Randomized controlled trial of topical EMLA and breastfeeding for reducing pain during wDPT vaccination

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.

Efficacy of topical lidocaine-prilocaine (EMLA®) for management of infant pain during pneumococcal vaccination: A randomized controlled trial

Few studies have evaluated whether topical anesthetic cream reduces pain during pneumococcal vaccination. This is crucial, since effective pain management should be evidence-based. Previous studies have shown that topical lidocaine-prilocaine (EMLA^®) reduces vaccination-related pain, measured using pain-rating instruments and observation of crying time. This intervention study aimed to compare the efficacy of topical lidocaine-prilocaine cream with that of the standard of care on the expression of pain during the first pneumococcal vaccination administered at age 3 months under the Swedish national vaccination program. A randomized controlled trial included 72 infants receiving their first pneumococcal vaccination (Prevenar 13^®). The study showed that topical lidocaine-prilocaine before pneumococcal vaccination significantly reduced infants' expression of pain according to the Face, Legs, Activity, Cry, Consolability (FLACC) score (P = .006) and increased latency to cry (P = .001). There were no statistically significant differences in the total crying time (P = .146) between the groups. Topical lidocaine-prilocaine cream reduced pain expression and increased latency to cry in infants receiving their first pneumococcal vaccine. Systematic efforts are needed to successfully implement the use of topical anesthetic cream and other effective non-pharmacological pain-relieving strategies during infant vaccination procedures.

Assessment and Management of Pain in Preterm Infants: A Practice Update

Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant.

Analgesic effects of breast- and formula feeding during routine childhood immunizations up to 1 year of age

BACKGROUND

Data on analgesic effects of breast/formula milk sucking while receiving routine childhood immunizations are available only in early infancy, have rarely been compared in the same study, and are not accompanied by information on mothers' satisfaction/acceptance. Here we aimed to compare the analgesic effect of both methods vs. held-only controls up to 1 year of age, and verify mothers' satisfaction.

METHODS

Two to 12 months children subjected to vaccine were allocated into three groups: breastfed, formula-fed, and held-only controls. A video recording was performed to analyze pain parameters: crying latency/duration and specific scales [FLACC (Face, Legs, Activity, Cry, and Consolability), NIPS (Neonatal Infant Pain Scale)]. After the procedure, mothers filled in a satisfaction questionnaire.

RESULTS

One-hundred and sixty-two children were recruited: 54 breastfed, 35 formula fed, and 73 controls. Breastfed showed the longest crying latency, and together with formula fed, had the shortest duration and lowest pain scores. Most mothers appreciated not only the respective feeding-mediated pain mitigation method used, but also the simply-holding procedure. In all cases, they felt reassured, with an unexpected frequent underestimation of their child's pain during the shot.

CONCLUSIONS

The analgesic effect of breastfeeding during vaccination extends also to children >6 months old, and is obtained by formula too. Embracing the child may help to reassure mothers.

IMPACT

We confirmed the analgesic effect of breastfeeding during the vaccination procedures in early infancy. We show for the first time that this effect is extended also to children up to 1 year of age, and it may be obtained by formula feeding as well. Most mothers appreciated pain mitigation not only through feeding, but also the simply-holding procedure. In all cases, mothers felt reassured, with an unexpected frequent underestimation of their child' pain during the shot. The promotion of these easily feasible and well-accepted strategies should be further encouraged within health professionals during vaccination procedures.

Randomized controlled trial of topical EMLA and vapocoolant spray for reducing pain during wDPT vaccination

BACKGROUND

Intramuscular vaccination is among the most common source of iatrogenic pain in infants. Vapocoolant sprays are rapid-acting alternative to topical anesthetics. They provide transient anesthesia via evaporation induced skin cooling, and reduce pain due to vaccine injection in children and adults. The objective was to compare the synergistic analgesic effect of eutectic mixture of local anesthetics (EMLA) with breastfeeding (EB group) and vapocoolant spay with breastfeeding (VB group) to that of only breastfeeding (BO group) during whole cell diptheria, pertussis and tetanus (wDPT) vaccination.

METHODS

A double blind randomized controlled trial was done to include infants up to 3 months of age who came for their first wDPT vaccination. The primary outcome variable was the duration of cry after vaccination. Secondary outcome variables were Modified Facial Coding Score, Neonatal Infant Pain Scale and latency of onset of cry.

RESULTS

Of the 201 eligible participants, 111 babies were excluded and remaining 90 babies were randomized into three groups of thirty each. The groups did not differ significantly in baseline characteristics. Median (interquartile range, IQR) of duration of cry was lesser [35.86 (21.07-107.75) seconds] in babies receiving EMLA cream with breast feeding (EB group) and in babies receiving vapocoolant spray with breast feeding (VB group) [32.58 (21.25-106.21) seconds] as compared to babies receiving only breast feeding (BO group) [67.5 (27.6-180) seconds] (P=0.147). Difference in median (IQR) of latency of cry was not statistically significant. Modified Facial Coding Score and Neonatal Infant Pain Scale at 1 minute and 3 minutes was significantly lower in the EB and VB group, as compared to the BO group (P<0.05).

CONCLUSION

Addition of topical EMLA application or vapocoolant spray to breastfeeding during wDPT vaccination does not reduce duration of cry in infants up to 3 months of age. However, they are able to show reduction in pain score and further studies are warranted to assess their efficacy as pain relief measures in infants and children.

A Longitudinal Randomized Trial of the Effect of Consistent Pain Management for Infant Vaccinations on Future Vaccination Distress

The objective was to determine if consistent pain management during vaccine injections has a beneficial effect on future infant pain reactivity. This was a multicenter, longitudinal, double-blind, double-dummy, add-on, randomized controlled trial. Healthy infants were randomized to 1 of 4 add-on pain management regimens for all vaccinations in the first year of life: 1) placebo control (standard care), 2) parent video education about infant soothing (video), 3) video and oral sucrose solution (sucrose), 4) video and sucrose and topical liposomal lidocaine (lidocaine). At 15-month vaccinations, all active pain interventions were administered (video and sucrose and lidocaine); however, individuals remained blinded to the original treatments given. Pain at 15 months was evaluated during 3 procedure phases (baseline, needle injection, and recovery) by a researcher unaware of group allocation using a validated measure, the Modified Behavioural Pain Scale (range, 0-10). Altogether, 352 infants participated; characteristics did not differ among groups (P > .05). Pain scores did not differ among groups during baseline (P = .642), needle injection (P = .739), or recovery (P = .750) phases. In conclusion, there was no evidence of a long-term benefit of consistent use of pain interventions in the first year of life on future infant pain responsivity at 15-month vaccinations.

PERSPECTIVE

This randomized controlled trial did not find a long-term benefit of consistent pain management during infant vaccinations on future infant pain responsivity at 15 months. The results are relevant to clinicians and researchers studying and evaluating pain interventions in children undergoing medical procedures.

Efficacy of Breastfeeding on Babies' Pain During Vaccinations

OBJECTIVE

The aim of this randomized controlled experimental study was to evaluate the effect of breastfeeding on the pain of babies during vaccination.

MATERIALS AND METHODS

The sample of the study consisted of 100 babies who complied with the sampling criteria between July and November 2012. The babies breastfed from their mothers 5 minutes before, during, and after the vaccine injections. The Neonatal Infant Pain Scale (NIPS), duration of crying, heart rate, and oxygen saturation were evaluated before, during, and after the vaccine injections. Data were evaluated by descriptive statistics, chi-square, Cronbach's alpha consistency coefficient, independent sample t-test, and Mann-Whitney U test.

RESULTS

The babies in the control group experienced severe pain and the babies in the breastfeeding group felt moderate pain during the vaccine injections (p < 0.05). The NIPS score of the babies in the breastfeeding group was lower than the control group during the vaccine injections. The breastfeeding group spent less time crying, and had lower heart rates and higher oxygen saturation values during vaccine injections Conclusion: Breastfeeding prevented increased heart rates, duration of crying, NIPS, falling oxygen saturation, and reduced pain during the invasive procedures in newborns more than control group.

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.

Breastfeeding for procedural pain in infants beyond the neonatal period

BACKGROUND

Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin-to-skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk.

OBJECTIVES

To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin-to-skin contact, expressed breast milk, formula milk, bottle feeding, sweet-tasting solutions (e.g. sucrose or glucose), distraction, or other interventions.

SEARCH METHODS

We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In-Process & Other Non-Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials.

SELECTION CRITERIA

We included RCTs and quasi-RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet-tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin-to-skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random-effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information.Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38-second reduction in cry time (MD -38, 95% CI -50 to -26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12-month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7-point reduction in standardised pain scores (SMD -1.7, 95% CI -2.2 to -1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD -3.6, -23 to 16).Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage.No included studies reported adverse events.

AUTHORS' CONCLUSIONS

We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin-breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted.

Effect of change in sequence of administration of DTwP and Hepatitis B vaccines on perception of pain in infants: A randomized control trial

OBJECTIVE

This study was designed with objective to study pain response of infants to change in sequence of administration of Hepatitis B and DTwP vaccines.

METHODS

This was a randomized parallel control trial. The study was carried out in the immunization clinic of the Department of Pediatrics, LLRM Medical College, Meerut. One hundred and thirty healthy term infants up to 4 months of age were injected either DTwP vaccine first or Hepatitis B vaccine first, followed one minute later by the other vaccine.

RESULT

Baseline characteristics did not differ between the groups. The mean (SD) of AUC of MFCS and NIPS was significantly more in DF group as compared to HF group (for MFCS 25.5 ± 5.4 versus 22.5 ± 5.5, p<0.01; for NIPS 31.77 ± 5.5 versus 27.64 ± 6.9, p < 0.01). Similarly mean (SD) of AUC of Heart rate and saturation of oxygen showed significant variation in DF group as compared to HF group (for heart rate 591.6 ± 55 versus 559.6 ± 49, p< 0.01; for SpO2 326.4 ± 12 versus 335 ± 8, p < 0.01).

CONCLUSION

These results showed that infant experienced lesser pain when Hepatitis B was administered first than when DTwP vaccine was given first.

Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-Analysis

BACKGROUND

This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan.

DESIGN/METHODS

Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI).

RESULTS

Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD -1.78 (CI, -2.35, -1.22) and (2) before vaccination (n=100): SMD -1.43 (CI, -2.14, -0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD -0.91 (CI, -1.36, -0.47) and self-reported pain in adults (n=60): SMD -0.85 (CI, -1.38, -0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD -0.76 (CI, -1.19, -0.34) or glucose (n=818): SMD -0.69 (CI, -1.03, -0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD -0.78 (CI, -1.08, -0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone.

CONCLUSIONS

Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

Oral glucose in preterm neonates during oropharyngeal suctioning: a randomized controlled cross-over trial

To investigate whether orally applied glucose reduces pain response during oropharyngeal suctioning in preterm infants with a birth weight >1500 g, we conducted a randomized, double-blind, placebo-controlled cross-over trial on 32 preterm infants undergoing oropharyngeal suctioning while on nasal continuous positive airway pressure (CPAP). The Premature Infant Pain Profile (PIPP) score was assessed and compared in a cross-over design to investigate whether there was a significant difference in the patients' pain response. The mean PIPP score during oropharyngeal suctioning after placebo was 8.6 (KI 7.8-9.4). After glucose administration, the mean PIPP score was 8.0 (KI 7.1-8.9). Comparison of the treatment effects reached no statistic significance (p = 0.23). During the oral study drug administration during nasal CPAP, we observed 47 adverse events, but none necessitated therapeutic intervention and none was classified as serious.

CONCLUSION

In our study, late preterm infants in the first days of life did not benefit significantly from analgesia with glucose during oropharyngeal suctioning. The oral administration of glucose under nasal CPAP led to no serious adverse events.