THE evaluation of pain in the human fetus and neonate is difficult because pain is generally defined as a subjective phenomenon.1 Early studies of neurologic development concluded that neonatal responses to painful stimuli were decorticate in nature and that perception or localization of pain was not present.2 Furthermore, because neonates may not have memories of painful experiences, they were not thought capable of interpreting pain in a manner similar to that of adults.3 4 5 On a theoretical basis, it was also argued that a high threshold of painful stimuli may be adaptive in protecting infants from pain during birth.6 These traditional . . .

Pain and its effects in the human neonate and fetus

Clinics in Developmental Medicine

Background

Tuberculous meningitis is a serious form of tuberculosis (TB) that affects the meninges that cover a person's brain and spinal cord. It is associated with high death rates and with disability in people who survive. Corticosteroids have been used as an adjunct to antituberculous drugs to treat people with tuberculous meningitis, but their role has been controversial.


Objectives

To evaluate the effects of corticosteroids as an adjunct to antituberculous treatment on death and severe disability in people with tuberculous meningitis.


Search methods

We searched the Cochrane Infectious Diseases Group Specialized Register up to the 18 March 2016; CENTRAL; MEDLINE; EMBASE; LILACS; and Current Controlled Trials. We also contacted researchers and organizations working in the field, and checked reference lists.


Selection criteria

Randomized controlled trials that compared corticosteroid plus antituberculous treatment with antituberculous treatment alone in people with clinically diagnosed tuberculous meningitis and included death or disability as outcome measures.


Data collection and analysis

We independently assessed search results and methodological quality, and extracted data from the included trials. We analysed the data using risk ratios (RR) with 95% confidence intervals (CIs) and used a fixed-effect model. We performed an intention-to-treat analysis, where we included all participants randomized to treatment in the denominator. This analysis assumes that all participants who were lost to follow-up have good outcomes. We carried out a sensitivity analysis to explore the impact of the missing data.


Main results

Nine trials that included 1337 participants (with 469 deaths) met the inclusion criteria.

At follow-up from three to 18 months, steroids reduce deaths by almost one quarter (RR 0.75, 95% CI 0.65 to 0.87; nine trials, 1337 participants, high quality evidence). Disabling neurological deficit is not common in survivors, and steroids may have little or no effect on this outcome (RR 0.92, 95% CI 0.71 to 1.20; eight trials, 1314 participants, low quality evidence). There was no difference between groups in the incidence of adverse events, which included gastrointestinal bleeding, invasive bacterial infections, hyperglycaemia, and liver dysfunction.

One trial followed up participants for five years. The effect on death was no longer apparent at this time-point (RR 0.93, 95% CI 0.78 to 1.12; one trial, 545 participants, moderate quality evidence); and there was no difference in disabling neurological deficit detected (RR 0.91, 95% CI 0.49 to 1.69; one trial, 545 participants, low quality evidence).

One trial included human immunodeficiency virus (HIV)-positive people. The stratified analysis by HIV status in this trial showed no heterogeneity, with point estimates for death (RR 0.90, 95% CI 0.67 to 1.20; one trial, 98 participants) and disability (RR 1.23, 95% CI 0.08 to 19.07; one trial, 98 participants) similar to HIV-negative participants in the same trial.


Authors' conclusions

Corticosteroids reduce mortality from tuberculous meningitis, at least in the short term.

Corticosteroids may have no effect on the number of people who survive tuberculous meningitis with disabling neurological deficit, but this outcome is less common than death, and the CI for the relative effect includes possible harm. However, this small possible harm is unlikely to be quantitatively important when compared to the reduction in mortality.

The number of HIV-positive people included in the review is small, so we are not sure if the benefits in terms of reduced mortality are preserved in this group of patients

/pdf/corticosteroids-for-managing-tuberculous-meningitis-16teimtw3t.pdf

Corticosteroids for managing tuberculous meningitis

Evaluation of pain in neonates is difficult due to their limited means of communication. The aim was to determine whether behavioural reactions of cry and facial activity provoked by an invasive procedure could be discriminated from responses to non-invasive tactile events. Thirty-six healthy full-term infants (mean age 2.2 h) received 3 procedures in counterbalanced order: intramuscular injection, application of triple dye to the umbilical stub, and rubbing thigh with alcohol. Significant effects of procedure were found for total face activity and latency to face movement. A cluster of facial actions comprised of brow bulging, eyes squeezed shut, deepening of the naso-labial furrow and open mouth was associated most frequently with the invasive procedure. Comparisons between the 2 non-invasive procedures showed more facial activity to thigh swabbing and least to application of triple dye to the umbilical cord. Acoustic analysis of cry showed statistically significant differences across procedures only for latency to cry and cry duration for the group as a whole. However, babies who cried to two procedures showed higher pitch and greater intensity to the injection. There were no significant differences in melody, dysphonation, or jitter. Methodological difficulties for investigators in this area were examined, including criteria for the selection of cries for analysis, and the logical and statistical challenges of contrasting cries induced by different conditions when some babies do not always cry. It was concluded that facial expression, in combination with short latency to onset of cry and long duration of first cry cycle typifies reaction to acute invasive procedures.

Neonatal facial and cry responses to invasive and non-invasive procedures

In this article I evaluate recent attempts to illuminate the human infant cry from an evolutionary perspective. Infants are born into an uncertain parenting environment, which can range from indulgent care of offspring to infanticide. Infant cries are in large part adaptations that maintain proximity to and elicit care from caregivers. Although there is not strong evidence for acoustically distinct cry types, infant cries may function as a graded signal. During pain-induced autonomic nervous system arousal, for example, neural input to the vocal cords increases cry pitch. Caregivers may use this acoustic information, together with other cues, to guide caregiving behavior. Serious pathology, on the other hand, results in chronically and severely abnormal cry acoustics. Such abnormal crying may be a proximate cause of adaptive infant maltreatment, in circumstances in which parents cut their losses and reduce or withdraw investment from infants with low survival chances. An increase in the amount of crying during the first few months of life is a human universal, and excessive crying, or colic, represents the upper end of this normal increase. Potential signal functions of excessive crying include manipulation of parents to acquire additional resources, honest signaling of need, and honest signaling of vigor. Current evidence does not strongly support any one of these hypotheses, but the evidence is most consistent with the hypothesis that excessive early infant crying is a signal of vigor that evolved to reduce the risk of a reduction or withdrawal of parental care.

/pdf/the-signal-functions-of-early-infant-crying-zov0kx5dyk.pdf

The signal functions of early infant crying.

The study of crying can be dealt with from many different perspectives: anatomical, physiological, psychological, phonetic, and pediatric. During the last two decades, the cry has also been an important factor in studies of mother-child interaction.

Twenty-Five Years of Scandinavian Cry Research

115 pain-induced cries from 45 full-term newborn infants with pre- and perinatal asphyxia were analyzed by sound spectrographic methods. All the infants had signs of intrauterine asphyxia and Apgar score of 6 or less at 5 min. The mean birth weight was 3170 g. The pain cries were recorded before the age of 8 days, 83% of the cries before 3 days of age. The cry analysis was compared with the pain cries of 75 full-term, healthy newborn infants of corresponding birth weight and gestational age. The results showed significant differences between the cries of the asphyxiated newborn and the healthy infants. The duration of the phonation was shorter, the maximum and minimum pitch of the fundamental frequency was significantly higher. Bi-phonation and vibrato occurred more often, double harmonic break and glottal roll less often. An increase in rising, falling-rising and flat types of melody was observed. Retrospectively, the cries were more abnormal if the infant was found to be neurologically damaged at t he check-up at 2-8 years.

Pain cry in full‐term asphyxiated newborn infants correlated with late findings

SUMMARY

A total of 110 pain-induced cries from 14 infants with bacterial meningitis were analysed by sound spectrographic methods. The infants were between four days and six months old, and the cries were analysed between one and 14 days after the diagnosis. The cry analysis was compared with the crying of 75 full-term healthy infants. 15 cry attributes were studied.



The results of the analysis showed significant differences between the cries of the meningitic infants and the controls. The duration of phonation was shorter, the pitch of the fundamental frequency was higher and more voiceless parts occurred in the signals. Biphonation, gliding and double harmonic break occurred significantly more often. The cries were more abnormal in the infants who had later neurological sequelae.



RESUME

Analyse spectographique sonore du pleur chez le nourrisson prŕsentant une mŕningite bactŕrienne



Une analyse de 110 pleurs induits par la douleur, chez 14 nourrissons (âgŕs de quatre jours a six mois) prŕsentant une mŕningite bactŕrienne a ŕtŕ effectuŕe un a 14 jours apres le diagnostic par mŕthode de spectographie sonore et comparŕe avec le pleur de 75 nourrissons en bonne santŕ nŕs a terme.



Les rŕsultats de 'analyse ont montrŕ des diffŕrences significatives entre les pleurs de nourrissons mŕningitiques et des nourrissons en bonne santŕ dans plusieurs caractŕristiques. La durŕe de la phonation ŕtait plus courte, la pointe de frŕquence fondamentale plus haute et les portions sans voix dans les signaux plus frŕquentes. La bi-phonation, le glissement et la rupture sur 'harmonique double survenaient significativement plus souvent chez les nourrissons mŕningitiques. Chez les nourrissons mŕningitiques, les pleurs ŕtaient plus anormaux chez les sujets ayant prŕsentŕ par la suite des sŕquelles neurologiques.



ZUSAMMENFASSUNG

Schallspektrographische Analyse des Schreiens yon Kindern mit bakterieller Meningitis



110 Schmerzschreie von 14 Kindern (im Alter von vier Tagen bis zu sechs Monaten) mit bakterieller Meningitis wurden vom 1. bis 14. Tag nach Diagnosestellung anhand schallspektrographischer Methoden analysiert und mit dem Schreien von 75 reifen gesunden Neugeborenen verglichen.



Die Ergebnisse der Analyse zeigten signifikante charakteristische Unterschiede zwischen dem Schreien der Kinder mit Meningitis und dem der gesunden Kinder. Die Dauer der Phonation was kurzer, die Tonhohe der Grundfrequenz war hoher und es gab mehr tonlose Anteile in der Lautgebung. Bi-Phonation, Abgleiten der Tone und Disharmonien traten signifikant haufiger bei Kindern mit Menigitis auf. Unter den Kindern mit Meningitis war das Schreien bei den Kindern haufiger auffallig, die spater neurologische Folgeerscheinungen hatten.



RESUMEN

Analisis del llanto por espectografia sonica de lactantes con meningitis bacteriana



Se realizo un analisis de 110 llantos inducidos por el dolor en 14 lactantes (edades desde cuatro dias a seis meses) que sufrian una meningitis bacteriana. El analisis se realizo de 1 a 14 dias despuŕs del diagnostico por mŕtodos de espectografia sonica y se comparo con el llanto de 75 lactantes a tŕrmino sanos.



Los resultados del analisis mostraban unas diferencias significativas entre los llantos de los ninos con meningitis y el de los ninos sanos con caracteristicas severas. La duracion de la fonacion era mas corta, el pico de la frecuencia fundamental era mas alto y en las senales ocurrian una mayor cantidad de partes sin voz. Bifonacion, arrastre y rupturas dobles armonicas ocurrian significativamente con mayor frecuencia en los lactantes con meningitis. Entre los lactantes con meningitis, los llantos eran mas anormales en aquellos ninos que despuŕs presentaron secuelas neurologicas.

Sound spectrographic cry analysis of infants with bacterial meningitis.

Un test de type du choix multiple montre que les infirmieres peuvent reconnaitre d'apres une bande magnetique la signification des emissions vocales preverbales repondant a des situations donnees (naissance, douleur, faim, plaisir) chez les enfants de moins de 8 mois. Chez les 80 infirmieres testees l'aptitude moyenne a l'identification fut de 67%. Nos etudes portant sur d'autres groupes humains seront publiees plus tard.

The identification of some specific meanings in infant vocalization.

SUMMARY

Using test subjects with and without experience in baby care, it has been possible to demonstrate the effect of experience on identification of the meanings of babies' vocal responses in the preverbal stage. The responses selected as test items were typical birth, hunger, pain and pleasure vocalizations. The multiple-choice technique was used, the subjects being asked to identify the meanings of 24 vocal items which they heard from a magnetic tape. In general, both women and men with experience did better than the inexperienced.



RESUME

Effet de l'entrainement sur l'aptitude a identifier les vocalisations preverbiales



En utilisant des sujets-tests avec et sans experience de puericulture, il a ete possible de demontrer l'effet de l'experience sur le faculte d'identifier le sens des reponses vocales des bebes au stage preverbial. Les reponses choisies pour le test etaient des vocalisations typiques de faim, douleur et plaisir. La technique du choix multiple etait employee, on demandait aux sujets d'identifier le sens de 24 vocalisations enregistrees sur bande magnet tique. En general, les femmes et les hommes experimentes avaient de meilleurs resultasque les inexperimentes.

Ole Wasz‐Höckert

Papers

Twenty-Five Years of Scandinavian Cry Research

Pain cry in full‐term asphyxiated newborn infants correlated with late findings

Sound spectrographic cry analysis of infants with bacterial meningitis.

The identification of some specific meanings in infant vocalization.

Effect of training on ability to identify preverbal vocalizations.