Effect of early procedural pain experience on subsequent pain responses among premature infants

The effect of the simulated intrauterine sound on behavioral and physiological indices of pain during capillary blood sampling for screening preterm infants: a randomized clinical trial study

INTRODUCTION

Due to medical procedures, preterm infants are at high risk for side effects of pain. In this regard, heel lancing for capillary blood sampling is a common painful procedure. The present study was conducted to assess the effectiveness of a simulated intrauterine sound on behavioral and physiological indices of pain due to heel-prick blood sampling in preterm infants.

METHODS

A double‑blind randomized clinical trial (RCT) was conducted. The data were collected from September 23 to December 22, 2019. We measured the effect of a simulated intrauterine sound on changes in the behavioral and physiological parameters of pain (heart rate, SPO2) caused by heel lance that was measured 5 min before the intervention, during the sampling, and 5 min after the procedure. We measured behavioral pain by video recording the infants' faces and then the scoring neonatal infant pain scale (NIPS). Heart rate and SPO2 were measured using a pulse oximeter device. The data were analyzed using analysis of variance (ANOVA) and independent t‑test in SPSS software version 20.0.

RESULTS

Eighty infants were randomized (40 in each group). Mean scores NIPS during and after intervention were in the intervention group (3.55 ± 0.84, 95% CI: 3.30-3.80(, and (1.15 ± 0.84, 95%: 0.95-1.35) and in the control group (5.57 ± 0.95, 95% CI:5.30-5.85) and (3.00 ± 0.98) respectively. There were significant differences in scores of NIPS between the two study groups during (p < 0.001) and five min after heel lancing (p < 0.001). Mean scores of heart rate in the three phases of before, during, and five min after the intervention were respectively in the intervention group (127.57 ± 4.45, 95% CI:126.27-128.99), (131.07 ± 6.54, 95% CI:129.20-133.22), (128.45 ± 5.15, 95% CI:127.02-130.07) and in the control group (128.67 ± 4.57, 95% CI:127.32-130.07), (136.07 ± 7.24, 95% CI:133.90-138.37), and (132.42 ± 6.47, 95% CI:130.37-134.49). There were significant differences in heart rate between the intervention and the control group during (p = 0.002) and five min after the heel lance (p = 0.003). Mean scores of SPO2 in the three phases of baseline, during, and five min after the intervention were respectively in the intervention group (96.72 ± 0.93, 95% CI:96.42-97.00), (91.47 ± 1.46, 95% CI:91.05-91.92), (94.17 ± 1.03, 95% CI:93.22-94.00) and in the control group (96.6 ± 0.84, 95% CI:96.35-96.85), (91.5 ± 1.24, 95% CI:91.12-91.87), and (93.60 ± 1.27, 95% CI:93.85-94.50).

CONCLUSION

This study showed that the simulated intrauterine sound reduces the behavioral pain and heart rate in the intervention group during and after heel lance. These results suggest using the method during the painful heel lancing to reduce pain parameters in preterm infants.

Non-pharmacological pain relief interventions in preterm neonates undergoing screening for retinopathy of prematurity: a systematic review

OBJECTIVE

The objective of this review was to determine the efficacy of non-pharmacological interventions for pain management during retinopathy of prematurity (ROP) screening.

METHODS AND ANALYSIS

Electronic search of Ovid MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Google Scholar and ClinicalTrials.gov (USA) was conducted. Search terms from the research question and inclusion criteria were used to select randomised control trials (RCT) published from January 2000 to May 2023. Relevant data were extracted, and risk of bias was assessed using the Cochrane Risk of Bias tool V.2. Critical appraisal and grading of the quality of evidence were done using the Critical Appraisal Skills Programme tool for RCTs and the Grading of Recommendations Assessment, Development and Evaluation, respectively.

RESULTS

Twenty-one RCTs were included; 14 used sweet taste, while 7 used modified developmental care, touch or positioning, multisensory stimulation, non-nutritive sucking or music. Six studies on sweet taste and all seven latter studies showed a difference in the pain scores in favour of the interventions. The quality of evidence was however judged low and moderate due to some concerns in the randomisation process, measurement of outcome assessment and selection of reported results domains.

CONCLUSION

The use of gentle touch, nesting, positioning, music, multisensory stimulation and developmental care in reducing pain during ROP screening is promising, however, larger studies designed to eliminate the identified concerns are needed. More evidence is also needed before sweet taste interventions can be recommended in routine practice.

Physiological Effects of Handling in Moderate to Late Preterm Infants Receiving Neonatal Intensive Care

BACKGROUND

Of all preterm births, approximately 82% are moderate to late preterm. Moderate to late preterm infants are often treated like full-term infants despite their physiological and metabolic immaturity, increasing their risk for mortality and morbidity.

PURPOSE

To describe the relationship between routine caregiving methods and physiological markers of stress and hypoxemia in infants born between 32 and 36 weeks' gestation.

METHODS

This descriptive study used a prospective observational design to examine the relationship between routine caregiving patterns (single procedure vs clustered care) and physiological markers of stress and hypoxemia such as regional oxygen saturation, quantified as renal and cerebral regional oxygen saturation (StO2), systemic oxygen saturation (Spo2), and heart rate (HR) in moderate to late preterm infants. Renal and cerebral StO2 was measured using near-infrared spectroscopy during a 6-hour study period. Spo2 and HR were measured using pulse oximetry.

RESULTS

A total of 231 procedures were captured in 37 participants. We found greater alterations in cerebral StO2, renal StO2, Spo2, and HR when routine procedures were performed consecutively in clusters than when procedures were performed singly or separately.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Our results suggest that the oxygen saturation and HR of moderate to late preterm infants were significantly altered when exposed to routine procedures that were performed consecutively, in clusters, compared with when exposed to procedures that were performed singly or separately. Adequately powered randomized controlled trials are needed to determine the type of caregiving patterns that will optimize the health outcomes of this vulnerable population.

The impact of multiple insertions on peripheral intravenous access in low-birth-weight infants in perinatology

Low-Birth-Weight (LBW) infants have very small veins, and there is a risk of needing multiple insertions to establish peripheral intravenous access. This study aimed to examine the impacts of multiple insertions during peripheral intravenous access in LBW infants. This cross-sectional study involved 216 respondents. Data were analyzed with the Spearman correlation. The results showed a significant relationship (p<α) between multiple insertions to establish peripheral intravenous access to LBW infants with increased pain, heart rate, respiratory rate, duration of crying, delayed treatment, duration of insertion, and high cost of care (p<0.001; r=0.358-0.836). Meanwhile, multiple insertions might decrease oxygen saturation and body temperature (p<0.001; r=0.358). In this study, multiple insertions were correlated with several negative impacts on the physiological function and discomfort of LBW infants. The study also highlights the effect on time of treatment precision and cost effectiveness. Recommendation: It is necessary to develop preventive measures to reduce the impact of multiple insertions to establish peripheral intravenous access in LBW infants.

Early Neonatal Pain-A Review of Clinical and Experimental Implications on Painful Conditions Later in Life

Modern health care has brought our society innumerable benefits but has also introduced the experience of pain very early in life. For example, it is now routine care for newborns to receive various injections or have blood drawn within 24 h of life. For infants who are sick or premature, the pain experiences inherent in the required medical care are frequent and often severe, with neonates requiring intensive care admission encountering approximately fourteen painful procedures daily in the hospital. Given that much of the world has seen a steady increase in preterm births for the last several decades, an ever-growing number of babies experience multiple painful events before even leaving the hospital. These noxious events occur during a critical period of neurodevelopment when the nervous system is very vulnerable due to immaturity and neuroplasticity. Here, we provide a narrative review of the literature pertaining to the idea that early life pain has significant long-term effects on neurosensory, cognition, behavior, pain processing, and health outcomes that persist into childhood and even adulthood. We refer to clinical and pre-clinical studies investigating how early life pain impacts acute pain later in life, focusing on animal model correlates that have been used to better understand this relationship. Current knowledge around the proposed underlying mechanisms responsible for the long-lasting consequences of neonatal pain, its neurobiological and behavioral effects, and its influence on later pain states are discussed. We conclude by highlighting that another important consequence of early life pain may be the impact it has on later chronic pain states-an area of research that has received little attention.

Assessment of the intensity of procedural pain in newborns treated in the intensive care unit measured by the Neonatal Infant Pain Scale (NIPS)

<b>Introduction:</b> Newborns born prematurely and treated in intensive care units are at greater risk of experiencing pain than patients treated in other units. <b>Purpose:</b> To evaluate the severity of pain perceived by children during the performance of medical procedures related to the treatment and care process. <b>Materials and methods:</b> The study was conducted at one of the Intensive Care Units in Opole. The study group consisted of 100 newborns, 60% of the subjects were prematurely born newborns, and 40% - were full-term. The degree of procedural pain associated with blood collection, peripheral puncture insertion, upper respiratory tract suction, gastric tube insertion and ophthalmic examination was assessed by an observation method using the standard Neonatal Infant Pain Scale Form (NIPS). <b>Results:</b> Out of the analysed medical procedures, 100% of children experienced acute, severe pain over the course of suction and ophthalmological examination. The highest perception of pain was experienced by 88.3% of premature newborns and 71.8% of full-term newborns. Over the course of medical procedures, 84% of male and 79.6% female newborns experienced acute pain. It was shown that the degree of pain perception was determined by the type of performed medical procedure (p=0.001) and the gestational age of the newborn (p=0.037). On the other hand, there was no correlation between the sex of the newborn child and the degree of pain perception (p=0.758). <b>Conclusions:</b> Based on the foregoing study result, bearing in mind the need to minimise the effects of pain stimulation, it seems important to use standardised tools to assess the severity of pain in newborns treated in Intensive Care Units on a larger scale.

[Evaluation of pain in children of 2, 4 and 6 months after the application of non-pharmacological analgesia methods during vaccination]

INTRODUCTION

Young children perceive pain as much, or even more than adults, and the pain may have short- and long-term consequences. The literature describes the use of non-pharmacological interventions to alleviate pain during vaccination. The aim of this study was to assess 3such interventions for analgesia during vaccination: non-nutritive sucking (NNS), breastfeeding (BF), and administration of a 50% dextrose solution (D50W).

MATERIALS AND METHODS

A prospective, non-randomised cohort study was carried out on infants aged 2, 4 and 6 months that received 1, 2, or 3 vaccines, respectively, according to the routine immunisation schedule. There were 3treatments: NNS, BF, and 2mL of D50W combined with NNS. Pain was assessed using the LLANTO scale, and the duration of crying.

RESULTS

The study included 387 infants. The mean scores in the LLANTO scale at ages 2 and 6 months were significantly lower in breastfed infants compared to infants managed with NNS (P=.025 and P<.001, respectively), or infants given D50W (P=.025 and P=.001), and the difference was not statistically significant at age 4 months (P=.21 and P=.27). There were no significant differences between infants managed with NNS and D50W at 2, 4, and 6 months (P=.66, P=.93 and P=.45, respectively). The duration of crying was significantly lower at age 6 months in breastfeed infants compared to infants managed with NNS or D50W (P=.013 and P=.017). No breastfed child (n=129) experienced side effects.

CONCLUSIONS

In infants born to term with adequate weight for gestational age, breastfeeding reduces pain on the administration of 1 or 2 vaccines. When 3 vaccines are given, the reduction is minimal. Administration of D50W does not have any additional analgesic effect in infants compared to being held by a parent combined with NNS during vaccination. BF during vaccination is not associated with any side effects.

Automatic Infants' Pain Assessment by Dynamic Facial Representation: Effects of Profile View, Gestational Age, Gender, and Race

Infants' early exposure to painful procedures can have negative short and long-term effects on cognitive, neurological, and brain development. However, infants cannot express their subjective pain experience, as they do not communicate in any language. Facial expression is the most specific pain indicator, which has been effectively employed for automatic pain recognition. In this paper, dynamic pain facial expression representation and fusion scheme for automatic pain assessment in infants is proposed by combining temporal appearance facial features and temporal geometric facial features. We investigate the effects of various factors that influence pain reactivity in infants, such as individual variables of gestational age, gender, and race. Different automatic infant pain assessment models are constructed, depending on influence factors as well as facial profile view, which affect the model ability of pain recognition. It can be concluded that the profile-based infant pain assessment is feasible, as its performance is almost as good as that of the whole face. Moreover, gestational age is the most influencing factor for pain assessment, and it is necessary to construct specific models depending on it. This is mainly because of a lack of behavioral communication ability in infants with low gestational age, due to limited neurological development. To our best knowledge, this is the first study investigating infants' pain recognition, highlighting profile facial views and various individual variables.