 Okay thank you Chris. So the presenter for this one would be Gerona Casella and she is 23 years old and lives in Rome. She's a young midwives. She graduated in aesthetics in November 2018 at the Catholic University of the Sacred Heart and she is particularly interested in scientific research. As she believes it is essential for continuous improvement in her clinical practice. She is a very empathetic person and she is eager to gain a lot of experience. So welcome Giovanna and over to you. Good afternoon everyone and thank you Lisa for the presentation. The topic of this to talk to you about the management of procedural pain in the healthy Leonardo's term of pregnancy with the use of methodenalgesics in pharmacological and specifically to deepen and benefit the adaptation in these terms. Okay. Let's start with a brief definition of pain. In 1986 the International Association for the Study of Pain gave a very clear definition. In fact it has been defined as a sensorial, emotional, unpleasant experience that can be associated with current potential or written in Italian. In general we must have clear the concept that the inability to communicate verbally does not deny the possibility of an individual to actually experience pain. And this is a particularly important concept in terms of our argument, precisely because we are not able to communicate to our sanitary operators to experience pain. To be able to understand the analgesic and non-pharmacological mechanism it is necessary to have a brief overview of the transmission of pain. Physiologically we know that it is a stimulus for the patients in our case the pain to be able to reach the central nervous system and therefore be elaborated and it is necessary that it is transmitted through a series of neurons of their communicators and that they are going to create a kind of skeleton in our nervous system, therefore a network of communication. To be able to guarantee a clear statement of information it is necessary that a single neuron is able to not only discriminate the various types of sensitivity that are received. In fact we know that a single neuron does not only add a type of information but moreover the neuron must be able to attribute to any information that is received a different priority in order to guarantee information as clear as possible at the level of the central nervous system. On the basis of this, in 1965, Mersake Wall elaborated a theory published in the Science magazine that is taking the name of the cancer theory according to which there is an interaction and a reciprocating modulation between the nociceptive fibers and the non-ciceptive fibers. This means that non-ciceptive fibers are able to influence, in our case positively, the non-ciceptive fibers and therefore modulate the painful experience if they are not even able to do it. In particular, according to this theory, thus giving various pleasant stimuli such as touch, the term auditory taste, to an individual who is trying a painful experience these can even modulate or overdo the perception of pain. It is precisely on this theory that the analgesic technique is based on a pharmacology proposed by the Italian pediatrics Carlo Valere Belliani who takes the name of sensory saturation and today it is considered precisely in the guidelines for prevention and treatment of the pain of the brain or in the Italian guidelines and even represents a degree of recommendation. Therefore, for the management of procedural pain, especially in the neonates and in the non-pharmacological technique, it is highly recommended. Thinking about it, during the treatment of the nerve, the neonator receives contemporary stimuli of various natures, gustative stimuli, tibia, viscimia, olfactory, thermal, terminal and proprioceptive. And precisely for this reason one could consider the treatment of the nerve just like a analgesic technique at the end of the sensory saturation. In fact, during the treatment of the nerve, the neonator does not only receive a purely mechanical stimulation that goes directly into the sucking, but it is also created by a multisensorial stimulation through which the neonate communicates with the mother, thus creating a real relational experience. Starting from this point, the goal of our study was to evaluate, first of all, the reaction to the stimulus of the nerve caused by the cut of the jaw in a design at the end of pregnancy. And the second goal was clearly to indicate the effect of the analgesic of the heart rate in combination with the contact of the skin, mother and child compared to other non-pharmacological methods that we have precisely considered. For the collaboration of our study, we conducted precisely our observational longitudinal study with a field of convenience within the Department of Aesthetics and Neonatology of the polyclinic Augustino Gemelli. And the collection of the data took place during the period between February and September 2018 and the reaction to the painful stimulus was analyzed at 72 hours of life and the reaction of the screening test for metabolic diseases that have effected on all the neonates, necessarily before the admission. They were included clearly the neonates that were respected by precise criteria, in particular, among the criteria of inclusion, we considered an informed, written and signed consensus between the parents. The stationery stage was taken at 3.37, 7 weeks plus zero days and 41 weeks plus six days. A clear hypnotic limit, a premature break of the lower membrane at 18 hours, a CTG of category 1 or category 2 during the expulsion period, a single fetus, a sepal presentation, an upper score at the first, at the fifth minute, at least several sets, and a birth weight between 3.500 grams and 4.500 grams. So, in general, we included in our study all the physiological neonates. They are excluded stages. Instead, all neonates, whose mothers suffered from conditions that were not compatible with the mental health system, and obviously all the children who received analgesics or sedatives, which would obviously have altered the response to the reaction to the painful stimulus. After the selection, the neonates were divided into three study groups. The first neonates of the first group were released to the stage and maintained in contact with the skin before, during and after the procedure. In particular, the release to the stage began a minute before the prelude so as to be able to allow the neonate to focus on the bone and not distract. The neonates instead started in the second group, received the group solution at 10% really during the tanning. The prelude was received on the stage and the group solution was then administered through a setting of 5 ml. In the end, the neonates belonged to the third study group. They were kept in the mother's arms and wrapped in a blanket. The blanket was used by the person of the neonate to be able to allow the child to feel their own scent and to feel, let's say, to create a much more familiar environment. All the preludes were kept inside the emergency room, while inside our pre-ruminine structure, the room had to be quiet and there was only the presence of the parents, of the pediatric nurse, of the hysteria that was kept in the prelude, of an observer. For the analysis of the pain, we have considered physical and clinical parameters. In particular, the heart rate and saturation for oxygen inferiors have been recorded with an oximeter pulse positioning the probe at the right wrist of the neonate. The evaluation scale used, instead of the neonate in fat-base scale and the numerous evaluation scales for the evaluation of the pain of the neonate we have chosen precisely this, in terms of the result of the electricity. They tell us that it is specific to the neonate at the end of the pregnancy, suitable for the analysis of the procedural pain and is present at a critical stage of analgesia. The Y-score was signed during the procedure only by a single observer. In particular, the behavior of the neonate has been observed, therefore, the behavior considered the expression of the visor, the plant, the movements of the upper and lower arches was the result of the neonate whether it was asleep or not, or whether it was more agitated. Each factor was assigned a score of 0 to 1, made exception for the plant, and provided a score of 2. The only physiological factor considered, instead, is the modification of the respiratory pattern, which therefore changed according to the child's state. If the child has more pain, or not. The entire procedure, let's say that we can schedule it in three fundamental moments, the moment T0, T1 and T2. The moment T0, we have defined as a baseline, we say that it was constituted of 10 minutes before the blood pressure, during which the neonate absolutely must not be under any stimulus. The moment T2, is the result of the procedure, which includes the puncture of the heel and the opening of the same, while the moment T2 is the result of recovery, i.e. 10 minutes after the procedure's end. Cardiac frequency and oxygen periferous saturation were recorded during each moment, while the initial score was defined only at the moment T1. Let's move on to our results. For the study we have selected a number of 64 children, three children, however, have been excluded as parents did not give the consent to the study, so in total, the numbers we have studied are 661, with a participation rate of 95%. After that, the numbers have been assigned to each group, a number of 21 neonates has been assigned to the group directly to the center of contact for the skin, 20 neonates to the group with the solution included, in relation to the mother and the child. So, keep your arm up and keep the cover. In demographic terms, we have not found statistically significant differences in terms of age, in terms of pregnancy, in terms of gestational age, in terms of birth, in terms of birth, in terms of birth, in terms of birth, in terms of birth, in terms of genetics, in terms of Corona, in the same slide, as it is necessary a complex evaluation, in fact, in the response to a painful stimulus, which logically responds with an increase in cardiac frequency and a contemporary desaturation. Here now we know exactly what we have noticed in these notes that we have studied. I am stopping at a T1 moment, which if you remember well is the moment of the procedure, so the puncture of the jaw and the squeeze. At the T1 moment we have observed, as shown in our P-Velue, an increase in cardiac frequency, which is statistically significant in all groups. However, observing the oxygen saturation, while in the first and second group the saturation remains somewhat stable, in the third group of children, at this moment of the cardiac frequency corresponds to an increase in desaturation, so these are certainly not the ones that are perceived in a more intense way, the painful stimulus. Let's stop here, instead, on the T2 moment, that is, the recovery phase. We immediately notice that the cardiac frequency, at 10 minutes from the end of the procedure, still tends to remain at higher values than those of departure. However, it is interesting to see how, in the third group of children, in only the relation between mother and child, not only in the recording of a significant decrease in cardiac frequency, but also a significant increase in oxygen saturation, so it is true that they have perceived so much pain, but at the same time they have quickly recovered. Clearly, the variations in the cardiac frequency of the saturation are fundamentally linked to the movements of the child, to the plant, and therefore to the behavior. In fact, during the plant, when the baby feels a lot of pain, not only the cry, but clinically we see that the baby is also expressed with the morphs, producing moments in a confused and intermittent way the superior and the inferior arts, and they are all the parameters suggested in the evolution scale in Y. Clearly, the association of the plant and the coordinated movements of the child will end a increase in the cardiac frequency, but also a desaturation, because fundamentally it does not breathe in a regular way, in addition to the lack of energy. As mentioned previously, the NIPZ SCORE takes into consideration precisely all these behavioral factors that the child has put during the painful stimulus and not precisely the modifications of the respiratory tract. In our study we considered, like 5, the cathode, over which a neonate perceives an intense pain that goes from moderate to severe. It is very interesting to note how, drawing a line of demarcation in our graph, while in the group of neonates, the attack on the breast, in contact with the skin with the mother, we have a 0% of children who perceive a pain of a certain degree of intensity. In 25% and 35% of the neonates who have received the only oral stimulation with the glucose solution and the children who find themselves alone with the mother. So, wrapped in the blanket and kept in their arms, respectively 25% and 35% of the children have had, let's say, immediately an experience of pain, particularly intense, compared to one of the first groups. In short, throughout this study, clearly there are some limits, but also a number of strength points. Surely the champion is limited to 61 children, they are not enough to be able to define certain concepts. The absence of a video recording has certainly allowed us to evaluate, give a clinical evaluation afterwards, of the reaction of the stimulus, of the reaction of the neonate to the painful stimulus and, moreover, it has allowed us to evaluate from the most observatory. In short, the genesis point has been designated exclusively by the observer present in the room at the time of the appointment, so it has not been possible to review it at a distance of time. In addition, the observers, inevitably we recognize in different groups why, because, clearly, the prelude mode was totally different from the other. On the other hand, our study is certainly due to reproducibility and applicability. It is about the techniques that can be put in place in the field of the daily techniques that can be reproduced in any hospital or non-hospital structure. We have used a standard procedure, the same for all neonates and obligatory for all, and the inferiors and the aesthetics that have been taken from the prelude are true that we recognize the various study groups, which were not the knowledge of the objective of the study. Therefore, this could have reduced one of the number of biases related to this factor. In conclusion, as I said previously, the champion that we have studied has turned out to be homogeneous. In conclusion, let's say, in short, we have registered, if we remember the graphic of the heart rate, we have registered at the time an increase in the heart rate in all study groups. Therefore, none of the pharmacological agents was able to completely eliminate the painful sensation, even if there were no significant variations of oxygen saturation in the first and the second group in particular. In the seno group, there is contact for the skin, both paramedics, both paramedics, which are the best results compared to other groups. Therefore, it can be said that the seno-relation with contact for the skin guarantees an immediate analgesic and superior compared to other groups, also compared to the group that received only the blood solution, because it is true that we had an increase in heart rate without desaturation, but temporarily we have registered it in this group of neonates in larger genits. If we remember, in fact, 25% of neonates have experienced a severe painful experience from moderate to severe. In the group instead of neonates belonging to maternal holding and swaddling and then only in the arms of mothers and in the cover we can say that the measure used was only the relation between mother and child. Techniques related to macrology have also been reported in literature. If you remember the graphics of the physiological parameters of the nipsus core, these children have been the ones who have experienced a more intense experience, a more intense painful experience, but in this I have registered it a little faster. In particular, it is on the basis of our data, therefore, on the basis of recent results that have been published last September by Bambi and collaborators it can be stated that the relation between mother and child could be considered more like an analgesic amplifier than an analgesic in itself. In fact, the only relation between mother and child allows a recovery chapter, but indeed during the talon does not allow the neonate to react in a more active way to the painful stimulus. In particular, when the relation between mother and child is associated with another non-pharmagological technique, for example, the sucking, the oral stimulation of the child as it happens in the attachment to the breast this could amplify and deepen the analgesic effect of the oral solution used. Finally, I would like to conclude my speech with a message to bring home, that is, to act with all the instruments that we have available to maintain the perception of pain is an imperative for our sanitary operators, both humanitarian and clinical. Not only in the adult population, but also in the neonates. Until 1970, in fact, we thought that the neonates could not be able to perceive the pain, due to the majority of the network of communication that consists of our nervous system. But thanks to scientific research today we know that even the smallest of the network of communication is not possible to remain indifferent to the question. The rest of the biggest challenge of medicine has always been and still is to fight the pain. Thank you for your attention. Okay, thank you, Giovanna. One question in the chat. I'm just asking why among the criteria there was also the clear amniotic league. Clear? Clear? Yes, because it comes back between the conditions of physiological neonates and, moreover, often wanting to enter our structure when we find ourselves in conditions of non-imperial amniotic often happens that it is related to different modern pathologies so it also enters in the criteria of inclusion of mothers. Okay, thank you. So basically she said when the amniotic fluid is not clear it means there are a few problems and pathologies both in child and mother that exclude them from being able to participate in this test. Any other questions? Okay, I have one. So among the... Wait, I'm going to pass it in the public chat, which is among the non-pharmacological techniques, which ones would you recommend to take a blood sample from a newborn among those you explained? Well, today we don't know for sure what the non-pharmacological is. Considering that the blood sample is based on the only relational experience between the mother and her child that the blood sample does not prevent any add-on in the artificial oral solutions we call them glucosate I think that the clearly combining the contact for the skin can be judged as the non-pharmacological intervention for the procedural pain management of less entity. Okay, thank you. Welcome to those joining us. We're currently taking questions about the presentations of the presentation. Okay, another question. How did you assign the NIPPS score when the blood draw had to be repeated to obtain a big enough sample? In the event of a insufficient sample, a score of a few seconds from the first. However, the score of the NIPPS was only referred to the first score, while the other outcomes of the physiological parameters, as well as the oxygen saturation, were evaluated during the procedure.