الفهرس 
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Abstract
Background : Nasal-Continuous Positive Airway Pressure (nCPAP) is frequently used as a respiratory support strategy for preterm infants with respiratory distress. CPAP is an attractive option for supporting neonates with respiratory distress. Naso/oropharyngeal suction is procedure which is used routinely in neonates on nCPAP is considered one of the painful procedures to which neonate are exposed in NICU. Previous studies found that suctioning procedure in neonates elicit physiologic changes. Exposure of preterm neonates to repetitive pain and stress in NICU leads to not only short-term but also long-term deleterious effects. The foundational first steps for the management of pain in the NICU should always be a combination of non-pharmacologic measures. Previous studies on the use of oral glucose 25% for pain relief during suctioning infants receiving nCPAP revealed conflicting results. Paracetamol (N-acetyl p-aminophenol, acetaminophen) has clear analgesic and antipyretic effect. It is the most prescribed drug to treat mild to moderate pain in neonates and young infants. Intravenous paracetamol can be used in the treatment of post-operative pain in preterm infants& decrease requirement of morphine. The aim of the work : to assess efficacy and safety of single-dose of intravenous paracetamol in decreasing pain during suctioning preterm neonates on nasal CPAP compared to oral glucose 25%. Type of study: prospective randomized double-blinded controlled study. Materials and Methods: we enrolled in our study 60 preterm infants (gestational age < 37 weeks), who received respiratory support using nCPAP at the NICU of Mansoura University children’s Hospital (MUCH) and required naso/oropharyngeal suctioning during the first week of life during the period between June 2018 and January, 2020. Neonates enrolled in the study were randomized into two groups according to the regimen of therapy : group 1 (Paracetamol group) : 30 neonates allocated for this received a single dose of intravenous Paracetamol [(Perfalgan 10 mg/ml), Bristol-Myers Squibb Pharmaceuticals, USA], 30 minute before first suctioning, at dosage of 20 mg/kg over 15 min, no intervention was done during the second suctioning. Thus, babies served as their own controls. group 2 (Dextrose 25%):30 neonates allocated for this group was receiving 25% dextrose at 0.3 ml/kg orally 3 minutes before first suction was done administration were done with a 1-ml syringe during constant nasal CPAP. This was done by a nurse not involved in the randomization or the analysis. No intervention was done during the second suctioning. Thus, babies served as their own controls. In both groups we assess premature infant pain profile (PIPP) score 5 min before, during and 5 min after suction. Also we assess HR, RR, FIO2, oxygen saturation, Silverman score, possible side effects of suctioning and possible side effects of paracetamol. Results : There were no significant differences in demographic data and baseline characteristics between the two groups with the exception that significantly higher number of mothers of infants in the paracetamol group received antenatal steroids compared to the 25% dextrose group. The main findings in our study were that naso/oropharyngeal suctioning in preterm infants receiving nCPAP, causes severe pain (PIPP score > 12). In both groups, the PIPP scores were significantly higher during suctioning, compared to the scores recorded before suctioning and 5 minutes after suctioning. We have also demonstrated that both single dose IV paracetamol and oral dextrose 25% significantly reduced this pain response, when compared to no intervention. Moreover, IV paracetamol had superior analgesic effect compared to oral dextrose 25%, however, we did not find a significant difference in number of cases with different grades of pain severity according to PIPP scores in both groups. In our study, there were significantly less duration of nCPAP and a trend towards less length of hospital stay in the paracetamol group compared to the 25% dextrose group. Conclusion : Our study has demonstrated that preterm infants manifest a pain response to suctioning during nCPAP therapy. Pretreatment with IV paracetamol was more effective than 25% dextrose in reducing this pain response. Recommendations : 1) IV paracetamol at a dose of 20 mg/kg to is preferable to 25% dextrose in alleviating the pain associated with naso/oropharyngeal suctioning in preterm infants receiving nCPAP. 2) Further RCTs on a larger sample of infants is required to confirm our results. 3) Further studies to ascertain the long-term safety of IV paracetamol and 25% dextrose on long-term neurodevelopmental outcomes. 4) Further RCTs evaluating non-pharmacological pain relieving interventions in alleviating the pain associated with naso/oropharyngeal suctioning in preterm infants receiving nCPAP. 5) Naso/oropharyngeal suctioning is a painful procedure, it should be performed only as needed 6) Nurses caring for infants receiving nCPAP should assess the pain response to suctioning using validated pain scores, and provide adequate pain relieving interventions for these infants.7) Every NICU should adopt an effective pain prevention protocol that includes plans for reducing the number of painful procedures performed as well as a pain assessment and management plan.