Assessment of pain in the neonate

Prolonged pain in premature neonates hospitalised in neonatal intensive care units: A scoping review

BACKGROUND

Exposure to repetitive pain during the neonatal period has been shown to have important short and long-term effects on the neurodevelopment of the premature neonate and can contribute to experienced prolonged pain. A uniform taxonomy of neonatal prolonged pain is still lacking to this day which contributes to suboptimal prolonged pain management in neonatal intensive care units. Accordingly, a scoping review exploring the state of knowledge about prolonged pain in preterm neonates hospitalised in the neonatal intensive care unit will contribute to the developing field of neonatal prolonged pain and provide recommendations for clinical prolonged pain management.

OBJECTIVE

To determine the scope, extent, and nature of the available literature on prolonged pain in premature neonates hospitalised in neonatal intensive care units.

DESIGN

Scoping review.

METHODS

An electronic search was conducted from inception to November 2023 in the databases of CINAHL, PubMed, Medline, Web of Science, GeryLit.org and Grey Source Index. Included studies discussed concepts related to neonatal prolonged pain such as definitions of prolonged pain, indicators of prolonged pain, contexts that result in prolonged pain, prolonged pain evaluation tools, consequences of prolonged pain and interventions for prolonged pain management.

RESULTS

Key concepts of neonatal prolonged pain were identified in the 86 included articles of this scoping review such as definitions (n = 26), indicators (n = 39), contexts (n = 49), scales (n = 56), consequences of prolonged pain (n = 30) and possible interventions for prolonged pain management (n = 22). Whilst a consensus on a definition has yet to be achieved, no proximate event was shown to cause prolonged pain and a time criterion was identified by authors as being relevant in defining prolonged pain. Interestingly, the context of hospitalisation was identified as being the most indicative of prolonged pain in premature neonates and should guide its evaluation and management, whilst only limited pain management interventions and consequences were discussed.

CONCLUSION

The findings of this scoping review contribute to the foundation of growing knowledge in neonatal prolonged pain and shed light on the ambiguity that currently exists on this topic in the scientific literature. This review summarises knowledge of key concepts necessary for a better understanding of prolonged pain and stresses the importance of considering contexts of hospitalisation for prolonged pain evaluation and management in neonatal intensive care units, with the objective of improving developmental outcomes of premature neonates.

TWEETABLE ABSTRACT

A scoping review reveals that the contexts of prolonged pain in premature neonates hospitalised in the neonatal intensive care unit are essential in guiding its evaluation and management.

An Evidence-Based Discussion of Fetal Pain and Stress

BACKGROUND

The concept of fetal pain results from procedures conducted without anesthesia in preterm newborns and fetuses, which indicate that it is possible to examine fetal pain based on stress hormone, metabolic, and behavioral changes. Anatomical and physiological data suggest that fetuses become capable of processing nociceptive stimuli around midgestation, although the associated changes in fetal brain development remain unclear. What constitutes fetal pain remains controversial in the light of the definition of pain adopted by the International Association for the Study of Pain (IASP), which posits pain as an "unpleasant sensory and emotional experience."

SUMMARY

Here, we examine the notion that human fetuses cannot "experience" pain and potential implications of this claim. We highlight the key scientific evidence related to fetal pain, including clinical studies on pain in fetuses and preterm newborns. We argue that consistent patterns of stress hormones, metabolic changes, body movements, hemodynamic changes, and pain-related facial expressions in fetuses exposed to invasive procedures overcome the need for subjective proof of pain as articulated in the IASP definition. No study to date has conclusively proven the absence of fetal pain beyond the age of viability.

KEY MESSAGES

Based on the current evidence, we propose that all fetuses receive anesthesia regardless of the invasive procedures being performed to guarantee the least possible pain and physiological, behavioral, or hormonal responses without exposing the mother or her baby to unnecessary complications.

Effect of Yakson touch and mother's voice on pain and comfort level during nasal CPAP application in Turkey: A randomized controlled study

PURPOSE

This study was conducted to evaluate the effects of Yakson touch and mother's voice on pain and comfort levels of preterm infants during nasal CPAP application.

DESIGN AND METHODS

The study was conducted as a randomized experimental study with a control group. It included 124 premature infants (mother's voice group = 31, Yakson touch group = 31, mother's voice+ Yakson touch group= 31, control group = 31) of 28-37 weeks of age who had nasal CPAP application in the NICU of a state hospital in souteastern Turkey between April 2019 and August 2020. While the infants in the experimental group received mother's voice, Yakson touch, and mother's voice+ Yakson touch procedures before, during and after nasal CPAP application, the infants in the control group received nasal CPAP application without extra intervention. "Newborn Infant Pain Scale (NIPS)" and "Premature Infant Comfort Scale (PICS)" were used to collect data.

RESULTS

Further analysis revealed that the Yakson Touch was the most beneficial intervention for reducing NIPS scores and PICS scores during and after nasal CPAP application in the experimental groups, followed by mother's voice + Yakson touch and lastly mother's voice.

CONCLUSION

Yakson touch and mother's voice+Yakson touch methods, are effective in neonatal pain and comfort management during and after the nasal CPAP application.

Effects of fentanyl and sucrose on pain in retinopathy examinations with pain scale, near-infrared spectroscopy, and ultrasonography: a randomized trial

BACKGROUND

This study aimed to compare the efficacy of intravenous, intranasal fentanyl and oral sucrose in reducing the pain response during retinopathy of prematurity examinations using premature infant pain profile (PIPP) scores.

METHOD

The study included 42 infants who underwent retinopathy screening examinations. The infants were divided into three groups: oral sucrose, intranasal fentanyl, and intravenous fentanyl. Vital signs (heart rate, arterial oxygen saturation, and mean arterial pressure) were recorded. The PIPP was used to determine pain severity. Cerebral oxygenation and middle cerebral artery blood flow were evaluated using near-infrared spectroscopy and Doppler ultrasonography, respectively. The data obtained were compared between groups.

RESULTS

There was no significant difference between the three groups regarding postconceptional and postnatal ages or birth weights and weight at the time of examination. All babies had moderate pain during the examination. No correlation was observed between analgesia method and pain scores (P = 0.159). In all three groups, heart rate and mean arterial pressure increased, whereas oxygen saturation decreased during the exam compared with pre-examination values. However, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation (sPO2) values did not differ between groups (HR, P = 0.150; MAP, P = 0.245; sPO2, P = 0.140). The cerebral oxygenation (rSO2) values between the three groups were found to be similar [rSO2: P = 0.545, P = 0.247, P = 0.803; fractional tissue oxygen extraction (FTOE): P = 0.553, P = 0.278]. Regarding cerebral blood flow values, we also did not find any difference between the three groups [mean blood flow velocity (Vmean): P = 0.569, P = 0.975; maximum flow velocity (Vmax): P = 0.820, P = 0.997].

CONCLUSIONS

Intravenous and intranasal fentanyl and oral sucrose were not superior to each other in preventing pain during the examination for retinopathy of prematurity (ROP). Sucrose may be a good alternative for pain control during ROP examination. Our findings suggest that ROP exam may not affect cerebral oxygenation or cerebral blood flow. Larger scale studies are needed to determine the best pharmacological option to reduce pain during ROP exams and evaluate the effects of this procedure on cerebral oxygenation and blood flow.

Intravenous acetaminophen for postoperative pain control after open abdominal and thoracic surgery in pediatric patients: a systematic review and meta-analysis

Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.

Avoiding use of lid speculum and indentation reduced infantile stress during retinopathy of prematurity examinations

PURPOSE

To study the safety and efficacy of indirect ophthalmoscopy with (Sp) or without (speculum free, SpF) the use of lid speculum and scleral indentation for retinopathy of prematurity (ROP) screening.

METHODS

In this crossover randomized controlled trial, preterm infants received either the Sp on their first and the SpF technique on their second examination a week later or vice versa. Video recordings of the infants' reactions were assessed by two observers, using Premature Infant Pain Profile-Revised score and the crying score of the Bernese Pain Scale for Neonates. Fundoscopy adequacy, its duration and adverse events within the first 24 hr postscreening were also recorded.

RESULTS

Thirty-seven infants with median (interquartile range) gestational age of 28.7 (28.0, 30.2) weeks and mean (standard deviation, SD) birth weight 1225 (377) grams were enrolled. The mydriasis-induced stress was similar between the Sp and SpF exam (mean difference [MD]: 0.78, 95% confidence interval [CI]: -0.83, 2.38; p = 0.33). The stress induced by fundoscopy (MD: 4.98, 95% CI: 3.58, 6.37; p < 0.001) and examination overall (MD: 2.32, 95% CI: 0.96, 3.67; p = 0.001) were higher in the Sp than in the SpF exam, and so was the crying score during fundoscopy (MD: 1.31, 95% CI: 1.06, 1.56; p < 0.001). Adverse events in the two groups were similar (p = 0.13). Fundoscopy was adequate in identifying the absence of treatment-requiring ROP in all cases, and lasted longer in the Sp than in the SpF exam (p < 0.001).

CONCLUSION

Our study suggests that the use of speculum and indentation should be reserved for the few cases where fundus visualization is insufficient for excluding the presence of severe ROP.

Measurement of Cumulative Preterm Neonatal and Maternal Stressors During Neonatal Intensive Care Unit Admission

OBJECTIVES

By nature, the neonatal intensive care unit (NICU) environment is stressful for both infants and mothers. This study aimed to explore and quantify the severity of early life stressors in premature infants admitted to the NICU and evaluate the effect of cumulative neonatal stressors on maternal mental health.

METHODS

This cross-sectional study included 100 preterm infants admitted to the NICU for at least 10 days. Daily experiences with painful/stressful procedures for 10 days were determined using the Neonatal Infant Stressor Scale. The included mothers were assessed for their psychological well-being 1 week after NICU admission using the Parental Stressor Scale: NICU and Edinburgh Postnatal Depression Scale.

RESULTS

During the first 10 days of NICU admission, preterm infants experienced an average of 350.76 ± 84.43 acute procedures and an average of 44.84 ± 11.12 cumulative hours of chronic events, with the highest scores recorded on first 3 days of admission. Although intravenous flushing for patency was the most frequent acute procedure, blood gas sampling was the most painful. Forty-five percent of the mothers showed significant depressive symptoms, with the maternal role alteration reported as the most stressful experience, especially for young and new mothers (p < .001). The cumulative stressors experienced by infants were significantly associated with elevated maternal perception of psychological maladjustment (p < .001).

CONCLUSION

This study confirmed that the NICU environment is stressful for both infants and mothers, with the total cumulative stressors experienced by preemies in the NICU having an negative impact on maternal mental health.

Model-Informed Bayesian Estimation Improves the Prediction of Morphine Exposure in Neonates and Infants

BACKGROUND

Pain control in infants is an important clinical concern, with potential long-term adverse neurodevelopmental effects. Intravenous morphine is routinely administered for postoperative pain management; however, its dose-concentration-response relationship in neonates and infants has not been well characterized. Although the current literature provides dosing guidelines for the average infant, it fails to control for the large unexplained variability in morphine clearance and response in individual patients. Bayesian estimation can be used to control for some of this variability. The authors aimed to evaluate morphine pharmacokinetics (PKs) and exposure in critically ill neonates and infants receiving standard-of-care morphine therapy and compare a population-based approach to the model-informed Bayesian techniques.

METHODS

The PKs and exposure of morphine and its active metabolites were evaluated in a prospective opportunistic PK study using 221 discarded blood samples from 57 critically ill neonates and infants in the neonatal intensive care unit. Thereafter, a population-based PK model was compared with a Bayesian adaptive control strategy to predict an individual's PK profile and morphine exposure over time.

RESULTS

Among the critically ill neonates and infants, morphine clearance showed substantial variability with a 40-fold range (ie, 2.2 to 87.1, mean 23.7 L/h/70 kg). Compared with the observed morphine concentrations, the population-model based predictions had an R of 0.13, whereas the model-based Bayesian predictions had an R of 0.61.

CONCLUSIONS

Model-informed Bayesian estimation is a better predictor of morphine exposure than PK models alone in critically ill neonates and infants. A large variability was also identified in morphine clearance. A further study is warranted to elucidate the predictive covariates and precision dosing strategies that use morphine concentration and pain scores as feedbacks.

Identification of Neonatal Infant Pain Assessment Tools as a Possibility of Their Application in Clinical Practice in Croatia: An Integrative Literature Review

OBJECTIVES

This article presents an integrative review of the literature with the aim of identifying instruments already in existence for measuring neonatal infant pain with a view to exploring possibilities of applying them in clinical practice in Croatia.

DESIGN

An integrative review.

DATA SOURCES

The databases searched included MEDLINE, Cinahl Cochrane Library, and Science Direct. The search was limited to available full-text articles in English published between 1990 and 2020. The studies were selected according to the PRISMA strategy and evaluated based on the methodologic framework proposed by Whittemore and Knafl.

REVIEW/ANALYSIS METHODS

The research identified 13 scales for assessing pain in neonatal infants, including 5 one-dimensional and 8 multidimensional scales that assess acute and prolonged pain in preterm and full-term infants.

RESULTS

Overall, the articles in this review confirm that pain is a multidimensional phenomenon and that professionals should consider other specific characteristics of the neonatal infant population while measuring pain.

CONCLUSIONS

Our review showed that various tools exist assessing pain in neonatal infants that could be used in clinical practice in Croatia. However, it is difficult to determine the most appropriate instrument at this stage, as the choice depends on various factors that still need to be considered. The decision on which pain scale to use or which is more appropriate should be based on further psychometric tests, its accuracy, and ease of use.

Preclinical Neuropathic Pain Assessment; the Importance of Translatability and Bidirectional Research

For patients suffering with chronic neuropathic pain the need for suitable novel therapies is imperative. Over recent years a contributing factor for the lack of development of new analgesics for neuropathic pain has been the mismatch of primary neuropathic pain assessment endpoints in preclinical vs. clinical trials. Despite continuous forward translation failures across diverse mechanisms, reflexive quantitative sensory testing remains the primary assessment endpoint for neuropathic pain and analgesia in animals. Restricting preclinical evaluation of pain and analgesia to exclusively reflexive outcomes is over simplified and can be argued not clinically relevant due to the continued lack of forward translation and failures in the clinic. The key to developing new analgesic treatments for neuropathic pain therefore lies in the development of clinically relevant endpoints that can translate preclinical animal results to human clinical trials. In this review we discuss this mismatch of primary neuropathic pain assessment endpoints, together with clinical and preclinical evidence that supports how bidirectional research is helping to validate new clinically relevant neuropathic pain assessment endpoints. Ethological behavioral endpoints such as burrowing and facial grimacing and objective measures such as electroencephalography provide improved translatability potential together with currently used quantitative sensory testing endpoints. By tailoring objective and subjective measures of neuropathic pain the translatability of new medicines for patients suffering with neuropathic pain will hopefully be improved.

Using sensor-fusion and machine-learning algorithms to assess acute pain in non-verbal infants: a study protocol

INTRODUCTION

Objective pain assessment in non-verbal populations is clinically challenging due to their inability to express their pain via self-report. Repetitive exposures to acute or prolonged pain lead to clinical instability, with long-term behavioural and cognitive sequelae in newborn infants. Strong analgesics are also associated with medical complications, potential neurotoxicity and altered brain development. Pain scores performed by bedside nurses provide subjective, observer-dependent assessments rather than objective data for infant pain management; the required observations are labour intensive, difficult to perform by a nurse who is concurrently performing the procedure and increase the nursing workload. Multimodal pain assessment, using sensor-fusion and machine-learning algorithms, can provide a patient-centred, context-dependent, observer-independent and objective pain measure.

METHODS AND ANALYSIS

In newborns undergoing painful procedures, we use facial electromyography to record facial muscle activity-related infant pain, ECG to examine heart rate (HR) changes and HR variability, electrodermal activity (skin conductance) to measure catecholamine-induced palmar sweating, changes in oxygen saturations and skin perfusion, and electroencephalography using active electrodes to assess brain activity in real time. This multimodal approach has the potential to improve the accuracy of pain assessment in non-verbal infants and may even allow continuous pain monitoring at the bedside. The feasibility of this approach will be evaluated in an observational prospective study of clinically required painful procedures in 60 preterm and term newborns, and infants aged 6 months or less.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Stanford University approved the protocol. Study findings will be published in peer-reviewed journals, presented at scientific meetings, taught via webinars, podcasts and video tutorials, and listed on academic/scientific websites. Future studies will validate and refine this approach using the minimum number of sensors required to assess neonatal/infant pain.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03330496).

The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates

BACKGROUND

The neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates.

OBJECTIVE

The objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates.

METHODS

Neonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score.

RESULTS

Nurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the 'variation in the timing of the pain score' and the 'integration of critical thinking and judgement' used when assessing pain in neonates.

CONCLUSIONS

The clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.

Sedation Practices of Neonates Receiving Extracorporeal Membrane Oxygenation

Neonatal sedation practices during extracorporeal membrane oxygenation (ECMO) are not well described and no universal guidelines exist. Current literature describes types of medications used in adult and pediatric ECMO patients, but to our knowledge no data is published on neonatal specific median daily dose requirements or descriptions of sedation practices. The objective of this study is to examine the types and median doses of sedation utilized and to describe sedation practices for neonatal patients requiring ECMO support. This study was a descriptive, retrospective analysis of sedation practices in a single center newborn/infant intensive care unit (N/IICU) from 2012 to 2016. Subjects included all neonates who required ECMO support in the N/IICU for >24 hours. Data were collected from 87 patients and showed the median daily dose of opioids converted to intravenous morphine equivalents was 1.2, 2.0, and 3.4 mg/kg on ECMO days 1, 7, and 14, respectively. The most commonly used continuous medication infusions included morphine, midazolam, and hydromorphone. Dexmedetomidine was used in eight patients and ketamine in two patients. Doses of opioids and sedatives typically escalated over time. Pain scores did not correlate with sedation or analgesic administrations.

Temporal assessment of neonatal pain after airway aspiration

OBJECTIVE

To temporally assess a painful stimulus in premature infants using 3 neonatal pain scales.

METHODS

A total of 83 premature infants were observed during airway aspiration by 3 evaluators (E1, E2 and E3) using 3 pain assessment scales (Neonatal Facial Coding System - NFCS; Neonatal Infant Pain Scale - NIPS; and Premature Infant Pain Profile - PIPP) at 5 time points: T1 (before airway aspiration), T2 (during airway aspiration), T3 (1 minute after airway aspiration), T4 (3 minutes after airway aspiration), and T5 (5 minutes after airway aspiration). Light's Kappa (agreement among examiners and among scales at each time point) and the McNemar test (comparison among time points) were used considering p < 0.05.

RESULTS

There was a significant difference between the 3 examiners for T1 and T2 using the 3 scales. In T3, pain was observed in 22.9%/E1, 28.9%/E2, and 24.1%/E3 according to the NFCS; 22.9%/E1, 21.7%/E2, and 16.9%/E3 according to the NIPS; and 49.4%/E1, 53.9%/E2, and 47%/E3 according to the PIPP. There was a difference between T1 and T3 using the 3 scales, except for 2 examiners for the PIPP (E2: p = 0.15/E3: p = 0.17). Comparing T4 and T5 to T1, there was no difference in the 3 scales.

CONCLUSION

Premature infants required at least 3 minutes to return to their initial state of rest (no pain).

Intranasal Fentanyl Use in Neonates

Background: The recent addition of intranasal medication options for procedural sedation and analgesia has decreased the need for additional painful procedures such as intravenous lines for medication administration. Intranasal fentanyl (INF) has been used in the prehospital setting, as well as in the emergency department for several years, and is increasingly utilized in other locations such as the neonatal intensive care unit (NICU). A paucity of data exists in these smallest children, so we sought to explore trends in INF use in our NICU. Objective: The objective of the study was to describe INF use in the NICU from December 2014 to December 2017. Design/Methods: A retrospective cohort study was conducted of patients receiving INF in the NICU of a large free-standing quaternary inner-city children's hospital from December 2014 to 2017. Demographic data were abstracted from the medical record including gestational age on administration, post-menstrual age, day of life on administration, sex, medication initial and total dose, reported indication, and documented adverse events. This study was approved by our local institutional review board. Results: A total of 54 patients received a total of 67 INF administrations: 32 women (59%), median day of life on administration = 57.1 (interquartile range [IQR] = 33.7-110.4), median weeks gestation = 26.0 (IQR = 24.1-36.1), post-menstrual age = 38.1 weeks (IQR = 33.1-45.4). Initial doses of medications were 1.49 µg/kg/dose INF (range = 0.5-2 µg/kg). Conclusions: Intranasal adjuncts are increasingly used in the NICU. Starting dose of INF is 1.5 µg/kg/dose, and typically, one dose is given.

NEONATAL PAIN: CHARACTERIZATION OF THE PHYSIOTHERAPIST'S PERCEPTION IN THE NEONATAL INTENSIVE CARE UNIT

OBJECTIVE

To describe the perception of physiotherapists in neonatal units regarding pain, the use of measurement scales and strategies that minimize pain.

METHODS

Interviews were conducted with physiotherapists in hospitals with neonatal units between 2013 and 2015 in Rio de Janeiro. The questions concerned the knowledge of the feeling of pain, from its recognition to its care or treatment. The description of the results was done by comparing public and private hospitals (Fisher''s Exact exact Testtest), considering p<0.05 as significant.

RESULTS

27 hospitals were visited. All the professionals interviewed (n=27) stated that the newborns feel pain, with facial expression being the most cited and known sign for pain. 26% of physiotherapists believe that newborns experience pain at the same magnitude as adults. Among the scales, the Neonatal Infant Pain Scale (NIPS) was the most well known, but only 37% of the units had routine pain assessment protocols. IV cannulation and blood collection were the most mentioned procedures as a cause of pain and there was no difference between public and private hospitals.

CONCLUSIONS

There is a gap in the knowledge about neonatal pain and how to evaluate it among the participating physiotherapists, with no systematization of care routines involving this assessment.

The Indonesian version of the Premature Infant Pain Profile-Revised: Translation and adaptation of a neonatal pain assessment

Purpose

Pain assessment is a key component of good pain management in hospitalized infants. This study aimed to translate and adapt a version of pain measurement in infants, the Premature Infant Pain Profile Revised (PIPP-R) into Indonesian.

Method

The adaptation process of the measuring instrument used a modified Brislin method which included forward translation, back translation 1, group discussion 1, back translation 2, group discussion 2, and pilot testing on neonatal nurses: feasibility test, inter-rater reliability using intraclass correlation (ICC), and internal consistency using Cronbach's α coefficient.

Results

The PIPP-R version in English has been translated into Indonesian. In general, nurses assessed this measuring instrument as feasible. The inter-rater reliability showed a high agreement (ICC = 0.968, P = 0.001) and this measuring instrument had good internal consistency (Cronbach's α = 0.856).

Conclusion

The Indonesian version of PIPP-R is easy to use and shows good psychometric properties. The use of this measuring instrument will help nurses and researchers obtain accurate infant pain intensity measurement values.

Evaluation of NICU Nurses' Competence in Pain Assessment 5 Years After Implementation of the COMFORTneo Scale

BACKGROUND

Adequate pain management of preterm and sick newborn infants is a critical issue in the neonatal intensive care unit, as the infants are small and vulnerable with limited resources to deal with pain and stressful experiences. The use of pain assessment instruments, however, must be applied correctly to achieve consistency and improve continuity in care and treatment among clinicians.

PURPOSE

To assess the development of neonatal intensive care unit nurses' interrater agreement in using the COMFORTneo pain assessment tool 5 years after initial implementation, and to identify items needing further development through analysis of discrepancies among nurses' COMFORTneo scores.

METHODS

An evaluation study with a pre- and postdesign comparing nurses' interrater reliability in assessing infant pain using the COMFORTneo pain assessment tool at baseline and 5-year follow-up.

RESULTS

Eighty-five percent of the nurses in the follow-up group (n = 26) had improved their skills 5 years after the implementation, and the improvement was significant (P < .000). We also found that interrater reliability was satisfactory (κ scores ≥0.65) for all the items of the COMFORTneo tool. However, to obtain "very good" interrater reliability (κ scores ≥0.80) 3 items were identified needing increased focus.

IMPLICATIONS FOR PRACTICE

A thorough implementation of a national clinical guideline has been partially effective in ensuring that nurses used the COMFORTneo in their daily practice, which increased their competence in pain assessment.

IMPLICATIONS FOR RESEARCH

Further research into the education of nurses on the efficacy of pain scales, nonpharmacologic and pharmacologic therapies, and individualized pain assessment is needed to better address pain management.

Neonatal painful stimuli: skin conductance algesimeter index to measure efficacy 24% of sucrose oral solution

Pain management is one of the main challenges in addressing the improved care of hospitalized newborns. The administration of oral sucrose with and without non-nutritive suction has been proposed as a nonpharmacological intervention to relieve procedural pain in newborns. The effects have not yet been well characterized. The aim of this study is to investigate, using skin conductance algesimeter (SCA) pain monitor index, the effects of 24% sucrose solution on pain perception during capillary and arterial blood sampling. It is a prospective, randomized controlled study: sucrose versus placebo. Sucrose was given orally to infants who were submitted to arterial or capillary sampling. The SCA was measured during, and for 3 min before and after the intervention. Fifty-six infants were enrolled: 31 in the sucrose group and 25 in the placebo group. SCA showed that the measurement of peaks per second of pain during and 3 min after the procedures was lower in the sucrose group than the placebo group and that this difference was statistically significant (p < .05). In conclusion, 24% sucrose administered orally is effective in reducing pain during and after capillary and arterial sampling in newborns and can be used for the prevention and treatment of pain in the Neonatal Intensive Care Unit.Brief rationaleTo treat neonatal pain, a tiered approach with nonpharmacological and pharmacological method can be used.Among nonpharmacological therapies, sucrose administration is safe and effective in reducing single episodes of minor procedural pain. This study aimed to investigate, the effects of 24% sucrose solution on pain perception during capillary and arterial blood withdrawn by using an objective method: skin conductance algesimeter (SCA) pain monitor index.This randomized controlled trial in which term and/or preterm neonates (postnatal age maximum of 28 days corrected for postmenstrual age) received sucrose for procedural pain. Oral sucrose was administered directly by a disposable plastic vial. SCA was measured by means of a specific device.We demonstrated, using SCA pain monitor index, the efficacy of 24% sucrose solution on pain perception during capillary and arterial blood withdrawn. The results of this study provide an objective evidence of sucrose efficacy for the prevention and treatment of neonatal painful procedures.

Turkish Neonatal Society guideline on the neonatal pain and its management

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

Pain measurement techniques: spotlight on mechanically ventilated patients

Background

Procedural pain is a frequent problem in intensive care units (ICUs). For that, pain assessment has been increasingly introduced to the ICU professional’s routine, and studies have been developed to show the relevance of measuring pain in critically ill patients.

Objective

This review aimed to describe pain measurement techniques for mechanically ventilated adult patients based on evidence and already published.

Method

Systematic literature search was performed on PubMed and Google Scholar. Keywords “pain”, “pain measurement”, “intensive care units” and “respiration, artificial” were combined to the Boolean operator AND. No language or publication year was limited in this search. The purpose and method of all papers were analyzed and only studies which described pain assessment in mechanically ventilated patients were included in this review.

Results

Objective methods were found in the literature to assess pain in mechanically ventilated adults. Behavioral scales were the most used method for pain measurement in noncommunicative patients. Vital signs were used, but the reliability of this method was questioned. Pupillometry, bispectral index and skin conductance were found and described as pain assessment methods.

Conclusion

This review showed that objective measures, as behavioral scales, are the gold standard tools to measure pain intensity in noncommunicative subjects. These data contribute to professionals’ knowledge about ICU pain measurement and emphasize its importance and consequences for adequate pain management.

Development and Usability Evaluation of a Desktop Software Application for Pain Assessment in Infants

BACKGROUND

Pain assessment is a key component of pain management and research in infants. We developed software to assist in coding of pain in infants called PAiN (Pain Assessment in Neonates).

AIMS

The aims of this study were to evaluate the usability of PAiN in terms of effectiveness, efficiency, and satisfaction among novice and expert users and to compare the efficiency and satisfaction of PAiN to existing software for coding of infant pain among expert users.

METHODS

A quantitative usability testing approach was conducted with two participant groups, representing novice and expert end-users. Testing included an observed session with each participant completing a pain assessment coding task, followed by administration of the Post Study System Usability Questionnaire and Desirability Toolkit. For comparison, the usability of existing coding software was also evaluated by the expert group.

RESULTS

Twelve novice and six expert users participated. Novice users committed 14 noncritical navigational errors, and experts committed six. For experts, the median time for completing the coding task was 28.6 min in PAiN, compared to 46.5 min using the existing software. The mean Post Study System Usability Questionnaire score among novice (1.89) and expert users (1.40) was not significantly different (P = 0.0917). Among experts, the score for the existing software (4.83) was significantly (P = 0.0277) higher compared to PAiN (1.40). Lower scores indicate more positive responses.

CONCLUSIONS

Users were highly satisfied with PAiN. Experts were more efficient with PAiN compared to the existing software. The study was critical to ensuring that PAiN is error free and easy to use prior to implementation.

Does Topical Lidocaine Reduce the Pain Associated With the Insertion of Nasal Continuous Positive Airway Pressure Prongs in Preterm Infants?: A Randomized, Controlled Pilot Trial

OBJECTIVE

To evaluate the efficacy of topical lidocaine 2% gel in reducing the pain associated with the insertion of nasal continuous positive airway pressure (nCPAP) prongs in preterm infants.

MATERIALS AND METHODS

A pilot randomized controlled trial. Sixty preterm infants, categorized into lidocaine (n=30) and control groups (n=30). The primary outcome was Premature Infant Pain Profile (PIPP) score, secondary outcomes included salivary cortisol, presence of cry, the duration of first cry, and adverse effects of lidocaine.

RESULTS

There were no statistically significant differences between lidocaine and control groups regarding PIPP scores (mean±SD: 7.2±2.3 vs. 9.3±3.0, respectively, P=0.086). None of the infants in the lidocaine group had severe pain defined as a PIPP score>12, compared with 3 (10%) infants in the control group (P=0.056). Salivary cortisol concentrations were not significantly different between the lidocaine and control groups (mean±SD: 2.57±1.79 vs. 4.82±1.61 μg/dL, respectively, P=0.11). Standardized effect sizes for topical lidocaine were medium to large for reduction in PIPP scores and large for reduction in salivary cortisol (Cohen d=-0.78 and -1.32, respectively). No adverse effects were reported in infants receiving lidocaine.

DISCUSSION

Our data suggest that topical lidocaine did not reduce the pain associated with the insertion of nCPAP prongs in preterm infants. However, the trends for lower PIPP scores in the lidocaine group and the effect sizes for lidocaine on PIPP scores and salivary cortisol were large enough so that a large-scale randomized clinical trial is warranted to confirm or refute our results. Such a study should compare 2 or more active pain interventions during nCPAP application, rather than evaluating a single intervention versus placebo or no treatment.

Individual contextual factors in the validation of the Bernese pain scale for neonates: protocol for a prospective observational study

Background

The Bernese Pain Scale for Neonates (BPSN) is a multidimensional pain assessment tool that is already widely used in clinical settings in the German speaking areas of Europe. Recent findings indicate that pain responses in preterm neonates are influenced by individual contextual factors, such as gestational age (GA), gender and the number of painful procedures experienced. Currently, the BPSN does not consider individual contextual factors. Therefore, the aim of this study is the validation of the BPSN using a large sample of neonates with different GAs. Furthermore, the influence of individual contextual factors on the variability in pain reactions across GA groups will be explored. The results will be used for a modification of the BPSN to account for individual contextual factors in future clinical pain assessment in neonates.

Methods and design

This prospective multisite validation study with a repeated measures design will take place in three university hospital neonatal intensive care units (NICUs) in Switzerland (Bern, Basel and Zurich). To examine the impact of GA on pain responses and their variability, the infants will be stratified into six GA groups ranging from 24 0/7 to 42 0/7. Among preterm infants, 2–5 routine capillary heel sticks within the first 14 days of life, and among full-term infants, two heel sticks during the first days of life will be documented. For each heel stick, measurements will be video recorded for each of three phases: baseline, heel stick, and recovery. The infants’ pain responses will be rated according to the BPSN by five nurses who are blinded as to the number of each heel stick and as to the measurement phases. Individual contextual factors of interest will be extracted from patient charts.

Discussion

Understanding and considering the influence of individual contextual factors on pain responses in a revised version of the BPSN will help the clinical staff to more appropriately assess pain in neonates, particularly preterm neonates hospitalized in NICUs. Pain assessment is a first step toward appropriate and efficient pain management, which itself is an important factor in later motor and cognitive development in this vulnerable patient population.

Trial registration

The study is registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461. Registration date: 12 April 2016.

Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit

Despite the recent improvements in perinatal medical care leading to an increase in survival rates, adverse neurodevelopmental outcomes occur more frequently in preterm and/or high-risk infants. Medical risk factors for neurodevelopmental delays like male gender or intrauterine growth restriction and family sociocultural characteristics have been identified. Significant data have provided evidence of the detrimental impact of overhelming environmental sensory inputs, such as pain and stress, on the developing human brain and strategies aimed at preventing this impact. These strategies, such as free parental access or sleep protection, could be considered 'principles of care'. Implementation of these principles do not require additional research due to the body of evidence. We review the scientific evidence for these principles here.

Is fetal analgesia necessary during prenatal surgery?

Fetal pain and fetal anesthesia are still matter of debate: some authors hypothesize that several intrauterine endocrine neuroinhibitors (ENIn) anesthetize the fetus, keeping it in a constant state of sleep, and making pharmacological fetal anesthesia useless for fetal surgery, while others argue fetal pain is possible and shoud be prevented with fetal anesthesy.

AIM

To retrieve evidences about fetal pain, fetal arousability and about the level of sedation induced by the ENIn, in order to assess the necessity of direct fetal anesthesia during prenatal fetal surgery.

METHODS

We performed a careful literature review (1990-2016) on fetal arousability, and on the possibility that ENIn at the average fetal blood levels induce actual anesthesia. We retrieved the papers that fulfilled the research criteria, with particular attention to the second half of pregnancy, the period when most fetal surgery is performed.

RESULTS

Fetuses are awake about 10% of the total time in the last gestational weeks, and they can be aroused by external stimuli. ENIn have not an anesthetic effect at normal fetal values, but only when they areartificialy injected at high doses; their blood levels in the last trimester of average pregnancies are not dissimilar either in the fetus or in the mother.

CONCLUSIONS

During the second half of the pregnancy, external stimuli can awake the fetuses, although they spend most of the time in sleeping state; the presence of ENIn is absolutely not enough to guarantee an effective anesthesia during surgery. Thus, direct fetal analgesia/anesthesia is mandatory, though further studies on its possible drawbacks are necessary.

Reduced Sufentanil Doses are Effective for Postoperative Analgesia After Ductal Closure in Extremely Premature Infants: A 10 Years Retrospective Cohort Study

OBJECTIVES

The objective of the study was to assess the efficacy of reduced sufentanil doses for postoperative analgesia following surgical ductal closure in extremely premature infants.

METHODS

This was a retrospective, single-center, cohort study comparing 2 sufentanil dosing regimens used between 2001 and 2010 and included all infants born at <28 weeks of gestation with surgical ductal closure. Sufentanil doses were reduced in 2007 as a standard of care. Time was divided into 3 epochs to distinguish the effects of practice changes over time from the effects of sufentanil dose change: epoch 1 (2001 to 2004), epoch 2 (May 2005 to 2007), and epoch 3 (June 2007 to 2010).

RESULTS

A total of 109 of 114 eligible infants were analyzed (mean [±SD], gestational age: 25.1 [±1.1] wk; mean [±SD], birth weight: 756 [±144] g). Median sufentanil doses were significantly higher during epochs 1 and 2 (0.1 to 0.2 µg/kg/h) than during epoch 3 (0.03 to 0.04 µg/kg/h) (P<0.0001). EDIN (Echelle de Douleur et d'Inconfort du Nouveau-né) pain scores were mostly ≤4 throughout the study period and their changes over time were not contemporaneous with the reduction in sufentanil doses; they were lower during epoch 1 versus epochs 2 and 3 (P<0.0001) and comparable between epochs 2 and 3. Midazolam doses and paracetamol use were not higher during epoch 3 as compared with epochs 1 and 2. No difference in opioid-related adverse events was observed between the 3 epochs.

CONCLUSION

Our study supports the use of low continuous intravenous sufentanil doses, consistent with morphine doses currently recommended in this population.

Pain and distress caused by endotracheal suctioning in neonates is better quantified by behavioural than physiological items: a comparison based on item response theory modelling

Pain cannot be directly measured in neonates. Therefore, scores based on indirect behavioural signals such as crying, or physiological signs such as blood pressure, are used to quantify neonatal pain both in clinical practice and in clinical studies. The aim of this study was to determine which of the physiological and behavioural items of 2 validated pain assessment scales (COMFORT and premature infant pain profile) are best able to detect pain during endotracheal and nasal suctioning in ventilated newborns. We analysed a total of 516 PIPP and COMFORT scores from 118 newborns. A graded response model was built to describe the data and item information was calculated for each of the behavioural and physiological items. We found that the graded response model was able to well describe the data, as judged by agreement between the observed data and model simulations. Furthermore, a good agreement was found between the pain estimated by the graded response model and the investigator-assessed visual analogue scale scores (Spearman rho correlation coefficient = 0.80). The information scores for the behavioural items ranged from 1.4 to 27.2 and from 0.0282 to 0.131 for physiological items. In these data with mild to moderate pain levels, behavioural items were vastly more informative of pain and distress than were physiological items. The items that were the most informative of pain are COMFORT items "calmness/agitation," "alertness," and "facial tension."

Morphine Pharmacodynamics in Mechanically Ventilated Preterm Neonates Undergoing Endotracheal Suctioning

To date, morphine pharmacokinetics (PKs) are well quantified in neonates, but results about its efficacy are ambiguous. This work presents an analysis of a previously published study on pain measurements in mechanically ventilated preterm neonates who received either morphine or placebo to improve comfort during invasive ventilation. The research question was whether morphine reduces the pain associated with endotracheal or nasal suctioning before, during, and after suctioning. Because these neonates cannot verbalize their pain levels, pain was assessed on the basis of several validated pain measurement instruments (i.e., COMFORT‐B, preterm infant pain profile [PIPP], Neonatal Infant Pain Scale (NIPS), and visual analogue scale (VAS)). The item response theory (IRT) was used to analyze the data in order for us to handle the data from multiple‐item pain scores. The analysis showed an intra‐individual relationship between morphine concentrations and pain reduction, as measured by COMFORT‐B and VAS. However, the small magnitude of the morphine effect was not considered clinically relevant for this intervention in preterm neonates.

What do we really know about newborn infant pain?

NEW FINDINGS

What is the topic of this review? Pain in infancy. What advances does it highlight? New neurophysiological research on pain processing in the human infant brain. Increased awareness of pain in the newborn has led to the development of numerous assessment tools for use in neonatal intensive care units. Here, I argue that we still know too little about the neurophysiological basis for infant pain to interpret data from clinical observational measures. With increased understanding of how the neural activity and CNS connections that underlie pain behaviour and perception develop in the newborn will come better measurement and treatment of their pain. This review focuses upon two interconnected nociceptive circuits, the spinal cord dorsal horn and the somatosensory cortex in the brain, to highlight what we know and what we do not know about infant pain. The effectiveness of oral sucrose, widely used in clinical practice to relieve infant pain, is discussed as a specific example of what we do not know. This 'hot topic review' highlights the importance of new laboratory-based neurophysiological research for the treatment of newborn infant pain.

Development of Cardiovascular Indices of Acute Pain Responding in Infants: A Systematic Review

Background. Cardiovascular indices of pain are pervasive in the hospital setting. However, no prospective research has examined the development of cardiac responses to acutely painful procedures in the first year of life. Objectives. Our main goal was to synthesize existing evidence regarding the development of cardiovascular responses to acutely painful medical procedures over the first year of life in preterm and term born infants. Methods. A systematic search retrieved 6994 articles to review against inclusion criteria. A total of 41 studies were included in the review. Results. In response to acutely painful procedures, most infants had an increase in mean heart rate (HR) that varied in magnitude both across and within gestational and postnatal ages. Research in the area of HR variability has been inconsistent, limiting conclusions. Conclusions. Longitudinal research is needed to further understand the inherent variability of cardiovascular pain responses across and within gestational and postnatal ages and the causes for the variability.

Intravenous Paracetamol Decreases Requirements of Morphine in Very Preterm Infants

OBJECTIVE

To determine whether intravenous paracetamol therapy is effective in pain therapy in premature infants.

STUDY DESIGN

From June 2009 to December 2011, 108 infants born very low gestational age (<32 weeks) (VLGA) were given intravenous paracetamol before the age of 72 hours. The loading dose was 20 mg/kg followed by 7.5 mg/kg every 6 hours. One hundred ten VLGA infants admitted from October 2007 to May 2009 formed the comparison group who received no paracetamol. Intravenous morphine was exclusively used as the opiate. Morphine dosage was calculated as the cumulative dose administered during the neonatal intensive care unit period. Pain symptoms were screened using pain scale scoring Neonatal Infant Acute Pain Assessment Scale. The number of apneas during the neonatal intensive care unit stay, and ventilation days per patient, were calculated.

RESULTS

The mean (SD) total number of paracetamol doses per patient was 16.9 (11.7), and the postnatal age for the first dose was 13.3 (13.8) hours. Infants in the paracetamol group needed significantly fewer morphine doses per patient than the comparisons, 1.78 (4.56) doses vs 4.35 (11.53), P = .044. The exposed had lower cumulative morphine dosage 0.17 (0.45) mg/kg vs 0.37 (0.96) mg/kg, P = .047. There were no differences in the Neonatal Infant Acute Pain Assessment Scale scores, or the numbers of apneas, or ventilation days. There was no evidence of adverse events including hepatic toxicity.

CONCLUSION

The need for morphine decreased significantly after the introduction of paracetamol for the VLGA infants.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Should we assess pain in newborn infants using a scoring system or just a detection method?

Newborn infants' pain should be scored indirectly using dedicated pain scales. Unfortunately, while some scales for prolonged pain have given good results, a gold standard to assess acute pain does not exist. Acute pain scales still have weak points, most are complex and are scarcely used in neonatal departments. Moreover, carefully scoring pain in clinical practice seems redundant, because any avoidable pain is a concern. This suggests that researchers must find new ways to assess acute pain. A possible approach is to settle for pain detection instead of pain scoring in selected cases. Here, we describe a two-point method that illustrates this approach.

CONCLUSION

For everyday practice, detecting pain is more useful than scoring it; acute pain scales should be reserved for research, for those clinical settings where the personnel has received a careful training and where overcrowding and hurry are absent.

Opioid Analgesics for Sedation and Analgesia During Mechanical Ventilation

Neonates are exposed to repetitive pain and stress during their stay in a NICU, which can lead to chronic complications related to their neurodevelopment and neurobehavior. Approximately 20 percent of all neonates in a NICU are intubated, mechanically ventilated, and require suctioning, which can cause both acute and chronic pain. Pain management in the neonate can be challenging. Nurses and other caregivers need to be well trained to assess pain in the neonate to effectively identify and provide appropriate pain management strategies. There is a lack of evidence to support routine administration of opiates in the neonate. As with any medication, the possibility of short- and long-term adverse reactions must be considered. Nonpharmacologic therapy should be used as much as possible.

The neurodevelopmental impact of neonatal morphine administration

Medical management of newborn infants often necessitates recurrent painful procedures, which may alter nociceptive pathways during a critical developmental period and adversely effect neuropsychological outcomes. To mitigate the effects of repeated painful stimuli, opioid administration for peri-procedural analgesia and ICU (intensive care unit) sedation is common in the NICU (neonatal intensive care unit). A growing body of basic and animal evidence suggests potential long-term harm associated with neonatal opioid therapy. Morphine increases apoptosis in human microglial cells, and animal studies demonstrate long-term changes in behavior, brain function, and spatial recognition memory following morphine exposure. This comprehensive review examines existing preclinical and clinical evidence on the long-term impacts of neonatal pain and opioid therapy.

Neonatal pain control and neurologic effects of anesthetics and sedatives in preterm infants

Preclinical and clinical studies have demonstrated the adverse consequences of untreated pain and stress on brain development in the preterm infant. Sucrose has widely been implemented as standard therapy for minor procedural pain. Anesthetics are commonly utilized in preterm infants during major surgery. Pharmacologic agents (benzodiazepines and opioids) have been examined in clinical trials of preterm infants requiring invasive mechanical ventilation. Controversy exists regarding the safety and long-term impact of these interventions. Ongoing multidisciplinary research will help define the impact of these agents and identify potential alternative therapies.