INFECTION JOURNAL READING

Comparison of High Loading Dose Versus Usual Dose of Rectal Acetaminophen in

the Treatment of Febrile Children Houman Hashemian, Mohammad Momtazbakhsh, Zahra Atrkar Roshan

Andhika Trisna Putra

Supervisor Dr. H. Rustam Siregar, Sp.A

BackgroundFever is a common symptom in children

Prematurity-related complications

Hypothermia

Hypoglycemia

Respiratory distress

Jaundice

Feeding difficulties

Raju, Higgins, Stark, Leveno, 2006; Darcy AE, 2009

world health organizationemphasizes a fever of more than 39°C which producescomplications for the patients, requires medical attention

Background

.

Background

Objective

to compare the antipyretic effectiveness of high loading dose (30 mg/kg) and standard dose (15mg/kg) of rectal

acetaminophen in febrile children

Noninferiority RCT

DESIGN

TIME PLACE SUBJECT

Late preterm neonates who had heel lancing procedure

August 2009 – May 2010

Neonatal unit of a university-affiliated Level III hospital

in Sao Paulo, Brazil

6

Methods

Inclusion Criteria• patients with rectal

temperatures of 39 °C and above

Exclusion Criteria• a history of diarrhea,

malignancy, renal or liver failure,

• neurologic disorders, seizure, vasculitis,

• allergy to acetaminophen

• and who evacuated suppository during the first 30 minutes, or

• had received acetaminophen in the previous 4 hours

Neonates who would have heel lancing procedure

2 ml of 25% glucose (CG)

Applied via a needleless syringe to the anterior portion of the tongue 2

minutes before the lancing procedure

Monitoring before HL : SpO2 and HR

Outcome

2 ml of EBM (EG)

OutcomePain intensity as

assessed with the PIPP

Behavioral

Primary outcomes

Contextual

Physiologic

Behavioral stateGA

Brow bulgingEye squeezing

Nasolabial furrowing

Heart rateOxygen saturation

Outcome

Percentage of time spent crying during the 3 minutes after lancing

Secondary outcomes

Crying incidence

The incidence of AEs

nausea regurgitationvomiting

choking

desaturationtachycardia

bradycardia

Results

Results

• The mean difference in PIPP scores at 30 seconds after lancing was 2.995 points with a 95% confidence interval of 1.507 to 4.483.

• On the ITT analyses, results favor glucose (25/57 [43.9%]) in comparison with EBM (40/56 [71.4%]; P = 0.003).

• A lower incidence of cry was observed for infants in the CG (19/45 [42.2%]) compared with the EG (33/42 [78.6%], P = 0.001).

Results

• Neonates who received glucose cried less (mean, 14.53%, ± 19.98%) than did those who received EBM (mean 32.02%, ± 29.02; P = 0.014)

• On the ITT analysis, a lower number of infants who received glucose cried after the procedure (31/57 [54.4%]) compared with those who received EBM (47/56 [83.9%], P = 0.001).

Results

DiscussionThere are analgesic effects of sweet solutions during minor painful procedures in healthy neonates and infants

Researchers compared the effects of EBM and sweet solutions on neonatal pain scores and crying no significant differences in cry duration were observed across the intervention groups

Discussion

The results of this study + previous evidence indicate that further research is required on EBM

Studies exploring the combination of EBM with other interventions such as skin-to-skin contact or sucking are required to verify synergic or addictive effects of these interventions

Conclusion

Based on PIPP scores and crying time indicate poorer effects of EBM compared with 25% glucose during heel lancing

Analgesic properties of EBM should be further investigated considering different volumes, administrations, and combinations with other pain relief strategies

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Critical AppraisalLate Preterm Infants Who Had Heel Lancing Procedure

Breast Milk

25% Glucose

Pain Score

Are the study result valid?1. Was the assignment of patients to treatment

randomized?Yes

2. Were the groups similar at the start of trial? Yes

3. Aside from the allocated treatment, were groups treated equally?

Yes

4. Were all patient who entered the trial accounted for? And were they analyzed in the groups to which they were randomized?

Yes

5. Were measures objective or were the patients and clinicians kept blind to which treatment was being received?

Yes

What were the result?1. How large was the

treatment effect?NNT can’t be calculated

Will the result help me in caring for my patient?

1. Is my patient so different to those in the study that the result cannot apply?

No

2. Is the treatment feasible in my setting? Yes

3. Will the potential benefits of treatment outweight the potential harms of treatment for my patient?

No

Conclusion• Valid• Important • Applicable

Level of evidence : 1b

Recomendation

Expressed breast milk and 25% glucose can be used to relieve the pain of late preterm infant during a heel lance procedure

Further research is required

Thank You

0 1 2 3

Gestational Age >= 36 weeks 32 weeks to 35 weeks 6 days

28 weeks to 31 weeks 6 days

< 28 weeks

Behavioral state before painful stimulus

active/awake eyes open facial movements

quiet/awake eyes open no facial movements

active/sleep eyes closed facial movements

quiet/sleep eyes closed no facial movements

HR change 0-4 beats per minute increase

5-14 beats per minute increase

15-24 beats per minute increase

>= 25 beats per minute increase

SpO2 Change 0 to 2.4% decrease

2.5 to 4.9% decrease

5.0 to 7.4% decrease

7.5% decrease or more

Brow bulging none (<= 9% of time)

minimum (10-39% of time)

moderate (40-69% of time)

maximum (>= 70% of time)

Eye squeezing none (<= 9% of time)

minimum (10-39% of time)

moderate (40-69% of time)

maximum (>= 70% of time)

Nasolabial furrowing

none (<= 9% of time)

minimum (10-39% of time)

moderate (40-69% of time)

maximum (>= 70% of time)

Premature Infant Pain Profile (PIPP)

Scores of 6 or less represent absence of pain or minimal pain