Non-pharmacological management of infant and young child procedural pain

Comparison of Sucrose vs. Swaddling in Pain Management during Birth Dose of Hepatitis B Vaccine: A Randomized Control Trial

OBJECTIVES

To evaluate the efficacy of pain management of 1 ml of 24% sucrose given orally compared to routine care given one minute before vaccination for reduction of pain.

METHODS

This double-blind randomized controlled trial included term neonates visiting Pediatric OPD for immunization. Neonates were randomly assigned into two groups (Group A- Sucrose, Group B- Swaddling). Commercially available sucrose solution (StayHappi solution 24%) was given in a dose of 1 ml to the neonates. Video recording of the neonate's facial expression was done during the procedure. Duration of cry, latency of onset of cry as well Modified Neonatal Facial Coding Score (MFCS) were the outcome variables.

RESULTS

The mean (SD) of birth weight and gestational age was 2729 (321.6) g and 38.24 (0.84) d, respectively. Analysis showed significant difference in total MFCS across the groups (P <0.001). Total MFCS was significantly lower in sucrose group [4.88 (1.07) vs. 7.17 (0.95)]. The duration of cry (in seconds) was also found to be significantly lower in sucrose group.

CONCLUSIONS

Administration of 1 ml 24% sucrose one minute prior to immunization is efficacious in pain management during injectable immunization.

The Effect of Breast Milk Odor on the Pain and Stress Levels of the Newborn During the Endotracheal Suction Procedure

Objective: The study aimed to determine the effect of the breast milk odor on the pain and stress levels of the newborn during the endotracheal suction procedure. Method: The study was conducted in the randomized-controlled experimental design at the neonatal intensive care unit of the hospital in eastern Turkey between March 2022 and December 2023. The study population included newborns at the 37th to 41st gestational weeks who were receiving mechanical ventilation treatment in the neonatal intensive care unit of a hospital in eastern Turkey. All newborns who met the inclusion criteria during the data collection phase were included in the study. The study was completed with 88 newborns (44 in the intervention group and 44 in the control group). The Newborn Introductory Information Form, ALPS-Neo Newborn Pain and Stress Assessment Scale, and follow-up form were used to collect the study data. The breast milk odor of the mothers of the newborns was used as the intervention group in the study. The mothers of the newborns were contacted to obtain breast milk, and the information was obtained from the mother on the day of the procedure. One milliliter of breast milk was taken and dropped into a sterile sponge, and it was held 10 cm away from the baby's nose from 5 minutes before to 5 minutes after endotracheal suction. A routine endotracheal suction process was performed in the control group. Ethical principles were followed in the study. Results: We found that the intervention group's pain and stress score averages were lower than the control group during and after the endotracheal suction procedure (p < 0.05). Conclusion: We found that the breast milk odor reduced the pain, stress levels, and crying duration of newborns during the endotracheal suction process.

The effect of the swaddling method on stress levels in newborns administered nasal CPAP

BACKGROUND

This study aims to investigate the effects of the swaddling method on the stress levels in newborns receiving nasal continuous positive airway pressure (nCPAP).

METHODS

The study was conducted between 1 June 2022 and 1 October 2022 with 40 newborns who underwent nCPAP in the second-level Neonatal Intensive Care Unit (NICU) of a city hospital in the Central Anatolia Region of Turkey. Data were collected using a descriptive form, including the characteristics of newborns, a patient follow-up chart, and the Newborn Stress Scale (NSS). The descriptive form, the patient follow-up chart, and the NSS were completed by the researcher 30 min after the nCPAP was started and the first saliva sample was taken. The patient follow-up chart and NSS were completed 30 min after applying the swaddling method and the second saliva sample was collected. The data were analyzed using IBM SPSS Statistics 25.0 package software and presented with number, percentage, mean, standard deviation, min-max, and t-test.

RESULTS

The study found that the mean score of the NSS after the intervention (3.52 ± 2.57) was lower than that before the intervention (10.02 ± 2.05) (p < 0.05). The mean saliva cortisol levels of the newborns after the intervention (4.99 ± 1.89) were lower than before the intervention (5.51 ± 1.65) (p < 0.05). The mean heart (135.50 ± 14.15) and respiratory rates (68.07 ± 10.16) of the newborns after the intervention were lower than those before the intervention (140.82 ± 18.11; 72.95 ± 9.06, respectively) (p < 0.05). There was no difference between the mean oxygen saturation of newborns before and after the intervention (p > 0.05).

CONCLUSIONS

The study showed that the swaddling method played a role in reducing the stress levels in newborns who underwent nCPAP. It is recommended that randomized controlled trials examining the effect of swaddling on the stress levels of newborns who underwent nCPAP be conducted.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Neonatal neuropalliative care

Neonatal neuropalliative care is directed toward patients and families impacted by serious, life limiting, or debilitating neurologic illness in the antenatal and newborn period. This chapter will outline key considerations for clinicians hoping to provide a neuropalliative care approach antenatally, at birth, and in the neonatal intensive care unit. We focus on three core domains: (1) family-centered communication and care, (2) prognostication and decision-making, and (3) pain and symptom management. In each domain, we outline key considerations in the antenatal period, at birth, and in the neonatal intensive care unit. We also address special considerations in care at the end of life and in varied cultural and practice contexts. We conclude with suggestions for future research and key considerations for neonatal clinicians who wish to incorporate a neuropalliative approach to care into their practice.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

Summary and Analysis of Relevant Evidence for Nondrug Nursing Programs in Neonatal Operational Pain Management

Purpose

To summarize the relevant evidence for nondrug nursing programs in neonatal operational pain management.

Methods

Computer search for the literature on neonatal procedural pain from 2015 to 2020 in Up To Date, JBI, NICE, SIGN, RNAO, NGC, PubMed, Cochrane Library, CNKI, and Wanfang database was conducted. All literature works that may meet the inclusion criteria were independently evaluated by two researchers to determine the quality grade of the articles.

Results

Finally, 9 literature works were extracted, including 4 guidelines, 3 systematic reviews, and 2 evidence summaries. The relevant contents of the literature were extracted and summarized, and 20 pieces of the best evidence were obtained.

Conclusion

Breast feeding, sweetener, Kangaroo mother care, sensory stimulation, nonnutritive sucking, and other nondrug nursing programs can reduce the neonatal operational pain, which has guiding significance in neonatal operational pain management.

"Holding-Cuddling" and Sucrose for Pain Relief During Venepuncture in Newborn Infants: A Randomized, Controlled Trial (CÂSA)

Objectives: Oral sucrose is commonly used to provide analgesia to neonates during painful procedures, such as venepuncture. The additional benefits of reducing pain during venepuncture when oral sucrose is combined with nonpharmacological strategies have not been extensively studied. This randomized controlled trial compared the efficacy of oral sucrose with nonnutritive sucking vs. oral sucrose with nonnutritive sucking plus "holding-cuddling" for pain management during venepuncture in term infants from birth to 3 months of life. Methods: Seventy-eight infants were equally randomized to receive 24% oral sucrose with nonnutritive sucking (control group) or 24% oral sucrose with nonnutritive sucking plus "holding-cuddling" (being held in a secure, cuddling position; experimental group) before venepuncture. Behavioral response to pain was measured by the 0-10 ranking scale "acute pain for neonates (APN)" at 30 and 60 s after venepuncture. Results: Within the study sample, APN scores were ≥ 2 for 32/68 (47%) infants. "Holding-cuddling" did not significantly reduce mean APN scores at 30 and 60 s, but the rate of infants experiencing a high pain score (APN ≥ 8) at 60 s after the venepuncture was significantly lower in the experimental group compared to controls [4/34 vs. 12/34 (p = 0.04)]. Conclusions: Venepuncture is a painful procedure in newborn and young infants. The implementation of behavioral strategies in association with oral sucrose may mitigate pain during this procedure. Clinical Trial Registration: This trial was registered at http://clinicaltrials.gov/ (NCT number 02803723).

The effect of facilitated tucking position during painful procedure in pain management of preterm infants in neonatal intensive care unit: a systematic review and meta-analysis

We performed a systematic review and meta-analysis to investigate the effects of facilitated tucking position during painful procedure in pain management of preterm infants. We searched MEDLINE, PEDro, SciELO and the Cochrane Library (until June 2019) for randomized controlled trials. An α value ≤ 0.05 was considered significant. Heterogeneity among studies was examined with Cochran's Q and I² statistic, in which values greater than 40% were considered indicative of high heterogeneity and random-effects model was chosen. Analyses were performed with Review Manager 5.3. Fifteen studies met the eligibility criteria, including 664 preterm infants. The meta-analyses showed a significant reduction in pain of - 1.02 (95% CI - 1.7 to - 0.4, N = 216) during endotraqueal suctioning for participants in the facilitated tucking position group (FTPG) compared with routine care group. The meta-analyses showed a non-significant difference in pain - 0.3 (95% CI - 2.05 to - 1.4, N = 88) during heel stick for participants in the FTPG compared with oral glucose group. The meta-analyses showed a non-significant difference in pain for participants in the FTPG compared with oral opioid group 0.2 (95% CI - 1.4 to 1.8, N = 140).Conclusion: Facilitated tucking position may improve the pain during painful procedures.What is Known:• Exposure of premature babies to painful procedures is associated with changes in brain development, regardless of other factors.• Facilitated tucking reduces the expression of pain in premature infants.What is New:• Facilitated tucking position was efficient in pain management of preterm infants when compared to routine care.• Facilitated tucking compared to opioid or oral glucose did not achieve a significant reduction in pain intensity.

Analgesic effect of non-nutritive sucking in term neonates: A randomized controlled trial

BACKGROUND

Newborns commonly experience pain due to a variety of reasons. Non-nutritive sucking (NNS) is thought to be an effective non-pharmacological method of pain-relief. However, the significant heterogeneity in some systematic reviews limited the certainty of the findings about NNS. Hence, this study was aimed at evaluating the analgesic effect and safety of NNS in healthy term neonates during the heel prick test, using the Neonatal Pain Agitation and Sedation Scale (N-PASS).

METHODS

In this randomized controlled trial, 42 term infants were included: 22 infants in the intervention group (receiving NNS) and 20 infants in the control group (not receiving NNS). In the intervention group, neonates were given a silicone pacifier 120 s before, during, and 120 s after the heel puncture, while neonates in the control group received routine care. Pain-related outcomes were assessed using the N-PASS at 30s, 60s, 90s, and 120s after the heel prick. Any adverse events during the procedure were noted. The Spearman correlation coefficients between the pain scores on the N-PASS and two other scales (NFCS and NIPS) were calculated at all four moments of evaluation.

RESULTS

The mean N-PASS pain scores at 30s, 60s, 90s, and 120s after heel prick were significantly lower in the NNS group than in the control group: 4.73 ± 2.78 vs. 7.90 ± 1.52 (p = 0.0002); 3.64 ± 3.06 vs. 5.55 ± 2.95 (p = 0.052); 2.59 ± 3.08 vs. 5.25 ± 3.51 (p = 0.011); and 2.05 ± 2.94 vs. 4.90 ± 3.99 (p = 0.013), respectively. No adverse events were detected in either group. Our findings revealed a strong positive correlation between the pain scores on the N-PASS and two other scales (NFCS and NIPS), which was statistically significant (p < 0.01).

CONCLUSIONS

NNS is considered a safe and effective pain-relief method during the heel prick procedure in term neonates, demonstrated using the N-PASS. These findings were correlated with the pain evaluation by NFCS and NIPS.

The influence of pain, agitation, and their management on the immature brain

Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct.

Neonatal Assessment Manual Score: Is There a Role of a Novel, Structured Touch-Based Evaluation in Neonatal Intensive Care Unit?

Despite the technological improvements in monitoring preterm infants in the neonatal intensive care unit, routine care in the neonatal ward is primarily based on manual procedures. Although manual clinical procedures play a critical role in neonatology, little attention has been paid to palpation as a clinical assessment tool. Palpation is a clinical evaluation tool that relies mostly on the senses of touch and proprioception. Based on recent studies investigating the role and clinical effectiveness of touch in full-term and preterm babies, this paper proposes an evaluative touch-based procedure-the Neonatal Assessment Manual Score (NAME) model-that could be useful in the neonatal ward and describes its rationale. The operator applies gentle light pressures to the infant's body. In essence, the touch stimulates low-threshold afferent fibers that could influence the interoceptive cerebral network and the autonomic nervous system, thus altering the blood flow and breathing rhythm. These events could change how bodily fluids distribute among body segments and hence the body volume. The volume modification could be felt manually through haptic perception owing to the high sensitivity of the fingers. On the basis of their clinical conditions and stage of development, infants will respond differently to the applied pressures. Evaluating the infant's response, the operator produces a score of "bad," "marginal," or "good" for communicating quickly and clearly the infant's conditions to other professionals. Because the NAME model is intended for every professional who is used to touch-based procedures, if future studies confirmed its validity and reliability in clinical practice, the NAME model could become a part of the neonatal ward routine care for better assessing and managing the infant's conditions, even during emergencies.

Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update

Infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available that may be used for these painful procedures, including swaddling/containment, pacifier/non-nutritive sucking, rocking/holding, breastfeeding and breastmilk, skin-to-skin care, sweet tasting solutions, music therapy, sensorial saturation, and parental presence. Adoption these interventions into routine clinical practice is feasible and should be a standard of care in quality health care for infants. This review summarizes the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions.

Changes in autonomic regulation due to Kangaroo care remain unaffected by using a swaddling device

Aim

To investigate the effects of a swaddling device known as the Hugsy (Hugsy, Eindhoven, the Netherlands) towards improving autonomic regulation. This device can be used both in the incubator and during Kangaroo care to absorb parental scent and warmth. After Kangaroo care, these stimuli can continue to be experienced by infants, while in the incubator. Additionally, a pre‐recorded heartbeat sound can be played.

Method

Autonomic regulation was compared in preterm infants before, during and after Kangaroo care with and without the use of a swaddling device in a within‐subject study carried out in a level III neonatal intensive care unit. Descriptive statistics and effect sizes were calculated corresponding to changes in heart rate, respiratory rate, oxygen saturation, temperature and heart rate variability on intervention versus control days.

Results

In this study of 20 infants with a median (interquartile range) gestational age of 28.4 (27–29.9) weeks, Kangaroo care was associated with a decrease in heart rate, respiratory rate and heart rate variability on both intervention and control days. There were no differences between intervention and control days.

Conclusion

The use of an alternative swaddling device aimed at facilitating Kangaroo care did not enhance autonomic regulation, as measured by vital signs and heart rate variability.

Turkish Neonatal Society guideline on the neonatal pain and its management

Pain control is an important ethical issue to be considered and constitutes the basis of treatment in premature and term newborns. The inadequacy of pain control in these infants in neonatal intensive care units leads to neurodevelopmental and behavioral problems in the long term. For this reason, it is extremely important to raise awareness of the presence of pain in newborn infants, to reduce invasive procedures applied to infants as much as possible, and to minimize pain with non-pharmacologic or pharmacologic treatments when it is inevitable.

Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative

BACKGROUND/OBJECTIVES

In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period.

METHODS

A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described.

RESULTS

All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites.

CONCLUSION

While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Pain-Relieving Interventions for Retinopathy of Prematurity: A Meta-analysis

CONTEXT

Retinopathy of prematurity eye examinations conducted in the neonatal intensive care.

OBJECTIVE

To combine randomized trials of pain-relieving interventions for retinopathy of prematurity examinations using network meta-analysis.

DATA SOURCES

Systematic review and network meta-analysis of Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and the World Health Organization International Clinical Trials Registry Platform. All databases were searched from inception to February 2017.

STUDY SELECTION

Abstract and title screen and full-text screening were conducted independently by 2 reviewers.

DATA EXTRACTION

Data were extracted by 2 reviewers and pooled with random effect models if the number of trials within a comparison was sufficient. The primary outcome was pain during the examination period; secondary outcomes were pain after the examination, physiologic response, and adverse events.

RESULTS

Twenty-nine studies (N = 1487) were included. Topical anesthetic (TA) combined with sweet taste and an adjunct intervention (eg, nonnutritive sucking) had the highest probability of being the optimal treatment (mean difference [95% credible interval] versus TA alone = -3.67 [-5.86 to -1.47]; surface under the cumulative ranking curve = 0.86). Secondary outcomes were sparsely reported (2-4 studies, N = 90-248) but supported sweet-tasting solutions with or without adjunct interventions as optimal.

LIMITATIONS

Limitations included moderate heterogeneity in pain assessment reactivity phase and severe heterogeneity in the regulation phase.

CONCLUSIONS

Multisensory interventions including sweet taste is likely the optimal treatment for reducing pain resulting from eye examinations in preterm infants. No interventions were effective in absolute terms.

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS)

PROBLEM

Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use.

ELIGIBILITY CRITERIA

Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included.

SAMPLE

Twenty-eight studies (8 psychometric and 20 RCTs) were included.

RESULTS

Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS.

CONCLUSIONS

It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children.

IMPLICATIONS

Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

Lidocaine Gel for Urethral Catheterization in Children: A Meta-Analysis

OBJECTIVE

To compare the efficacy and safety of lidocaine gel vs nonanesthetic gel (NAG) in reducing transurethral bladder catheterization (TUBC) procedural pain in children.

STUDY DESIGN

A systematic literature search was done using electronic medical databases and trial registries up to September 2016 with no language restrictions. Randomized controlled trials (RCTs) that assessed the efficacy and safety of lidocaine gel vs NAG in reducing TUBC-associated pain in children were screened, identified, and appraised. Risks of bias and study quality of the eligible trials were assessed according to the Cochrane Collaboration recommendations. Various pain assessment scales from the included studies were extracted as mean differences and standard deviations for each treatment group. Standardized mean differences (SMDs) were generated with 95% CIs for between-group difference estimation. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed for different age groups.

RESULTS

Five RCTs (with a total of 369 children) were included. Overall pooled effect estimates showed that compared with NAG, lidocaine gel has no significant benefit in decreasing TUBC-associated pain in children (SMD, -0.22; 95% CI, -0.65 to 0.21). Effect estimates from 4 studies revealed no difference in pain reduction between the lidocaine gel and NAG in children aged <4 years (SMD, 0.01; 95% CI, -0.22 to 0.24). No serious adverse events from the lidocaine gel use were reported in any of the studies.

CONCLUSIONS

Lidocaine gel does not appear to reduce TUBC pain compared with NAG, specifically in children aged <4 years.

PROSPERO REGISTRATION NUMBER

CRD42016050018.

Pain and distress outcomes in infants and children: a systematic review

The aim of the present study was to systematically review the recent literature about pain and distress outcomes in children and critically analyze the methodological quality of the reports. The systematic review was based on the PRISMA statement and performed by selecting articles that are indexed in scientific databases. The methodological quality of reports was examined using STROBE statement, for observational studies, and CONSORT statement, for randomized controlled trials. The PedIMMPACT consensus was used to evaluate the psychometric quality of pain instruments. We analyzed 23 empirical studies, including 14 randomized controlled trials, seven cross-sectional studies, and two studies with cohort designs. Fourteen studies included preschool- and schoolchildren, and nine studies included infants. Regarding studies with infants, pain responses were evaluated by heart rate, crying and behavioral observation scales, and distress was evaluated only by salivary cortisol. Four-handed care and sensorial saturation interventions were used to evaluate efficacy to reduce pain and distress responses. Concerning studies with children, both pain and distress responses were evaluated by self- and hetero-reports, behavioral observation and/or physiological measures. Distraction was effective for reducing pain and distress during burn dressing changes and needle procedures, and healing touch intervention reduced distress and pain in chronic patients. All of the studies scored at least 60% in the methodological quality assessment. The pain outcomes included measures of validity that were classified as well-established by the PedIMMPACT. This systematic review gathers scientific evidence of distress-associated pain in children. Pain and distress were measured as distinct constructs, and their associations were poorly analyzed.

Effect of combined music and touch intervention on pain response and β-endorphin and cortisol concentrations in late preterm infants

BACKGROUND

Preterm neonates undergo many painful procedures as part of their standard care in the neonatal intensive care unit. However, pain treatment is inadequate in many of these routine procedures. In the present study, we investigated the impact and mechanism of combined music and touch intervention (CMT) on the pain response in premature infants.

METHODS

Sixty-two preterm neonates (gestational age of <37 weeks) were randomly assigned to either the experimental or control group. Infants in the experimental group underwent painful procedures with CMT, and those in the control group underwent painful procedures without CMT. Blood samples were collected from all infants at the beginning of hospitalization and 2 weeks later to assess the cortisol and β-endorphin concentrations. Differences in the levels of cortisol and β-endorphin between two groups were examined using analysis of covariance (ANCOVA).

RESULTS

In total, 3707 painful procedures were performed on 62 neonates during their hospitalization. The average number of painful procedures in the control group (n = 35.5) was higher than that in the experimental group (n = 29.0) during hospitalization, although no significant difference was reached (P > 0.05). After 2 weeks, the Premature Infant Pain Profile scores were significantly higher in the control group than experimental group (13.000 ± 0.461 vs 10.500 ± 0.850, respectively; P < 0.05). The cortisol concentration was not significantly different between the control and experimental groups either at the beginning of hospitalization (131.000 ± 18.190 vs 237.200 ± 43.860, respectively; P > 0.05) or 2 weeks later (162.400 ± 23.580 vs 184.600 ± 21.170, respectively; P > 0.05). However, the serum β-endorphin concentration was higher in the experimental group than in the control group both at the beginning of hospitalization (1.640 ± 0.390 vs 1.179 ± 0.090, respectively; P < 0.05) and 2 weeks later (2.290 ± 0.740 vs 1.390 ± 0.410, respectively; P < 0.05).

CONCLUSIONS

CMT might decrease the pain response of preterm neonates by significantly improving the β-endorphin concentration, but not the blood cortisol concentration.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14131492 . Registered on 01 Aug 2016.

A feasibility and efficacy randomised controlled trial of swaddling for controlling procedural pain in preterm infants

AIMS AND OBJECTIVES

This study aimed to investigate the feasibility and efficacy of swaddling to control procedural pain among preterm infants.

BACKGROUND

Swaddling has been recommended for controlling neonatal pain. However, the feasibility for use is uncertain and insufficient evidence is available among preterm infants.

DESIGN

A two-arm randomised controlled trial with repeated measures.

METHOD

The study was conducted in a 21-bed neonatal intensive care unit of a regional hospital in Hong Kong. Preterm infants who required heelstick procedure were eligible. Fifty-four preterm infants between 30-37 gestational weeks were randomly assigned to swaddling (n = 27) and control (standard care, n = 27) groups. Pain assessment was performed pre, during, immediate, two, four, six and eight minutes after heelstick procedure using the Premature Infant Pain Profile.

RESULTS

The mean Premature Infant Pain Profile scores were significantly reduced in the intervention group compared to the control group during, immediate, two, four, and six minutes after the heelstick procedure. The mean changes of heart rate and oxygen saturation in the intervention group were significantly lower than that of the control group at all measured time points. Notably, the swaddled infants quickly resumed to the baseline level at two minutes whereas the control group reached the stable state at an extended period of six minutes.

CONCLUSION

The findings show that swaddling is feasible and efficacious in controlling pain for heelstick procedure among preterm infants. No adverse effects were observed.

RELEVANCE TO CLINICAL PRACTICE

This article presents the feasibility and efficacy of swaddling as a non-pharmacological and non-invasive intervention to relieve pain during the heelstick procedures among preterm infants. Swaddling can contribute to control minor procedural pain in neonates as one of the simple, safe, cost effective, humanistic and natural analgesia alternatives.

Managing Pediatric Pain in the Emergency Department

Far more attention is now given to pain management in children in the emergency department (ED). When a child arrives, pain must be recognized and evaluated using a pain scale that is appropriate to the child's development and regularly assessed to determine whether the pain intervention was effective. At triage, both analgesics and non-pharmacological strategies, such as distraction, immobilization, and dressing should be started. For mild pain, oral ibuprofen can be administered if the child has not received it at home, whereas ibuprofen and paracetamol are suitable for moderate pain. For patients who still require pain relief, oral opioids could be considered; however, many EDs have now replaced this with intranasal fentanyl, which allows faster onset of pain relief and can be administered on arrival pending either intravenous access or definitive care. Intravenous opioids are often required for severe pain, and paracetamol or ibuprofen can still be considered for their likely opioid-sparing effects. Specific treatment should be used for patients with migraine. In children requiring intravenous access or venipuncture, non-pharmacological and pharmacological strategies to decrease pain and anxiety associated with needle punctures are mandatory. These strategies can also be used for laceration repairs and other painful procedures. Despite the gaps in knowledge, pain should be treated with the most up-to-date evidence in children seen in EDs.

Yakson touch as a part of early intervention in the Neonatal Intensive Care Unit: A systematic narrative review

Yakson is a Korean therapeutic touch given to neonates and infants by caressing their abdomen with one hand while the other hand is placed on the back of the neonate\infant either to relieve their pain or to calm them down. It was traditionally used by Koreans by caressing the aching body part of their children with a belief that it would relieve their pain. In spite of clinical evidence of its usefulness, there is limited literature available on Yakson touch. A systematic narrative review (SNR) was undertaken on studies that were carried out on the effectiveness of Yakson touch on infants and neonates. Only seven studies were detected from five major electronic databases, searched with the keywords: “Yakson,“ “Yakson touch,” and “Yakson in neonates”. One of the studies has been included in two Cochrane reviews by the same group of researchers published in 2011 and 2015, respectively, and also in a literature review. The evidence from these articles suggests that Yakson touch is able to increase the sleep scores of infants, affects their behavioral response, decreases the stress levels, increases maternal attachment, and has calming effects on them. However, the number of studies is limited, and thus the efficacy of this intervention has not been sufficiently established. Hence, there is a definite need for future studies to prove the efficacy of Yakson to include it in the early intervention programs. This SNR is aimed at compiling the studies which determined to prove the efficacy of the intervention of Yakson.

Psychological Interventions for Vaccine Injections in Young Children 0 to 3 Years: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

Supplemental Digital Content is available in the text.

Background:

This systematic review evaluated the effectiveness of distraction for reducing infant distress during vaccinations in young children aged 0 to 3 years.

Design/Methods:

Database searches identified relevant randomized and quasi-randomized controlled trials. Three separate clinical questions related to variants of the psychological strategy of distraction (directed video; directed toy; nondirected toy) were pursued. Distress was identified as the critical outcome to assess the benefits of distraction and extracted from relevant trials. Distress was analyzed by phase of procedure (distress preprocedure; distress acute; distress recovery; idiosyncratic phases based on some or all of the 3 aforementioned phases).

Results:

Ten studies were included in the review. Significant results are presented herein. For directed video distraction, moderate quality evidence suggested that distress was lowered in the treatment group standardized mean difference (SMD −0.68 lower [95% confidence interval (CI), −1.04 to −0.32]) for the acute+recovery phase as well as the preprocedure phase (SMD −0.49 lower [95% CI, −7.6 to −0.22]). For directed toy distraction, the analysis of low-quality evidence for a combined preprocedure+acute+recovery phase of distress (analysis n=81), suggested that distress was lowered in the treatment group (SMD −0.47 lower [95% CI, −0.91 to −0.02]). An effect for nondirected toy distraction was also seen, analyzing very–low-quality evidence, for the acute distress phase (n=290; SMD −0.93 lower [95% CI, −1.86 to 0.00]).

Conclusion:

Generally low-quality to very–low-quality evidence suggests that there may be an effect of directed (toy and video) and nondirected toy distraction for children aged 0 to 3 years, for certain phases of the vaccination.

Skin-to-skin contact reduces near-infrared spectroscopy pain responses in premature infants during blood sampling

AIM

This study investigated if skin-to-skin contact could provide pain relief, measured with near-infrared spectroscopy (NIRS), during venepuncture in premature infants.

METHODS

Ten infants born at 26-35 weeks of gestation were examined during a blood-sampling procedure with venepuncture under two different conditions: in skin-to-skin contact with their mother or lying in their incubator or crib. A double-channel NIRS device was used, and oxygen saturation and heart rate were measured using pulse oximetry. The infant's face and the pulse oximetry values were videotaped throughout the procedures, so that we could carry out a pain assessment using the Premature Infant Pain Profile-Revised (PIPP-R).

RESULTS

We found a significantly smaller increase in oxygenated haemoglobin on the contralateral side during venepuncture when the infants were in skin-to-skin contact with their mothers, compared to when they were laying in their incubator or crib. When venepuncture was compared with a sham procedure, oxygenated haemoglobin increased significantly more with the infant in the incubator or crib than held skin-to-skin, but no significant differences could be seen in the PIPP-R results between the two groups.

CONCLUSION

This study showed that skin-to-skin contact between premature infants and their mothers during venepuncture had a pain-relieving effect.

Oral Sucrose for Pain in Neonates During Echocardiography: A Randomized Controlled Trial

OBJECTIVE

To test the efficacy of oral sucrose in reducing pain/stress during echocardiography as estimated by Premature Infant Pain Profile score.

DESIGN

Double-blind, parallel-group, randomized control trial.

SETTING

Tertiary-care neonatal care unit located in Western India.

PARTICIPANTS

Neonates with established enteral feeding, not on any respiratory support and with gestational age between 32 and 42 weeks requiring echocardiography.

INTERVENTIONS

Neonates in intervention group received oral sucrose prior to echocardiography.

MAIN OUTCOME MEASURES

Assessment was done using Premature Infant Pain Profile score.

RESULTS

There were 104 examinations; 52 in each group. Baseline characteristics like mean gestational age (37.6 vs. 37.1), birth weight (2.20 vs. 2.08), and feeding status (Breastfeeding- 59.6% vs. 44.2%, paladai feeding- 13.5% vs. 13.5%, and gavage feeding- 26.9% vs. 42.3%) were comparable. The mean (SD) premature infant pain profile score was significantly higher in control group [(7.4 (3.78) vs. 5.2 (1.92), P <0.001].

CONCLUSION

Oral sucrose significantly reduces pain, and is safe to administer to neonates.

A Guide to Pain Assessment and Management in the Neonate

Newborn infants experience acute pain with various medical procedures. Evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes. Multiple validated scoring systems exist to assess pain in a neonate; however, there is no standardized or universal approach for pain management. Healthcare facilities should establish a neonatal pain control program. The first step is to minimize the total number of painful iatrogenic events when possible. If a procedure cannot be avoided, a tiered approach to manage pain using environmental, non-pharmacologic, and pharmacologic modalities is recommended. This systematic approach should decrease acute neonatal pain, poor outcomes, and provider and parent dissatisfaction.

The Effects of Kangaroo Mother Care and Swaddling on Venipuncture Pain in Premature Neonates: A Randomized Clinical Trial

Background

Hospitalized premature babies often undergo various painful procedures. Kangaroo mother care (KMC) and swaddling are two pain reduction methods.

Objectives

This study was undertaken to compare the effects of swaddling and KMC on pain during venous sampling in premature neonates.

Patients and Methods

This study was performed as a randomized clinical trial on 90 premature neonates. The neonates were divided into three groups using a random allocation block. The three groups were group A (swaddling), group B (KMC), and group C (control). In all three groups, the heart rate and arterial oxygen saturation were measured and recorded in time intervals of 30 seconds before, during, and 30, 60, 90, and 120 seconds after blood sampling. The neonate’s face was video recorded and assessed using the premature infant pain profile (PIPP) at time intervals of 30 seconds. The data was analyzed using the t-test, chi-square test, Repeated Measure analysis of variance (ANOVA), Kruskal-Wallis, Post-hoc, and Bonferroni test.

Results

The findings revealed that pain was reduced to a great extent in the swaddling and KMC methods compared to the control group. However, there was no significant difference between KMC and swaddling (P ≥ 0.05).

Conclusions

The results of this study indicate that there is no meaningful difference between swaddling and KMC on physiological indexes and pain in neonates. Therefore, the swaddling method may be a good substitute for KMC.

Missed Opportunities for Sedation and Pain Management at a Level III Neonatal Intensive Care Unit, India

BACKGROUND

Neonates in the neonatal intensive care unit (NICU) undergo a multitude of painful and stressful procedures during the first days of life. Stress from this pain can lead to neurodevelopmental problems that manifest in later childhood and should be prevented.

OBJECTIVE

To determine the number of painful procedures performed per day for each neonate, to verify documentation of painful procedures performed, and to, subsequently, note missed opportunities for providing pain relief to neonates.

METHODS

We conducted a cross-sectional study at a level III NICU located in a rural part of western India. A total of 69 neonates admitted for more than 24 h were included. Twenty-nine neonates were directly observed for a total of 24 h each, and another 40 neonatal records were retrospectively reviewed for the neonate's first 7 days of admission. All stressful and painful procedures performed on the neonate were recorded. Also recorded were any pharmaceutical pain relief agents or central nervous system depressants administered to the neonate before or at the time of the procedures. Average nurse-patient ratio was also calculated. Data were analyzed using descriptive statistics.

RESULTS

A documentation deficit of 2.2% was observed. The average nurse-patient ratio was 1.53:1. A total of 13711 procedures were recorded, yielding 44.1 (38.1 stressful, 3.8 mildly painful, and 2.2 moderately painful) procedures per patient day. Common stressful procedures were position changing (2501) and temperature recording (2208). Common mildly and moderately painful procedures were heel prick (757) and endotracheal suctioning (526), respectively. Use of pharmacological agents coincided with 33.48% of the procedures. The choice of drug and time of administration were inappropriate, indicating that the pharmacological agents were intended not for pain relief but rather for a coexisting pathology or as sedation from ventilation with no analgesia.

CONCLUSION

Stressful procedures are common in the NICU; mildly and moderately painful procedures fairly common. Almost two-thirds of the times, no pharmaceutical pain relief methods were used, and when administered, the pharmaceutical agents were seldom intended for pain relief; this implies poor pain management practices and emphasizes the imperative need for educating NICU nurses, residents, fellows, and attendings.

Care-related pain in hospitalized patients: severity and patient perception of management

BACKGROUND

Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP.

METHODS

All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included.

RESULTS

From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases.

CONCLUSIONS

Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

HELPinKids&Adults Knowledge Synthesis of the Management of Vaccination Pain and High Levels of Needle Fear: Limitations of the Evidence and Recommendations for Future Research

The HELPinKids&Adults knowledge synthesis for the management of vaccination-related pain and high levels of needle fear updated and expanded upon the 2010 HELPinKIDS knowledge synthesis and clinical practice guideline for pain mitigation during vaccine injections in childhood. Interventions for vaccine pain management in adults and treatment of individuals with high levels of needle fear, phobias, or both were included, thereby broadening the reach of this work. The present paper outlines the overarching limitations of this diverse evidence base and provides recommendations for future research. Consistent with the framing of clinical questions in the systematic reviews, the Participants, Intervention, Comparison, Outcome, Study design (PICOAS) framework was used to organize these predominant issues and research directions. The major limitations we identified across systematic reviews were an overall dearth of trials on vaccination, lack of methodological rigor, failure to incorporate important outcomes, poor study reporting, and various sources of heterogeneity. Future research directions in terms of conducting additional trials in the vaccination context, improving methodological quality and rigor, assessment of global acceptability and feasibility of interventions, and inclusion of outcomes that stakeholders consider to be important (eg, compliance) are recommended. Given concerns about pain and fear are known contributors to vaccine hesitancy, improving and expanding this evidence base will be integral to broader efforts to improve vaccine compliance and public health worldwide.

Procedural and Physical Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

BACKGROUND

This systematic review evaluated the effectiveness of physical and procedural interventions for reducing pain and related outcomes during vaccination.

DESIGN/METHODS

Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Data were extracted according to procedure phase (preprocedure, acute, recovery, and combinations of these) and pooled using established methods.

RESULTS

A total of 31 studies were included. Acute infant distress was diminished during intramuscular injection without aspiration (n=313): standardized mean difference (SMD) -0.82 (95% confidence interval [CI]: -1.18, -0.46). Injecting the most painful vaccine last during vaccinations reduced acute infant distress (n=196): SMD -0.69 (95% CI: -0.98, -0.4). Simultaneous injections reduced acute infant distress compared with sequential injections (n=172): SMD -0.56 (95% CI: -0.87, -0.25). There was no benefit of simultaneous injections in children. Less infant distress during the acute and recovery phases combined occurred with vastus lateralis (vs. deltoid) injections (n=185): SMD -0.70 (95% CI: -1.00, -0.41). Skin-to-skin contact in neonates (n=736) reduced acute distress: SMD -0.65 (95% CI: -1.05, -0.25). Holding infants reduced acute distress after removal of the data from 1 methodologically diverse study (n=107): SMD -1.25 (95% CI: -2.05, -0.46). Holding after vaccination (n=417) reduced infant distress during the acute and recovery phases combined: SMD -0.65 (95% CI: -1.08, -0.22). Self-reported fear was reduced for children positioned upright (n=107): SMD -0.39 (95% CI: -0.77, -0.01). Non-nutritive sucking (n=186) reduced acute distress in infants: SMD -1.88 (95% CI: -2.57, -1.18). Manual tactile stimulation did not reduce pain across the lifespan. An external vibrating device and cold reduced pain in children (n=145): SMD -1.23 (95% CI: -1.58, -0.87). There was no benefit of warming the vaccine in adults. Muscle tension was beneficial in selected indices of fainting in adolescents and adults.

CONCLUSIONS

Interventions with evidence of benefit in select populations include: no aspiration, injecting most painful vaccine last, simultaneous injections, vastus lateralis injection, positioning interventions, non-nutritive sucking, external vibrating device with cold, and muscle tension.

Comforting strategies and perceived barriers to pediatric pain management during IV line insertion procedure in Uganda's national referral hospital: A descriptive study

BACKGROUND

Venipuncture and intravenous (IV) cannula insertions are the two common sources of pain in hospitalized children and health care today. The WHO asserts that, pain relief is a basic fundamental right and requires a multidisciplinary approach. Nonpharmacological comforting strategies when implemented are important to relive pain related distress in children during peripheral IV line insertion. However, evidence to date that suggests implementation of such strategies and their barriers in Uganda remains very limited. This study aimed at establishing the current practices in regard to the use of comforting strategies and the perceived barriers faced by health care providers to implement pediatric pain management during IV line insertion procedure in Uganda's national referral hospital, Mulago.

METHOD

A cross sectional and descriptive study was conducted between December 1, 2012 and February 28, 2013 involving doctors, nurses and interns in six pediatric wards of Mulago Hospital in Uganda. A pre-tested self- administered and semi- structured questionnaire was used to collect the data. Data was entered into SPSS and descriptive statistics run on all the variables.

RESULTS

Of the 120 questionnaires distributed, 105 (RR = 87.5%) were returned and completed. The evidence based comforting strategies used for pain management during IV line insertion by the majority of health care professionals were; skin to skin (51%) and appropriate upright positioning of the child on mother's lap (69%). The least used comforting strategies were; allowing the child to suck his thumb or hand (70%), use of distraction (69%) and directing the child to suck one of his fingers into his mouth (90%). The identified barriers to implementing comforting strategies were; lack of time (42%), having emergency situations (18%), and not knowing the right method to use (11%). Of 105, 100 (95%) reported that there is need for continuous professional development on comforting strategies.

CONCLUSIONS

Findings demonstrated that fewer health care providers used some evidence based comforting strategies of pain relief during pediatric peripheral IV line insertion. Distraction and other evidence based strategies for pain and distress relieve are less often used by the majority of the health care providers. Incorporating pediatric pain management content in all health professionals training curricula could improve the current practices for better health outcomes.

Non-pharmacological interventions for assisting the induction of anaesthesia in children

BACKGROUND

Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.

OBJECTIVES

To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.

SEARCH METHODS

In this updated review we searched CENTRAL (the Cochrane Library 2012, Issue 12) and searched the following databases from inception to 15 January 2013: MEDLINE, EMBASE, PsycINFO and Web of Science. We reran the search in August 2014. We will deal with the single study found to be of interest when we next update the review.

SELECTION CRITERIA

We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed risk of bias in trials.

MAIN RESULTS

We included 28 trials (2681 children) investigating 17 interventions of interest; all trials were conducted in high-income countries. Overall we judged the trials to be at high risk of bias. Except for parental acupuncture (graded low), all other GRADE assessments of the primary outcomes of comparisons were very low, indicating a high degree of uncertainty about the overall findings. Parental presence: In five trials (557 children), parental presence at induction of anaesthesia did not reduce child anxiety compared with not having a parent present (standardized mean difference (SMD) 0.03, 95% confidence interval (CI) -0.14 to 0.20). In a further three trials (267 children) where we were unable to pool results, we found no clear differences in child anxiety, whether a parent was present or not. In a single trial, child anxiety showed no significant difference whether one or two parents were present, although parental anxiety was significantly reduced when both parents were present at the induction. Parental presence was significantly less effective than sedative premedication in reducing children's anxiety at induction in three trials with 254 children (we could not pool results). Child interventions (passive): When a video of the child's choice was played during induction, children were significantly less anxious than controls (median difference modified Yale Preoperative Anxiety Scale (mYPAS) 31.2, 95% CI 27.1 to 33.3) in a trial of 91 children. In another trial of 120 children, co-operation at induction did not differ significantly when a video fairytale was played before induction. Children exposed to low sensory stimulation were significantly less anxious than control children on introduction of the anaesthesia mask and more likely to be co-operative during induction in one trial of 70 children. Music therapy did not show a significant effect on children's anxiety in another trial of 51 children. Child interventions (mask introduction): We found no significant differences between a mask exposure intervention and control in a single trial of 103 children for child anxiety (risk ratio (RR) 0.59, 95% CI 0.31 to 1.11) although children did demonstrate significantly better co-operation in the mask exposure group (RR 1.27, 95% CI 1.06 to 1.51). Child interventions (interactive): In a three-arm trial of 168 children, preparation with interactive computer packages (in addition to parental presence) was more effective than verbal preparation, although differences between computer and cartoon preparation were not significant, and neither was cartoon preparation when compared with verbal preparation. Children given video games before induction were significantly less anxious at induction than those in the control group (mYPAS mean difference (MD) -9.80, 95% CI -19.42 to -0.18) and also when compared with children who were sedated with midazolam (mYPAS MD -12.20, 95% CI -21.82 to -2.58) in a trial of 112 children. When compared with parental presence only, clowns or clown doctors significantly lessened children's anxiety in the operating/induction room (mYPAS MD -24.41, 95% CI -38.43 to -10.48; random-effects, I² 75%) in three trials with a total of 133 children. However, we saw no significant differences in child anxiety in the operating room between clowns/clown doctors and sedative premedication (mYPAS MD -9.67, 95% CI -21.14 to 1.80, random-effects, I² 66%; 2 trials of 93 children). In a trial of hypnotherapy versus sedative premedication in 50 children, there were no significant differences in children's anxiety at induction (RR 0.59, 95% CI 0.33 to 1.04). Parental interventions: Children of parents having acupuncture compared with parental sham acupuncture were less anxious during induction (mYPAS MD -17, 95% CI -30.51 to -3.49) and were more co-operative (RR 1.59, 95% CI 1.01 to 2.53) in a single trial of 67 children. Two trials with 191 parents assessed the effects of parental video viewing but did not report any of the review's prespecified primary outcomes.

AUTHORS' CONCLUSIONS

This review shows that the presence of parents during induction of general anaesthesia does not diminish their child's anxiety. Potentially promising non-pharmacological interventions such as parental acupuncture; clowns/clown doctors; playing videos of the child's choice during induction; low sensory stimulation; and hand-held video games need further investigation in larger studies.

Comparing the effect of swaddling and breastfeeding and their combined effect on the pain induced by BCG vaccination in infants referring to Motahari Hospital, Jahrom, 2010-2011

BACKGROUND AND AIM

Despite the clinical importance of pain, many neonates are subjected to numerous painful invasive procedures and their complications as part of their care. This study has been designed to investigate the effect of swaddling and breastfeeding, and their combined effect on the pain induced by BCG vaccination in healthy term infants.

METHOD

This randomized double-blind intervention study was performed on 131 healthy term neonates in Motahari Hospital of Jahrom. The samples were randomly assigned into three intervention groups and a control group. The infants in the swaddled group were swaddled 2 minutes before and 2 minutes after vaccination. The infants in the breastfed group were breastfed within 45 minutes before vaccination. The infants in the combination group were both breast fed before and swaddled within vaccination but the infants in the control group were vaccinated without any intervention. Heart rate and oxygen saturation level of neonates were recorded in the 3 phases of: baseline, injection and 2 minutes after injection. Furthermore, the neonates' faces were recorded using a video camera. Then pain intensity was measured by Neonatal Facial Coding System (NFCS). Mean Score of pain intensity and physiological responses of subjects were statistically analyzed using non parametrical Kruskal-Wallis test and Mann-Whitney.

RESULTS

The mean of pain intensity (NFCS) and changes in the heart rate at injection time to the baseline in the three intervention groups in comparison with the control group showed statistically significant difference (p=0.003 and p=0.002 respectively). However changes in blood oxygen saturation level, were not statistically significant difference between four groups.

CONCLUSION

Regarding to the significant impact of both breastfeeding and swaddling on the pain reduction of vaccination, it is recommended to take benefit of these two safe and available non-pharmacological methods in order to relief pain during painful procedures.

[Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: Austrian interdisciplinary recommendations on pediatric perioperative pain management]

Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.

Changes of locoregional skin temperature in neonates undergoing laser needle acupuncture at the acupuncture point large intestine 4

Laser acupuncture bears a potential risk for the skin surface, especially in neonates whose skin has histological and physiological peculiarities. We evaluated thermal changes of skin temperature in neonates during laser acupuncture by using a thermal camera (Flir i5, Flir Systems Inc., Portland, USA). Laserneedles (Laserneedle GmbH, Glienicke/Nordbahn, Germany) were fixed to the skin at Large Intestine 4 (LI 4, Hegu), bilaterally. Before application of laser acupuncture (685 nm, 15 mW, 500 μm), as well as after 1, 5, and 10 min, thermographic pictures of both hands were taken. The measuring was carried out on the 23rd day after birth (20 neonates, mean postmenstrual gestational age 38 + 2, mean weight 2604 g). Compared to the initial temperature of 34.2°C on the right hand, the skin temperature had increased to 35.3°C (P < 0.05) after 5 min and up to 36.1°C (P < 0.05) after 10 min of stimulation. Equally, on the left hand, an increase of the skin temperature from 34.5°C to 35.9°C (P < 0.05) and 35.9°C (P < 0.05) was measured. The highest measured skin temperature after 10 min of stimulation amounted to 38.7°C, without any clinically visible changes on the skin surface.

Assessment of pain during application of nasal-continuous positive airway pressure and heated, humidified high-flow nasal cannulae in preterm infants

OBJECTIVE

To assess pain and compare its severity in preterm infants during application of nasal-continuous positive airway pressure (nCPAP) and heated, humidified high-flow nasal cannulae (HHHFNC).

STUDY DESIGN

An observational cross-sectional study. Sixty preterm infants, categorized into nCPAP (n=37) and HHHFNC groups (n=23). Pain response was assessed using Premature Infant Pain Profile (PIPP), duration of first cry and salivary-cortisol concentrations.

RESULT

The PIPP scores were significantly higher in the nCPAP compared with HHHFNC group (10 (7-12) vs 4 (2-6), P<0.01). None of the infants in the HHHFNC group had severe pain defined as a PIPP score >12, compared with 5 (13.5%) infants in the nCPAP group. Salivary-cortisol concentrations were significantly higher in nCPAP group compared with the HHHFNC group (5.0 (3.6-5.9) vs 1.6 (1.0-2.3) nmol l(-1), P<0.01). A lower incidence of cry was observed for infants in the HHHFNC group compared with the nCPAP group (11 (47.8%) vs 30 (81.1%), P<0.001), however, the duration of first cry was not significantly different between groups. The respiratory rate was significantly lower after application of HHHFNC compared with nCPAP (P<0.001). There were no significant differences between groups with regard to fraction of inspired oxygen (FiO2), oxygen saturation by pulse oximeter (SpO2) and heart rate.

CONCLUSION

The application of HHHFNC in preterm infants is associated with less pain compared with nCPAP, as it is associated with less PIPP scores and lower salivary-cortisol concentrations.

Practice guidelines for sedation and analgesia management of critically ill children: a pilot study evaluating guideline impact and feasibility in the PICU

AIMS

The aim of this study was to develop and implement guidelines for sedation and analgesia management in the paediatric intensive care unit (PICU) and evaluate the impact, feasibility and acceptability of these as part of a programme of research in this area and as a prelude to future trial work.

METHOD

This pilot study used a pre-post design using a historical control.

SETTING

Two PICUs at different hospitals in an Australian metropolitan city.

PARTICIPANTS

Patients admitted to the PICU and ventilated for ≥24 h, aged more than 1 month and not admitted for seizure management or terminal care.

INTERVENTION

Guidelines for sedation and analgesia management for critically ill children including algorithm and assessment tools.

OUTCOME VARIABLES

In addition to key outcome variables (ventilation time, medication dose and duration, length of stay), feasibility outcomes data (recruitment, data collection, safety) were evaluated. Guideline adherence was assessed through chart audit and staff were surveyed about merit and the use of guidelines.

RESULTS

The guidelines were trialled for a total of 12 months on 63 patients and variables compared with the historical control group (n=75). Analysis revealed differences in median Morphine infusion duration between groups (pretest 3.63 days (87 h) vs post-test 2.83 days (68 h), p=0.05) and maximum doses (pretest 120 μg/kg/h vs post-test 97.5 μg/kg/h) with no apparent change to ventilation duration. Chart audit revealed varied use of tools, but staff were positive about the guidelines and their use in practice.

CONCLUSIONS

The sedation guidelines impacted on the duration and dosage of agents without any apparent impact on ventilation duration or length of stay. Furthermore, the guidelines appeared to be feasible and acceptable in clinical practice. The results of the study have laid the foundation for follow-up studies in withdrawal from sedation, point prevalence and longitudinal studies of sedation practices as well as drug trial work.

Pain in the neonate: focus on nonpharmacologic interventions

The assessment and treatment of pain in the neonate, especially preterm neonates, has been a challenge in the NICU for many years. Nurses caring for these vulnerable patients are in a key position to not only recognize when the neonate is experiencing pain but to also work collaboratively with other health care providers in determining the best method to treat and help prevent pain associated with procedures and routine caregiving activities. The American Academy of Pediatrics along with parent groups has recognized the importance of pain-prevention programs in treating pain in the neonate. Nurses, by anticipating and reducing both painful procedures and bedside interruptions, along with innovative nonpharmacologic interventions, can dramatically decrease the neonate's exposure to pain and the potential for long-term effects. An overview of nonpharmacologic interventions in the treatment of neonatal pain is provided for NICU nurses to help them effectively reduce their patient's pain and discomfort.

Parental experiences of providing skin-to-skin care to their newborn infant--part 2: a qualitative meta-synthesis

AIM

To synthesize and interpret qualitative research findings focusing on parental experiences of skin-to-skin care (SSC) for newborn infants.

BACKGROUND

SSC induces many benefits for newborn infants and their parents. Three meta-analyses have been conducted on physiological outcomes, but no previous qualitative meta-synthesis on parental experiences of SSC has been identified.

DESIGN

The present meta-synthesis was guided by the methodology described by Paterson and co-workers.

DATA SOURCES

Four databases were searched, without year or language limitations, up until December 2013. Manual searches were also performed. The searches and subsequent quality appraisal resulted in the inclusion of 29 original qualitative papers from 9 countries, reporting experiences from 401 mothers and 94 fathers.

REVIEW METHODS

The meta-synthesis entails a meta-data analysis, analysis of meta-method, and meta-theory in the included primary studies. Based on the three analyses, the meta-synthesis represents a new interpretation of a phenomenon. The results of the meta-data analysis have been presented as a qualitative systematic review in a separate paper.

RESULTS

When synthesizing and interpreting the findings from the included analyses, a theoretical model of Becoming a parent under unfamiliar circumstances emerged. Providing SSC seems to be a restorative as well as an energy-draining experience. A supportive environment has been described as facilitating the restorative experience, whereas obstacles in the environment seem to make the provision of SSC energy-draining for parents. When the process is experienced as positive, it facilitates the growth of parental self-esteem and makes the parents ready to assume full responsibility for their child.

CONCLUSION

The results show that SSC can be interpreted not only as a family-including and important health care intervention but also in terms of actually becoming a parent. The process of becoming a parent in this specific situation is influenced by external factors in three different levels; family and friends, community, and society at large. The descriptions of providing SSC are similar to what has previously been described as the natural process of becoming a mother or a father.

Parental experiences of providing skin-to-skin care to their newborn infant--part 1: a qualitative systematic review

AIM

To describe parental experiences of providing skin-to-skin care (SSC) to their newborn infants.

BACKGROUND

SSC care for newborn infants has been reported to have positive physiological and psychological benefits to the infants and their parents. No systematic review regarding parental experiences has been identified.

DESIGN

In this first part of a meta-study, the findings of a systematic literature review on parental experience of SSC care are presented.

DATA SOURCES

Four databases were searched, without year or language limitations, up until December 2013. Manual searches were performed in reference lists and in a bibliography of the topic.

REVIEW METHODS

After a quality-appraisal process, data from the original articles were extracted and analysed using qualitative content analysis.

RESULTS

The systematic and manual searches led to the inclusion of 29 original qualitative papers from nine countries, reporting experiences from 401 mothers and 94 fathers. Two themes that characterized the provision of SSC emerged: a restoring experience and an energy-draining experience.

CONCLUSION

This review has added scientific and systematic knowledge about parental experiences of providing SSC. Further research about fathers' experiences is recommended.

Experienced nurses' use of non-pharmacological approaches comprise more than relief from pain

This study investigated the use of, and reasoning by, experienced nurses regarding non-pharmacological pain approaches to care for children in hospitals, with the aim of increasing our understanding, and hence optimizing, these approaches. Three focus-group interviews with 14 experienced nurses, were conducted in 2009. Our findings emphasized the role of non-pharmacological methods in building and maintaining cooperation with the child and in caring for the child by individualizing the use of non-pharmacological methods.