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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

Background
Fever is a common symptom in children

Hypoglycemia

Hypothermia

Prematurity-related
complications
Feeding
difficulties

Jaundice

Respiratory
distress

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

Background

world health organization


emphasizes a fever of more than 39C which produces
complications for the patients, requires medical attention

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

Methods
Late preterm neonates who had
heel lancing procedure

August 2009 May 2010

DESIG
N

Noninferiority RCT

TIME

PLACE

SUBJECT

Neonatal unit of a universityaffiliated Level III hospital


in Sao Paulo, Brazil

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 EBM (EG)

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

Outcome
Primary
outcomes
Contextual

Pain intensity as
assessed with the
PIPP
Behavioral
state
GA
Brow bulging

Behavioral

Physiologic

Eye squeezing
Nasolabial
furrowing
Heart rate
Oxygen saturation

Outcome
Crying incidence

Secondary
outcomes

Percentage of time spent


crying during the 3 minutes
after lancing

nausea
bradycardia

regurgitation
The incidence
of AEs

tachycardia

vomiting
choking

desaturation

Results

Results

On the ITT analyses, results favor glucose (25/57


[43.9%]) in comparison with EBM (40/56 [71.4%]; P =
0.003).

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.

Results

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).

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).

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)

Results

Discussion
There 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

Critical Appraisal
P
I

Late 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


Yes
accounted for? And were they analyzed in the
groups to which they were randomized?
5. Were measures objective or were the patients Yes
and clinicians kept blind to which treatment
was being received?

What were the result?


1. How large was the
treatment effect?

NNT cant 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


No
outweight the potential harms of treatment
for my patient?

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

Premature Infant Pain Profile (PIPP)


0

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 (1039% of time)

moderate (4069% of time)

maximum (>=
70% of time)

Eye squeezing

none (<= 9%
of time)

minimum (1039% of time)

moderate (4069% of time)

maximum (>=
70% of time)

Nasolabial
furrowing

none (<= 9%
of time)

minimum (1039% of time)

moderate (4069% of time)

maximum (>=
70% of time)

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