Pharmacological treatment of neonatal pain: are we ready for a paradigm shift? Comment on Br J Anaesth 2021; 126: e133–5

Editor—It is extremely difficult to evaluate the effects of pharmacological treatment pain in newborn infants. This because major challenges measurement and relief these vulnerable patients, continuously changing pharmacokinetics (PK) pharmacodynamics (PD) drugs currently used clinical practice treat neonatal pain.1Van den Anker J. Reed M. Allegaert K. Kearns G. Developmental changes pharmacodynamics.J Clin Pharmacol. 2018; 58: S10-S25Crossref PubMed Scopus (86) Google Scholar As a consequence, dosing analgesic preterm term neonates needs be based on relevant physiological characteristics neonate their PK PD parameters.2Allegaert van Neonatal drug therapy: first frontier therapeutics for children.Clin Pharmacol Ther. 2015; 98: 288-297Crossref (58) In practice, measurements effect(s) pharmacotherapy infants during stay ICU (NICU) are commonly subjective, intermittent interpretations parameters. Therefore, many conditions real-time visualisation analysis may not only improve assessment condition neonate, but also allow more continuous therefore accurate evaluation pharmacotherapy. Clearly feasibility new approaches determined. The recent correspondence Hartley colleagues3Hartley C. Baxter L. Moultrie F. et al.Predicting severity adverse cardiorespiratory morphine premature infants: post hoc Procedural Pain Premature Infants trial data.Br J Anaesth. 2021; 126: e133-e135Abstract Full Text PDF (4) British Journal Anaesthesia help commence discussion whether we need keep current paradigm {drug dose–drug concentration–drug effect (both desired [efficacy] undesired [side-effects])} or shift effect–drug dose paradigm! They electronically captured vital signs 15 who were treated with 0.1 mg kg−1 orally ∼1 h before procedure 24 after show that there was wide variation baseline stability Moreover, indicated approach able predict which at risk events from use pain-relieving medicines, underscored value monitoring optimise medicines individual neonates. authors state modelling might facilitate personalised ultimately safeguard against preventable iatrogenic harm. study has clearly shown it possible sign monitor data objective parameters stark contrast such, this shows an incentive bedside trend pharmacotherapeutic unstable patients. However, ready forfeit information settings relief? other words, administer amount oral one bioavailability infants, using newly proposed method treatment.3Hartley Based could adjusted without any knowledge concentration patient find optimal unique patient. Or do want assure effect–concentration–dose relationship still proper neonate. If latter preferred path then measure concentrations tiny neonates, available neonates4Knosgaard Foster D. Kreilgaard Sverrisdottir E. Upton R. Pharmacokinetic models its metabolites neonates: systematic comparisons literature, development meta-model.Eur Pharm Sci. 2016; 92: 117-130Crossref (20) lack concentration–response curve,5Anderson B.J. J.N. Why no concentration-response curve acute pain?.Pediatr Anesth. 2014; 24: 233-238Crossref (15) necessary anymore. summary, must suffering clear endpoint: relief. question can reach endpoint having administered drug. Are bridge too far? I think dose–concentration–effect towards effect–(concentration)–dose, especially growing number NICUs capable performing supports above-mentioned shift, objectively author declares they have conflict interest. Predicting dataBritish AnaesthesiaVol. 126Issue 4PreviewEditor—Hospitalised experience essential procedures. analgesics infrequently prescribed, often out fear effects.1,2 Opioids analgesics, associated events, primarily prescribed ventilated infants.3 Neonatologists face considerable when trying ensure balance between obtaining clinically significant analgesia whilst minimising effects. Full-Text Open Access