibboel D (1999a) Multiple-dose pharmacokinetics of rectally administered acetaminophen in term infants. Clin Pharmacol Ther, 66: 509–515
van Lingen RA, Deinum JT, Quak JME, Kzizenga AJ, van Dam JG, Anand KJS, Tibboel D, Okken A (1999b) Pharmacokinetics and metabolism of rectally administered paracetamol in preterm neonates. Arch Dis Child Fetal Neonatal Ed, 80: F59–63
Ward-Larson C, Horn RA, Gosnell F (2004) The efficacy of facilitated tucking for relieving procedural pain of endotracheal suctioning in very low birthweight infants. Am J Matern Child Nurs, 29(3): 151–156
Winberg J (1998) Do neonatal pain and stress program the brain’s response to future stimuli? Acta Paediatr, 87: 723–725
Wolf AR (1997) Pain, nociception and the developing infant. Paediatr Anaesth, 9: 7–17
Yaster M, Bean JD, Schulman SR, Rogers MC (1996) Pain, sedation, and postoperative anesthetic management in the pediatric intensive care unit. In M. Rogers (Hrsg.), Textbook of pediatric intensive care (S. 1547–1593) Baltimore: Williams and Wilkins
Zernikow B, Hechler T (2008) Schmerztherapie bei Kindern und Jugendlichen. Dtsch Ärztebl, 105(28–29): 511–522
Zhang GH, Sweitzer SM (2008) Neonatal morphine enhances nociception and decreases analgesia in young rats. Brain Res, 1199: 82–90
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Michel, E., Zernikow, B. (2009). Schmerztherapie auf der (neonatologischen) Intensivstation. In: Zernikow, B. (eds) Schmerztherapie bei Kindern, Jugendlichen und jungen Erwachsenen. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-74065-0_16
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