Olfactory experience mediates response to pain in preterm newborns

Effects of vanilla odor on hypoxia-related periodic breathing in premature newborns: A pilot study

BACKGROUND

Periodic breathing (PB)-related intermittent hypoxia can have long-lasting deleterious consequences in preterm infants. Olfactory stimulation using vanilla odor is beneficial for apnea of prematurity in the first postnatal days/weeks. We aimed to determine for the first time whether vanilla odor can also decrease PB-related intermittent hypoxia.

METHOD

This pilot study was a balanced crossover clinical trial including 27 premature infants born between 30 and 33+6 weeks of gestation. We performed 12-h recordings on two nights separated by a 24-h period. All infants were randomly exposed to vanilla odor on the first or second study night. The primary outcome was the desaturation index, defined as the number per hour of pulse oximetry (SpO2) values <90 % for at least 5 s, together with a drop of ≥5 % from the preceding value. Univariate mixed linear models were used for the statistical analysis.

RESULTS

Overall, exposure to vanilla odor did not significantly decrease the desaturation index (52 ± 22 events/h [mean ± SD] on the intervention night vs. 57 ± 26, p = 0.2); furthermore, it did not significantly alter any secondary outcome. In a preliminary post hoc subgroup analysis, however, the effect of vanilla odor was statistically significant in infants with a desaturation index of ≥70/h (from 86 ± 12 to 65 ± 23, p = 0.04).

CONCLUSION

In this pilot study, vanilla odor overall did not decrease PB-related intermittent hypoxia in infants born at 30-33+6 weeks of gestation, which is when they are close to term. Preliminary results suggesting a beneficial effect in infants with the highest desaturation index, however, justify further studies in the presence of PB-related intermittent hypoxia as well as in infants born more prematurely.

Infant pain vs. pain with parental suppression: Immediate and enduring impact on brain, pain and affect

BACKGROUND

In the short term, parental presence while a human infant is in pain buffers the immediate pain responses, although emerging evidence suggests repeated social buffering of pain may have untoward long-term effects.

METHODS/FINDING

To explore the short- and long-term impacts of social buffering of pain, we first measured the infant rat pup's [postnatal day (PN) 8, or 12] response to mild tail shock with the mother present compared to shock alone or no shock. Shock with the mother reduced pain-related behavioral activation and USVs of pups at both ages and reduced Fos expression in the periaqueductal gray, hypothalamic paraventricular nucleus, and the amygdala at PN12 only. At PN12, shock with the mother compared to shock alone differentially regulated expression of several hundred genes related to G-protein-coupled receptors (GPCRs) and neural development, whereas PN8 pups showed a less robust and less coherent expression pattern. In a second set of experiments, pups were exposed to daily repeated Shock-mother pairings (or controls) at PN5-9 or PN10-14 (during and after pain sensitive period, respectively) and long-term outcome assessed in adults. Shock+mother pairing at PN5-9 reduced adult carrageenan-induced thermal hyperalgesia and reduced Fos expression, but PN10-14 pairings had minimal impact. The effect of infant treatment on adult affective behavior showed a complex treatment by age dependent effect. Adult social behavior was decreased following Shock+mother pairings at both PN5-9 and PN10-14, whereas shock alone had no effect. Adult fear responses to a predator odor were decreased only by PN10-14 treatment and the infant Shock alone and Shock+mother did not differ.

CONCLUSIONS/SIGNIFICANCE

Overall, integrating these results into our understanding of long-term programming by repeated infant pain experiences, the data suggest that pain experienced within a social context impacts infant neurobehavioral responses and initiates an altered developmental trajectory of pain and affect processing that diverges from experiencing pain alone.

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.

Comparison of the analgesic effect of inhaled lavender vs vanilla essential oil for neonatal frenotomy: a randomized clinical trial (NCT04867824)

It is necessary to treat neonatal pain because it may have short- and long-term adverse effects. Frenotomy is a painful procedure where sucking, a common strategy to relieve pain, cannot be used because the technique is performed on the tongue. In a previous randomized clinical trial, we demonstrated that inhaled lavender essential oil (LEO) reduced the signs of pain during neonatal frenotomy. We aimed to find out whether inhaled vanilla essential oil (VEO) is more effective in reducing pain during frenotomy than LEO. Randomized clinical trial with neonates who underwent a frenotomy for type 3 tongue-ties between May and October 2021. Pain was assessed using pre and post-procedure heart rate (HR) and oxygen saturation (SatO2), crying time, and NIPS score. Neonates were randomized into "experimental" and "control" group. In both groups, we performed swaddling, administered oral sucrose, and let the newborn suck for 2 min. We placed a gauze pad with one drop of LEO (control group) or of VEO (experimental group) under the neonate's nose for 2 min prior to and during the frenotomy. We enrolled 142 neonates (71 per group). Both groups showed similar NIPS scores (2.02 vs 2.38) and crying times (15.3 vs 18.7 s). We observed no differences in HR increase or in SatO2 decrease between both groups. We observed no side effects in either of the groups.

CONCLUSIONS

We observed no appreciable difference between LEO and VEO; therefore, we cannot conclude which of them was more effective in treating pain in neonates who underwent a frenotomy.

TRIAL REGISTRATION

 This clinical trial is registered with www.

CLINICALTRIALS

gov with NCT04867824.

WHAT IS KNOWN

• Pain management is one of the most important goals of neonatal care as it can have long-term neurodevelopmental effects. • Lavender essential oil can help relieve pain due to its sedative, antispasmodic, and anticolic properties.

WHAT IS NEW

• Lavender and vanilla essential oils are safe, beneficial, easy to use, and cheap in relieving pain in neonates who undergo a frenotomy for type 3 tongue-ties.

Analgesic effect of inhaled lavender essential oil for frenotomy in healthy neonates: a randomized clinical trial

BACKGROUND

Neonatal pain may affect long-term neurodevelopment and must be treated. Frenotomy is a painful procedure wherein a common strategy to relieve pain (sucking) cannot be used because the technique is performed on the tongue. Lavender essential oil (LEO) has sedative and antispasmodic properties and has been successfully used to treat pain during heel puncture and vaccination. Our aim was to demonstrate if the use of inhaled LEO is effective in reducing pain during frenotomy in healthy, full-term neonates.

METHODS

We conducted a randomized clinical trial in neonates who underwent a frenotomy between August 2020 and April 2021. We assessed pain using pre and post-procedure heart rate and oxygen saturation, crying time and Neonatal Infant Pain Scale (NIPS) score. Patients with type 3 tongue tie were randomized into the "experimental group" and "control group". In both groups, we performed swaddling, administered oral sucrose, and let the newborn suck for two minutes. In the experimental group, we also placed a gauze pad with one drop of LEO under the neonate's nose for two minutes prior to and during the frenotomy.

RESULTS

We enrolled 142 patients (71 per group). The experimental group showed significantly lower NIPS scores (1.88 vs 2.92) and cried almost half the amount of time (14.8 vs. 24.6 seconds, P = 0.006). Comparing with the control group, we observed no side effects in either of the groups.

CONCLUSIONS

We observed a significant decrease in crying time and lower NIPS scores in the neonates who received inhaled LEO and underwent a frenotomy for type 3 tongue-ties. Thus, we recommend using inhaled LEO during neonatal frenotomies.

Pain Control with Lavender Oil in Premature Infants: A Double-Blind Randomized Controlled Study

Objectives: Aromatherapy has become popular in pain control in recent years compared with other complementary methods. Lavender (Lavandula angustifolia Miller) is a fragrant essential oil used in aromatherapy for its antibacterial, antifungal, muscle-relaxing, and analgesic effects. The smell of lavender oil, known for its soothing effect on adults, has not been adequately investigated in regards to pain control in premature infants. The purpose of our study was to assign the effect of the scent of lavender oil on pain in preterm infants during heel lancing. Design: A double-blind randomized controlled clinical study. Settings/Location: The study was conducted in a third-level neonatal intensive care unit of Bezmialem Vakif University Hospital from March 2019 to November 2019. It consisted of two groups. Subjects: Sixty-one premature babies (24-37 weeks of gestation) were enrolled in the study. Interventions: Heel stick sampling for metabolic screening was used for both study groups. The interventions were performed by two experienced nurses. Heart rate, oxygen saturation, and the baby's facial expression were recorded by a camera 3 min before the intervention, during the sampling, and 3 min after the procedure. After collecting the data, the head researcher and the assistant researcher separately watched the videos and scored them by using the Premature Infant Pain Profile-Revised (PIPP-R). Outcome measures: The difference of pain scores (PIIP-R) between two groups. Results: There was a statistically significant difference between the two groups in terms of PIPP-R scores during and after the sampling (p = 0.008 and p = 0.03 respectively). The PIPP-R scores at the beginning of the procedure were not found to be significantly different between the groups (p > 0.05). Conclusions: Inhalation of lavender scent is effective in pain control in premature infants. It is safe and low cost; it does not interfere with medical care.

Human neonates prefer colostrum to mature milk: Evidence for an olfactory bias toward the "initial milk"?

OBJECTIVES

Colostrum is the initial milk secretion which ingestion by neonates warrants their adaptive start in life. Colostrum is accordingly expected to be attractive to newborns. The present study aims to assess whether colostrum is olfactorily attractive for 2-day-old newborns when presented against mature milk or a control.

METHODS

The head-orientation of waking newborns was videotaped in three experiments pairing the odors of: (a) colostrum (sampled on postpartum day 2, not from own mother) and mature milk (sampled on average on postpartum day 32, not from own mother) (n tested newborns = 15); (b) Colostrum and control (water; n = 9); and (c) Mature milk and control (n = 13).

RESULTS

When facing the odors of colostrum and mature milk, the infants turned their nose significantly longer toward former (32.8 vs 17.7% of a 120-s test). When exposed to colostrum against the control, they responded in favor of colostrum (32.9 vs 16.6%). Finally, when the odor of mature milk was presented against the control, their response appeared undifferentiated (26.7 vs 28.6%).

CONCLUSIONS

These results indicate that human newborns can olfactorily differentiate conspecific lacteal fluids sampled at different lactation stages. They prefer the odor of the mammary secretion - colostrum - collected at the lactation stage that best matches the postpartum age of their own mother. These results are discussed in the context of the earliest mother-infant chemo-communication. Coinciding maternal emission and offspring reception of chemosignals conveyed in colostrum may be part of the sensory precursors of attunement between mothers and infants.

Comparison of the Effects of Visual and Auditory Distractions on Fistula Cannulation Pain among Older Patients Undergoing Hemodialysis: A Randomized Controlled Clinical Trial

Pain associated with fistula cannulation is a challenge for nurses who provide care to older patients undergoing hemodialysis. Several non-pharmacological methods have been suggested for relieving fistula cannulation pain, but the benefits of visual and auditory distraction methods among older patients undergoing hemodialysis have not been investigated yet. Therefore, this study aimed to compare the effects of visual and auditory distractions on fistula cannulation pain among older patients undergoing hemodialysis. This randomized controlled clinical trial was conducted on 120 older patients undergoing hemodialysis. They were randomly assigned to three groups of visual distraction, auditory distraction, and the control (n = 40 in each group) using a simple random assignment method. The distraction interventions continued for three consecutive sessions and the numeric rating scale of pain severity was used for data collection. Descriptive and inferential statistics were used for data analysis using SPSS. It was found that pain severity significantly reduced after the distraction interventions in either the auditory or visual distraction groups and also after all three distraction sessions (p = 0.001). However, visual distraction had a better effect on the reduction of pain severity. Therefore, while both visual and auditory distractions reduced pain severity in older patients undergoing hemodialysis, visual distraction was more effective. Nurses are encouraged to incorporate visual distraction as a safe and non-pharmacologic technique into routine nursing care for reducing older patients’ suffering and improving their wellbeing when fistula cannulation is performed.

Systematic review and meta-analysis of olfactive stimulation interventions to manage procedural pain in preterm and full-term neonates

BACKGROUND

Preterm and full-term neonates undergo many painful procedures during their hospitalization in the neonatal intensive care unit. Unrelieved and repeated pain can have important repercussions on their motor and intellectual development. Still, pain management interventions are limited for neonates.

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of olfactive stimulation interventions on the pain response of preterm and full-term infants during painful procedures.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

An electronic search was conducted from inception to August 2019 in PubMed, MEDLINE, Embase, CINAHL, PsycINFO, Web of Sciences, CENTRAL, Scopus and ProQuest.

REVIEW METHODS

Study selection, data extraction, assessment of risk of bias and quality of evidence were performed by two independent reviewers.

RESULTS

3311 studies were screened. Of the 14 studies included studies (n = 1028 infants), results from 10 were combined in meta-analysis. The latter demonstrated that olfactive stimulation interventions using a familiar odor were effective compared to standard care on pain reactivity (SMD -0.69; 95% CI -0.93 to -0.44; I² = 20%, p < 0.00001), pain regulation (SMD -0.40; 95% CI -0.66 to -0.14; I² = 13%, p = 0.002), crying duration during (SMD -0.42; 95% CI -0.73 to -0.10; I² = 47%, p = 0.009) and after the procedure (SMD -0.37; 95% CI -0.68 to -0.07; I² = 0%, p = 0.01), heart rate after the procedure (MD -3.87; 95% CI -7.36 to -0.38; I² = 99%, p = 0.03), oxygen saturation during (MD -0.47; 95% CI -0.86 to -0.08; I² = 91%, p = 0.02) and after the procedure (MD -0.56; 95% CI -0.99 to -0.13; I² = 99%, p = 0.01). No adverse event was reported.

CONCLUSION

These findings are based on low to very low quality of evidence limiting our confidence in effect estimates. More rigorous trials with a larger sample size are needed to enhance the comprehension of the mechanisms underlying olfactive stimulation interventions and the interventions' efficacy.

A novel, short and easy-to-perform method to evaluate newborns' social olfactory preferences

Humans' early olfactory perception has been studied mainly within the framework of mother-offspring interactions and only a few studies have focused on newborns' abilities to discriminate body odors per se. The aim of this study was to develop a method to evaluate olfactory social preferences of infants at term-equivalent age. Twenty dyads of infants (10 born preterm and 10 born at term) at term-equivalent age and their mothers were included. We analyzed the behavioral reactions of infants to their mother's upper-chest odor (that bears social, non-food related information). The two impregnated gauzes and a control gauze were presented to the infants for 10 s each, in a random order. We compared two durations of gauze impregnation: 30 min and 12 h. This study reveals that mothers' upper chest emits sufficient olfactory information to induce reactions in infants born full-term or born preterm and that a short impregnation is preferable to evaluate their perception of body odors, notably for those born preterm.

Effects of smelling amniotic fluid on preterm infant's pain and stress during peripheral cannulation: A randomized controlled trial

AIM

To investigate the effect of smelling amniotic fluid on preterm infants' pain and stress caused by peripheral cannulation.

METHODS

This was a randomized controlled trial. The study sample consisted of 80 preterm infants meeting the case selection criteria and infants were randomly assigned to each group. However, in addition to the infants excluded from the study, total number of the infants in all the groups was 61. Infants in the amniotic fluid group smelled amniotic fluid for 15 min before, during, and after the application of peripheral cannulation while those in the control group received routine care during the procedure. The Premature Infant Pain Profile was used to assess their pain levels, and salivary cortisol analysis was performed to evaluate stress levels.

RESULTS

Preterm infants in the amniotic fluid and control groups had similar baseline characteristics. However, the pain levels of infants in the amniotic fluid group were significantly lower than of those in the control group during and after the procedure. After the procedure, cortisol levels of the infants in the amniotic fluid group were lower than of those in the control group, although this difference was not significant.

CONCLUSION

The intervention of smelling amniotic fluid is a practice that can be used for reducing pain and stress of preterm infants during peripheral cannulation.

[The Effects of Breast Milk Olfactory Stimulation on Physiological Responses, Oral Feeding Progression and Body Weight in Preterm Infants]

PURPOSE

This study was conducted to evaluate the effect of breast milk olfactory stimulation on physiological responses, oral feeding progression, and body weight in preterm infants.

METHODS

A repeated measures design with nonequivalent control group was used. The participants were healthy, preterm infants born at a gestational age of 28~32 weeks; 12 in the experimental group and 16 in the control group. Data were collected prospectively in the experimental group, and retrospectively in the control group, by the same methods. Breast milk olfactory stimulation was provided 12 times over 15 days. The data were analyzed using the chi-square test, Mann-Whitney U test, Wilcoxon signed rank test and linear mixed models using SPSS 19.

RESULTS

The gastric residual volume (GRV) of the experimental group was significantly less than that of the control group. The heart rate, oxygen saturation, respiration rate, transition time to oral feeding, and body weight were not significantly different between the two groups.

CONCLUSION

These findings indicate that breast milk olfactory stimulation reduces GRV and improves digestive function in preterm infants without inducing distress.

The Effect of Aromatherapy by Lavender Oil on Infant Vaccination Pain: a Double Blind Randomized Controlled Trial

Introduction: Exposure to noxious stimuli can cause pain in infants. This study was conducted to evaluate the effects of the lavender oil inhalation on the pain resulting from the pentavalent vaccination. Methods: This clinical trial consisted of two groups: the lavender oil group with 42 infants and the placebo group with 57 infants. The healthy infants without congenital abnormalities in need of pentavalent vaccine also participated in our study. The infants started the lavender oil or placebo aromatherapy one minute before injection. The pain was assessed three times, using the Neonatal Infant pain Scale (NIPS): before vaccination, 15 s, and 5 min after vaccination. Also, the duration of crying was measured in both groups. Results: At baseline, the two groups were similar in relation to the NIPS scores. While, after 5 minutes, the NIPS score was significantly lower in the lavender group. Based on the repeated measures analysis, the NIPS score changed over time totally. However, the two groups were significantly different in relation to the NIPS score over time. The duration of crying was 75.47 (60.675) second in the lavender group and 105.22 (75.739) s in the control group. The statistical test showed a significant difference between the two groups. Conclusion: A low concentration of the lavender oil inhalation can reduce the pain and improve soothing in the infants with the pentavalent vaccine injection.

The human newborn's umwelt: Unexplored pathways and perspectives

Historically, newborns, and especially premature newborns, were thought to "feel nothing." However, over the past decades, a growing body of evidence has shown that newborns are aware of their environment, but the extent and the onset of some sensory capacities remain largely unknown. The goal of this review is to update our current knowledge concerning newborns' perceptual world and how ready they are to cope with an entirely different sensory environment following birth. We aim to establish not only how and when each sensory ability arises during the pre-/postbirth period but also discuss how senses are studied. We conclude that although many studies converge to show that newborns are clearly sentient beings, much is still unknown. Further, we identify a series of internal and external factors that could explain discrepancies between studies, and we propose perspectives for future studies. Finally, through examples from animal studies, we illustrate the importance of this detailed knowledge to pursue the enhancement of newborns' daily living conditions. Indeed, this is a prerequisite for assessing the effects of the physical environment and routine procedures on newborns' welfare.

The Analgesic Effects of Maternal Milk Odor on Newborns: A Meta-Analysis

OBJECTIVE

The objective of this study was to evaluate the analgesic effects of maternal milk odor on newborns.

MATERIALS AND METHODS

We searched the literature in PubMed, MEDLINE, CINAHL, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) and collected all the randomized controlled trials (RCTs) investigating the effects of maternal milk odor versus scentless or other odors on procedural pain in newborns. The quality of included studies was assessed by the Cochrane Collaboration Risk of Bias tool. A meta-analysis was undertaken with the Review Manager 5.3 software and Stata version 11.0. Subgroup comparisons were prespecified according to the types of control groups.

RESULTS

Eight RCTs included a total of 453 participants. The results of meta-analysis showed that compared with the scentless group, the maternal milk odor group had lower pain scores during blood sampling (standardized mean difference, -0.81; 95% confidence interval [95% CI], -1.18 to -0.44; p < 0.001) and shorter crying time afterward (mean difference, -8.10; 95% CI, -15.46 to 0.73; p = 0.03). The maternal milk odor group had lower heart rate variability and oxygen saturation variability during and after a procedure, compared with both the scentless group and the vanilla group. However, no significant difference was identified in the mean heart rate and mean oxygen saturation in terms of the maternal milk odor group compared with amniotic fluid odor or mother's scent. The maternal milk odor group versus the formula milk odor group had shorter crying duration and lower levels of salivary cortisol after sampling.

CONCLUSIONS

Maternal milk odor appears to play an analgesic role in newborns. However, more high-quality studies are needed to confirm and quantitate the effect.

The Impact of Preterm Infants' Continuous Exposure to Breast Milk Odor on Stress Parameters: A Pilot Study

OBJECTIVE

This pilot study aimed to assess the effect of continuous exposure to the odor of own mothers' breast milk (BM) on the stress parameters of preterm infants.

MATERIALS AND METHODS

Fifteen healthy preterm infants were included. Mean heart rate and salivary cortisol were measured over three consecutive time periods, each lasting 2 days: (1) preintervention (odor free); (2) intervention, during which a cotton pad soaked with 1.5 mL of BM was placed near the infant's head with the aim of providing continuous exposure to its odor; (3) postintervention period (odor free).

RESULTS

Saliva cortisol levels differed significantly between the three exposure periods (pre-, during, and post-BM odor exposure): 11.38 ± 5.03, 9.51 ± 4.38, and 4.99 ± 3.42 nmol/L, respectively. A repeated univariate analysis of the cortisol measure showed a significant difference (F = 9.34; df = 2.28, p < 0.001). There was no difference in mean heart rate over the three study periods.

CONCLUSIONS

Preterm infants exposed to BM odor from their own mothers demonstrate a persistent decrease in saliva cortisol levels, which continues after termination of the intervention. This finding may suggest that exposure to own mothers' BM odor has a soothing effect on preterm infants. Further randomized controlled studies are needed to evaluate this simple, safe, and inexpensive intervention.

Effects of Having Preterm Infants Smell Amniotic Fluid, Mother's Milk, and Mother's Odor During Heel Stick Procedure on Pain, Physiological Parameters, and Crying Duration

OBJECTIVE

The study aims to assess effects of having preterm infants smell amniotic fluid, mother's milk, and mother's odor during heel stick procedure on pain, physiological parameters, and crying duration.

MATERIALS AND METHODS

The study was a randomized controlled experimental research. The population of the study was made up of preterm infants receiving treatment and care at a neonatal intensive care unit, where the study was conducted between January 2015 and March 2016. The study was performed with 85 preterm infants who met the selection criteria. Infants were randomized into four groups: amniotic fluid, mother's milk, mother's odor, and control group. Data obtained were analyzed by percentage distributions, means, standard deviation, chi-square test, Kruskal-Wallis, and Dunnett's test.

RESULTS

While no significant difference was found between the groups in terms of total preterm infant pain profile score before, during, and after the heel stick procedure (p > 0.05), a significant difference was found in terms of SO₂ values (p < 0.05) and the difference was caused by the amniotic fluid group. Although no significant difference was found between the groups in terms of crying duration (p > 0.05), the amniotic fluid group had the lowest score, followed by the mother's milk group, the mother's odor group, and the control group.

CONCLUSIONS

Amniotic fluid, mother's milk, and mother's odor were not effective in preterm infants during painful procedures.

Breast-Feeding Analgesia in Infants: An Update on the Current State of Evidence

To provide an updated synthesis of the current state of the evidence for the effectiveness of breast-feeding and expressed breast milk feeding in reducing procedural pain in preterm and full-term born infants. A systematic search of key electronic databases (PubMed, CINAHL, EMBASE) was completed. Of the 1032 abstracts screened, 21 were found eligible for inclusion. Fifteen studies reported on the use of breast-feeding or expressed breast milk in full-term infants and 6 reported on preterm infants. Direct breast-feeding was more effective than maternal holding, maternal skin-to-skin contact, topical anesthetics, and music therapy, and was as or more effective than sweet tasting solutions in full-term infants. Expressed breast milk was not consistently found to reduce pain response in full-term or preterm infants. Studies generally had moderate to high risk of bias. There is sufficient evidence to recommend direct breast-feeding for procedural pain management in full-term infants. Based on current evidence, expressed breast milk alone should not be considered an adequate intervention.

The Effectiveness of Aromatherapy in Reducing Pain: A Systematic Review and Meta-Analysis

Background. Aromatherapy refers to the medicinal or therapeutic use of essential oils absorbed through the skin or olfactory system. Recent literature has examined the effectiveness of aromatherapy in treating pain. Methods. 12 studies examining the use of aromatherapy for pain management were identified through an electronic database search. A meta-analysis was performed to determine the effects of aromatherapy on pain. Results. There is a significant positive effect of aromatherapy (compared to placebo or treatments as usual controls) in reducing pain reported on a visual analog scale (SMD = −1.18, 95% CI: −1.33, −1.03; p < 0.0001). Secondary analyses found that aromatherapy is more consistent for treating nociceptive (SMD = −1.57, 95% CI: −1.76, −1.39, p < 0.0001) and acute pain (SMD = −1.58, 95% CI: −1.75, −1.40, p < 0.0001) than inflammatory (SMD = −0.53, 95% CI: −0.77, −0.29, p < 0.0001) and chronic pain (SMD = −0.22, 95% CI: −0.49, 0.05, p = 0.001), respectively. Based on the available research, aromatherapy is most effective in treating postoperative pain (SMD = −1.79, 95% CI: −2.08, −1.51, p < 0.0001) and obstetrical and gynecological pain (SMD = −1.14, 95% CI: −2.10, −0.19, p < 0.0001). Conclusion. The findings of this study indicate that aromatherapy can successfully treat pain when combined with conventional treatments.

Effects of Breast Milk and Vanilla Odors on Premature Neonate's Heart Rate and Blood Oxygen Saturation During and After Venipuncture

BACKGROUND

Different studies have shown that the use of olfactory stimuli during painful medical procedures reduces infants' response to pain. The main purpose of the current study was to investigate the effect of breast milk odor and vanilla odor on premature infants' vital signs including heart rate and blood oxygen saturation during and after venipuncture.

METHODS

A total of 135 preterm infants were randomly selected and divided into three groups of control, vanilla odor, and breast milk odor. Infants in the breast milk group and the vanilla group were exposed to breast milk odor and vanilla odor from 5 minutes prior to sampling until 30 seconds after sampling.

RESULTS

The results showed that breast milk odor has a significant effect on the changes of neonatal heart rate and blood oxygen saturation during and after venipuncture and decreased the variability of premature infants' heart rate and blood oxygen saturation. Vanilla odor has no significant effect on premature infants' heart rate and blood oxygen saturation.

CONCLUSION

Breast milk odor can decrease the variability of premature infants' heart rate and blood oxygen saturation during and after venipuncture.

Pain Tolerance Selectively Increased by a Sweet-Smelling Odor

The mechanism underlying reported analgesic effects of odors in humans is unclear, although odor hedonics has been implicated. We tested whether odors that are sweet smelling through prior association with tasted sweetness might influence pain by activating the same analgesic mechanisms as sweet tastes. Inhalation of a sweet-smelling odor during a cold-pressor test increased tolerance for pain compared with inhalation of pleasant and unpleasant low-sweetness odors and no odor. There were no significant differences in pain ratings among the odor conditions. These results suggest that smelled sweetness can produce a naturally occurring conditioned increase in pain tolerance.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.  This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'.

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). 

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update.

DATA COLLECTION AND ANALYSIS

Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method.

MAIN RESULTS

Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.

Comparison of Breastmilk Odor and Vanilla Odor on Mitigating Premature Infants' Response to Pain During and After Venipuncture

OBJECTIVE

The main purpose of this study was to investigate the calming effects of breastmilk odor and vanilla odor on preterm infants during and after venipuncture.

SUBJECTS AND METHODS

One hundred thirty-five preterm infants were randomly selected and divided into three groups: control, vanilla odor, and breastmilk odor. Infants in the breastmilk group were exposed to breastmilk odor, and infants in the vanilla group were exposed to vanilla odor from 5 minutes before the start of sampling until 30 seconds after sampling. The Premature Infant Pain Profile was used for calculating quality of pain in infants during and after sampling.

RESULTS

Statistical analyses showed that both vanilla and breastmilk odors had calming effects on premature infants during sampling, but just breastmilk odor had calming effects on infants after the end of sampling. Compared with vanilla odor, breastmilk odor has more calming effects on premature infants.

CONCLUSIONS

Breastmilk odor can be used for calming premature infants during and after venipuncture.

[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.

The effects of olfactory stimulation and gender differences on pain responses in full-term infants

AIM

Studies have reported conflicting findings on whether different smells can reduce distress when infants undergo painful procedures. Our study assessed the impact of vanilla on infants' responses to a painful toe lance, including possible gender differences.

METHODS

We measured the pain responses of 69 full-term infants - 34 girls and 35 boys - during toe lance, using two multidimensional scales - the Neonatal Facial Coding System and Behavioural Indicators of Infant Pain - together with crying duration and hand movements. Three sets of data were collected during baseline, toe lance and recovery, while the babies were exposed to the odour of vanilla (n = 39) or odourless water (n = 30).

RESULTS

Pain responses increased significantly during toe lance, then declined during recovery. Crying duration correlated significantly with finger splaying/fisting and both pain scale scores, with boys displaying higher pain scores than girls. Vanilla had no impact on pain levels.

CONCLUSION

Crying and finger splaying/fisting were observable responses that may be useful for screening pain or distress in healthy neonates. Increased pain reactions by boys may reflect higher irritability. Exposure to an unfamiliar odour did not have a calming effect on full-term neonates.

Cobedding of twin premature infants: calming effects on pain responses

BACKGROUND

The purpose of this trial was to determine whether cobedding of preterm twins has analgesic effects during heel lancing or not.

METHODS

One hundred premature twins (50 sets) born between 26 weeks' and 34 weeks' gestation undergoing heel blood sampling were randomly assigned into two groups: the cobedding group (receiving care in the same incubator) and the standard care group (receiving care in separate incubators). Pain was assessed using the premature infant pain profile score. Duration of crying was measured after heel blood sampling, and salivary cortisol was measured prior to and after heel blood sampling.

RESULTS

Infants in the standard care group cried for a longer time during heel lancing than those in the cobedding group (42.6 ± 19.8 seconds vs. 36.4 ± 21.7 seconds, p = 0.03). The mean premature infant pain profile score after heel lancing was significantly higher in the standard care group (9.8 ± 2.6 vs. 8.06 ± 2.8, p = 0.002). The mean salivary cortisol after heel lancing was also significantly higher in the standard care group (24.3 ± 7.4 nmol/L vs. 20.8 ± 7.4 nmol/L, p = 0.02). No significant adverse effects were seen with cobedding.

CONCLUSION

Cobedding is a comforting measure for twin premature infants during heel lancing, which can be performed without any significant adverse effects.

How do children with autism spectrum disorders express pain? A comparison with developmentally delayed and typically developing children

There is a lack of knowledge about pain reactions in children with autism spectrum disorders (ASD), who have often been considered as insensitive to pain. The objective of this study was to describe the facial, behavioral and physiological reactions of children with ASD during venipuncture and to compare them to the reactions of children with an intellectual disability and nonimpaired control children. We also examined the relation between developmental age and pain reactions. The sample included 35 children with ASD, 32 children with an intellectual disability, and 36 nonimpaired children. The children were videotaped during venipuncture and their heart rate was recorded. Facial reactions were assessed using the Child Facial Coding System (CFCS) and behavioral reactions were scored using the Noncommunicating Children's Pain Checklist (NCCPC). A linear mixed-effects model showed that children's reactions increased between baseline and venipuncture and decreased between the end of venipuncture and the recovery period. There was no significant difference between groups regarding the amount of facial, behavioral and physiological reactions. However, behavioral reactions seemed to remain high in children with ASD after the end of the venipuncture, in contrast with children in the 2 other groups. Moreover, we observed a significant decrease in pain expression with age in nonimpaired children, but no such effect was found regarding children with ASD. The data reveal that children with ASD displayed a significant pain reaction in this situation and tend to recover more slowly after the painful experience. Improvement in pain assessment and management in this population is necessary.

Adding odor: Less distress and enhanced attention for 6-month-olds

The effect of odor on cognitive and emotional processes has been studied in adults and children, but less so in infants. In this study twenty-seven six-month-olds were presented with a video while in either an odor (pine or baby-powder) or a no odor control condition. The video was a 92-s audiovisual presentation of a woman expressing happiness and sadness, with the order of emotion counterbalanced. Infant attention (looking time) and emotional expression (smiling, crying, mouthing) were coded. Infants looked longer in the presence of odor and expressed less crying and mouthing but more smiling behavior. Presence of odor markedly reduced infant emotional distress and increased attention, suggesting that the olfactory sensory system provides cues to infants that support mood regulation and maintain attention. These results have implications for optimizing infant environments for emotional health and cognitive development.

Pediatric feeding and swallowing disorders after bone marrow transplant

Reduced oral intake is a known complication of bone marrow transplant (BMT) and may result in short-term tube feedings. Although most children return to typical eating habits, a subgroup of children requires intervention. The focus of the current investigation was to retrospectively identify the incidence and characteristics of feeding and swallowing disorders in pediatric patients during the first 100 days after BMT and to determine what factors contribute to feeding/swallowing disorders past the BMT acute phase (100+ d). The charts of 292 sequential patients undergoing BMT were reviewed. Seventy-two children (25%) were referred for feeding and/or swallowing intervention with a mean age of 78.6 months (SD=±63.4). Sixteen patients underwent instrumental evaluation with swallowing dysfunction identified in 50% (n=8) of the patients. Oral-motor dysfunction was reported in 33% (n=24) and feeding disorders occurred in 61% (n=44) of the patients referred for treatment. This single-institution review describes the impact of this interruption in the first 100 days after transplant on feeding and swallowing and determined what factors place a child at an increased risk for requiring tube feeding for 100+ days after transplant. The type of BMT, the use of a tube during the first 100 days, and the age were all significant predictors of requiring a tube when considered together for the individual patient. Children who do not require a tube in the first 100 days are significantly less likely to require one in future, approximately 85% less likely to require one whereas children receiving an autologous transplant are approximately 70% less likely to require a tube than children receiving an allogenic transplant. Providers should consider an intervention for younger children undergoing BMT to help maintain or facilitate the development of their feeding and swallowing skills. This may lead to improved feeding outcome in the pediatric BMT population.

Systematic review on phytotherapy in neonatology

BACKGROUND

There is an enormous economical significance of phytotherapy at least in Germany, the huge demand of patients was repeatedly proven. Simultaneously data exist for different application areas and ages as for younger children and pregnancy until birth. The actual neonatal period can be of interest because phytotherapy is used in younger children and until birth, it is not very likely that there is a gap in this period of life.

AIM

To give an overview on the current literature on phytotherapy in neonatology.

METHODS

A systematic review was performed in the following databases: Cochrane, EM-BASE Alert, AMED, NCCAM, NLM, DIMDI, CAMbase, BIOSIS Previews, DAHTA, SciSearch, and Medline as well as in the archives of GMS, Karger, Kluwer, Thieme, Krause and Pachernegg, Wiley-Interscience/Phytotherapy Research, Springer and Merkurstab publishers. Keywords were neonatology, newborn, preterm, phytotherapy, phytomedicine, and herbal drugs in clinical randomized controlled studies.

RESULTS

We found 14 articles that fulfilled the inclusion criteria: 10 case control studies, 1 observational study, 1 study with interview, 1 with a questionnaire, and 1 retrospective study. Topics were aromatherapy, external applications, and internal effects of herbal teas.

CONCLUSION

Indications, study design and explantory power of these publications were quite heterogeneous. Most promising was the study situation in aromatherapy. Due to the fact that phytotherapy is frequently used and there is a high demand of parents, methodologically excellent studies are needed to evaluate the significance of phytotherapy in the neonatal period. The aim is to fulfill scientific as well as economical needs. This review shows that there is no such evidence yet.

The effect of a familiar scent on the behavioral and physiological pain responses in neonates

There are adverse physiologic effects of pain in neonates, and effective pain management must be an essential aspect of neonatal care. In this study we assessed the effect of a nonmaternal familiar scent on the neonatal pain responses. This study included 135 neonates randomly assigned to one of three groups. During arterial puncture, one group was exposed to a vanillin scent on a gauze pad held next to their nose. They were familiarized with it the night before blood sampling by a scented gauze pad placed in the incubator next to their head for an average duration of 8.65 hours. The second group was not familiarized with the scent but was exposed to it during the procedure. The third group was neither familiarized nor exposed to the scent. The duration of crying in the familiar scent group was significantly lower than in the two other groups. Comparison of the physiologic parameters showed less variation in oxygen saturation level during arterial puncture in the familiar scent group. In this study, a familiar scent could reduce crying and oxygen consumption during arterial puncture.

The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates

BACKGROUND

Neonates in a neonatal intensive care unit are exposed to a high number of painful procedures. Since repeated and sustained pain can have consequences for the neurological and behaviour-oriented development of the newborn, the greatest attention needs to be paid to systematic pain management in neonatology. Non-pharmacological treatment methods are being increasingly discussed with regard to pain prevention and relief either alone or in combination with pharmacological treatment.

AIMS

To identify effective non-pharmacological interventions with regard to procedural pain in neonates.

METHODS

A literature search was conducted via the MedLine, CINAHL, Cochrane Library databases and complemented by a handsearch. The literature search covered the period from 1984 to 2004. Data were extracted according to pre-defined criteria by two independent reviewers and methodological quality was assessed.

RESULTS

13 randomised controlled studies and two meta-analyses were taken into consideration with regard to the question of current nursing practice of non-pharmacological pain management methods. The selected interventions were "non-nutritive sucking", "music", "swaddling", "positioning", "olfactory and multisensorial stimulation", "kangaroo care" and "maternal touch". There is evidence that the methods of "non-nutritive sucking", "swaddling" and "facilitated tucking" do have a pain-alleviating effect on neonates.

CONCLUSIONS

Some of the non-pharmacological interventions have an evident favourable effect on pulse rate, respiration and oxygen saturation, on the reduction of motor activity, and on the excitation states after invasive measures. However, unambiguous evidence of this still remains to be presented. Further research should emphasise the use of validated pain assessment instruments for the evaluation of the pain-alleviating effect of non-pharmacological interventions.

The effects of skin-to-skin contact during acute pain in preterm newborns

BACKGROUND AND PURPOSE

Several promising non-pharmacological interventions have been developed to reduce acute pain in preterm infants including skin-to-skin contact between a mother and her infant. However, variability in physiological outcomes of existing studies on skin-to-skin makes it difficult to determine treatment effects of this naturalistic approach for the preterm infant. The aim of this study was to test the efficacy of mother and infant skin-to-skin contact during heel prick in premature infants.

METHOD

Fifty nine stable preterm infants (born at least 30 weeks gestational age) who were undergoing routine heel lance were randomly assigned to either 15 min of skin-to-skin contact before, during and following heel prick (n=31, treatment group), or to regular care (n=28, control group). Throughout the heel lance procedure, all infants were assessed for change in facial action (NFCS), behavioral state, crying, and heart rate.

RESULTS

Statistically significant differences were noted between the treatment and control groups during the puncture, heel squeeze and the post phases of heel prick. Infants who received skin-to-skin contact were more likely to show lower NFCS scores throughout the procedure. Both groups of infants cried and showed increased heart rate during puncture and heel squeeze although changes in these measures were less for the treated infants.

CONCLUSIONS

Skin-to-skin contact promoted reduction in behavioral measures and less physiological increase during procedure. It is recommended that skin-to-skin contact be used as a non-pharmacologic intervention to relieve acute pain in stable premature infants born 30 weeks gestational age or older.

The effect of olfactory stimulation on energy expenditure in growing preterm infants

AIM

To test the hypothesis that olfactory stimulation in growing healthy preterm infants leads to an increase in resting energy expenditure (REE).

DESIGN

A prospective, randomized clinical trial with crossover was conducted in 20 healthy, appropriate weights for gestational age, gavage-fed preterm infants. Infants were studied while asleep and cared for in a skin servo-controlled convective incubator. Using a pipette, 15 drops of saturated solution of vanillin (Aldrich, Fallavier, France) were dripped to a cloth diaper that was placed on the opposite side of the incubator. REE was measured by indirect calorimetry (DeltaTrac II, Helsinki, Finland) exactly 1 h after feeding. Each infant was studied twice by randomization: after a period of 20 min of vanillin odour or after 20 min without vanillin odour.

RESULTS

We found no statistically significant difference in REE of preterm infants when exposed to vanillin odour (74.5 ± 10.1 kcal/kg/day) in comparison with their REE when not exposed to vanillin odour (79.0 ± 11.3 kcal/kg/day).

CONCLUSIONS

Vanillin odour does not significantly influence REE in metabolically and thermally stable preterm infants.

Nonpharmacological management of procedural pain in infants and young children: an abridged Cochrane review

BACKGROUND

Acute pain and distress during medical procedures are commonplace for young children.

OBJECTIVE

To assess the efficacy of nonpharmacological interventions for acute procedural pain in children up to three years of age.

METHODS

Study inclusion criteria were: participants <3 years of age, involved in a randomized controlled or crossover trial, and use of a 'no treatment' control group (51 studies; n=3396). Additional studies meeting all criteria except for study design (eg, use of active control group) were qualitatively described (n=20).

RESULTS

For every intervention, data were analyzed separately according to age group (preterm-born, term-born neonate and older infant ⁄ young child) and type of pain response (pain reactivity, immediate pain-related regulation). The largest standardized mean differences (SMD) for pain reactivity were as follows: sucking-related interventions (preterm: -0.42 [95% CI -0.68 to -0.15]; neonate -1.45 [CI -2.34 to -0.57]), kangaroo care (preterm -1.12 [95% CI -2.04 to -0.21]), and swaddling ⁄ facilitated tucking (preterm -0.97 [95% CI -1.63 to -0.31]). For immediate pain-related regulation, the largest SMDs were: sucking-related interventions (preterm -0.38 [95% CI -0.59 to -0.17]; neonate -0.90 [CI -1.54 to -0.25]), kangaroo care 0.77 (95% CI -1.50 to -0.03]), swaddling ⁄ facilitated tucking (preterm -0.75 [95% CI -1.14 to -0.36]), and rocking ⁄ holding (neonate -0.75 [95% CI -1.20 to -0.30]). The presence of significant heterogeneity limited confidence in nonsignificant findings for certain other analyses.

CONCLUSIONS

Although a number of nonpharmacological treatments have sufficient evidence supporting their efficacy with preterm infants and healthy neonates, no treatments had sufficient evidence to support efficacy with healthy older infants ⁄ young children.

Infant bonding and attachment to the caregiver: insights from basic and clinical science

Early life infant-caregiver attachment is a dynamic, bidirectional process that involving both the infant and caregiver. Infant attachment appears to have a dual function. First, it ensures the infant remains close to the caregiver in order to receive necessary care for survival. Second, the quality of attachment and its associated sensory stimuli organize the brain to define the infant's cognitive and emotional development. Here we present attachment within an historical view and highlight the importance of integrating human and animal research in understanding infant care.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan. 

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation). 

SEARCH STRATEGY

We searched CENTRAL in The Cochrane Library (2011, Issue 1), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), PsycINFO (1967 to April 2011), Cumulative Index to Nursing and Allied Health Literature (1982 to 2011), Dissertation Abstracts International (1980 to 2011) and www.clinicaltrials.gov. We also searched reference lists and contacted researchers via electronic list-serves.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomized controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results.

DATA COLLECTION AND ANALYSIS

We refined search strategies with three Cochrane-affiliated librarians. At least two review authors extracted and rated 51 articles. Study quality ratings were based on a scale by Yates and colleagues. We analyzed the standardized mean difference (SMD) using the generic inverse variance method. We also provided qualitative descriptions of 20 relevant but excluded studies.

MAIN RESULTS

Fifty-one studies, with 3396 participants, were analyzed. The most commonly studied acute procedures were heel-sticks (29 studies) and needles (n = 10 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (preterm: SMD -0.42; 95% CI -0.68 to -0.15; neonate: SMD -1.45, 95% CI -2.34 to -0.57), kangaroo care (preterm: SMD -1.12, 95% CI -2.04 to -0.21), and swaddling/facilitated tucking (preterm: SMD -0.97; 95% CI -1.63 to -0.31). For immediate pain-related regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.38; 95% CI -0.59 to -0.17; neonate: SMD -0.90, 95% CI -1.54 to -0.25), kangaroo care (SMD -0.77, 95% CI -1.50 to -0.03), swaddling/facilitated tucking (preterm: SMD -0.75; 95% CI -1.14 to -0.36), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). The presence of significant heterogeneity limited our confidence in the lack of findings for certain analyses.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.

Procedural pain management for neonates using nonpharmacological strategies: part 2: mother-driven interventions

This is the second of a 2-part series to provide an overview of our current level of knowledge related to nonpharmacological strategies to diminish the pain associated with commonly performed procedures in the NICU. In our first article we discussed the prevalence of repeated pain exposure in the NICU and the importance of nonpharmacological strategies specifically containment or facilitated tucking, swaddling, positioning, nonnutritive sucking, and sweet solutions. These strategies are generally nurse-driven and we believe their importance has been underutilized. In this article we will emphasize the importance of maternal presence as a mediator for pain relief. The efficacy of breastfeeding, maternal skin-to-skin care (often referred to as kangaroo care), and multisensorial stimulation such as auditory and olfactory recognition will be the primary focus of our discussion. In addition, although primarily mother-driven, these strategies are ultimately nurse-enabled, thus the importance of this connection cannot be under appreciated with respect to successful implementation in the NICU.

Exploring the olfactory environment of premature newborns: a French survey of health care and cleaning products used in neonatal units

AIM

To assess the main determinants of the newborn's nosocomial olfactory environment.

METHODS

An electronic questionnaire was sent to 99 neonatal units in France. Senior nurses and/or physicians described the nature and use of skin care products (e.g. umbilical cord and skin disinfectants, adhesive removers), lubrications used for tubes positioning, disinfectants used to clean materials, hand hygiene products (e.g. alcohol-based hand rubs, soaps) and newborns' bath.

RESULTS

Nine groups of products and 76 distinct commercial preparations were identified. Depending on their level of respiratory support, preterm newborns were estimated to be exposed to nosocomial odours (NO) an average of 1320-1800 times during their first month of life. During their whole hospital stay, newborns of 28 and 32 weeks of gestational age could be exposed to NOs products an average of 3448 and 2024 times, respectively. The use of these products varied among medical centres. Newborns were most frequently exposed to the odour of aqueous alcoholic solutions.

CONCLUSIONS

Vulnerable preterm infants are daily exposed to multiple NOs most of them be considered as irritant for the nose. Minimizing infants' exposure to them would be beneficial. Future studies should describe the exact olfactory properties of the products considered essential for infant care and should assess their effects on the infant's well-being and development.

Randomized crossover trial of kangaroo care to reduce biobehavioral pain responses in preterm infants: a pilot study

Kangaroo care (KC), skin-to-skin contact between mother and infant, is a promising method for blunting pain responses. This crossover pilot tested KC effects on biobehavioral responses to heel stick in preterm infants (30-32 weeks' gestational age, 2-9 days old) measured by Premature Infant Pain Profile (PIPP) and salivary and serum cortisol. Mother-infant dyads were randomly assigned to KC heel stick (KCH) first or incubator heel stick (IH) first. Study 1 (80-min study, N = 18) tested the effect of 80 min of KC before and throughout the heel stick procedure versus incubator care. Study 2 (30-min study, N = 10) tested 30 min of KC before and throughout the heel stick versus incubator care. KCH and IH began during a premeasurement phase and continued through four data collection phases: baseline, heel warming, heel stick, and recovery. PIPP responses were measured every 30 s during data collection; salivary cortisol was measured at the end of baseline and recovery; and serum cortisol was measured during heel stick. Study 1 showed no differences between KCH and IH. Study 2 showed lower PIPP scores at four time points during recovery (p < .05 to p < .001), lower salivary cortisol at the end of recovery (p < .05), and lower serum cortisol during heel stick for the KCH condition (p < .05) as well as clinically lower PIPP scores in the KCH condition during heel stick. Thirty minutes of KC before and throughout the heel stick reduced biobehavioral responses to pain in preterm infants.

Pain in neonates is different

Pain processing and management in neonates, especially preterm neonates, differs from older populations. In this review, a brief background on pain processing in neonatal life, pain exposure in Neonatal Intensive Care Units (NICU), the consequences of untreated pain, and the difficulties in treating procedural pain pharmacologically will be presented. A more detailed review of non-pharmacological interventions for procedural pain in neonates will include sensory stimulation approaches, oral sweet solutions, and maternal interventions. Some possible mechanisms for the effectiveness of non-pharmacological interventions are offered. Finally, avenues of research into similar interventions as adjuvant therapies or drug-sparing effects in older populations are suggested.

Co-bedding as a Comfort measure For Twins undergoing painful procedures (CComForT Trial)

Background

Co-bedding, a developmental care strategy, is the practice of caring for diaper clad twins in one incubator (versus separating and caring for each infant in separate incubators), thus creating the opportunity for skin-to-skin contact and touch between the twins. In studies of mothers and their infants, maternal skin-to-skin contact has been shown to decrease procedural pain response according to both behavioral and physiological indicators in very preterm neonates. It is uncertain if this comfort is derived solely from maternal presence or from stabilization of regulatory processes from direct skin contact. The intent of this study is to compare the comfort effect of co-bedding (between twin infants who are co-bedding and those who are not) on infant pain response and physiologic stability during a tissue breaking procedure (heelstick).

Methods/Design

Medically stable preterm twin infants admitted to the Neonatal Intensive Care Unit will be randomly assigned to a co-bedding group or a standard care group. Pain response will be measured by physiological and videotaped facial reaction using the Premature Infant Pain Profile scale (PIPP). Recovery from the tissue breaking procedure will be determined by the length of time for heart rate and oxygen saturation to return to baseline. Sixty four sets of twins (n = 128) will be recruited into the study. Analysis and inference will be based on the intention-to-treat principle.

Discussion

If twin contact while co-bedding is determined to have a comforting effect for painful procedures, then changes in current neonatal care practices to include co-bedding may be an inexpensive, non invasive method to help maintain physiologic stability and decrease the long term psychological impact of procedural pain in this high risk population. Knowledge obtained from this study will also add to existing theoretical models with respect to the exact mechanism of comfort through touch.

Trial registration

NCT00917631

Kangaroo Care modifies preterm infant heart rate variability in response to heel stick pain: pilot study

BACKGROUND

Heel stick is the most common painful procedure for preterm infants in neonatal intensive care units. Resultant pain causes adverse physiological effects in major organ systems. Kangaroo Care (KC), involving mother-infant skin-to-skin contact is a promising analgesic for infant pain; however, the effect of KC on the autonomic nervous system's response to pain is unknown.

AIM

To determine if KC results in improved balance in autonomic responses to heel stick pain than the standard method where infants remain in an incubator care (IC) for the heel stick.

STUDY DESIGN

A randomized cross-over trial.

SUBJECTS

Fourteen preterm infants, 30-32 weeks gestational age and less than 9 days postnatal age.

OUTCOME MEASURES

Infant behavioral state, heart rate, heart rate variability (HRV) indices including low frequency (LF) and high frequency (HF) power, and the LF/HF ratio measured over Baseline, Heel Warming, Heel Stick, and Recovery periods in KC and IC conditions.

RESULTS

HRV differences between KC and IC were that LF was higher in KC at Baseline (p<.01) and at Heel Stick (p<.001), and HF was higher in KC at Baseline than in the IC condition (p<.05). The LF/HF ratio had less fluctuation across the periods in KC than in IC condition and was significantly lower during Recovery in KC than in IC (p<.001).

CONCLUSIONS

Infants experienced better balance in response in KC than IC condition as shown by more autonomic stability during heel stick. KC may be helpful in mediating physiologic response to painful procedures in preterm infants.