Acupressure at BL60 and K3 Points Before Heel Lancing in Preterm Infants

Clinical Issues - June 2024

Addressing pediatric perioperative anxiety Key words: pediatric patient, anxiety, parental presence, stress-diversion activities, anxiolytic medications. Using acupressure to reduce perioperative anxiety in children Key words: acupressure, anxiety, pediatric patient, complementary care interventions, acupressure wristband. Screening for obstructive sleep apnea in pediatric surgical patients Key words: obstructive sleep apnea (OSA), pediatric patient, adenotonsillectomy, screening tool, polysomnography. Assessing fire risk Key words: fire risk assessment, fire prevention, algorithm, cognitive aid, fire triangle.

Analgesic Effect of Low-Level Laser Therapy before Heel Lance for Pain Management in Healthy Term Neonates: A Randomized Controlled Trial

Currently, the prevention, assessment, and management of procedural pain in neonates continues to challenge clinicians and researchers. Objective. To investigate the analgesic effect of low-level laser therapy (LLLT) during heel lance compared to breast milk (BM) feeding in healthy term neonates. In this randomized controlled trial, healthy term neonates who underwent heel lance were randomly assigned to an LLLT or a BM group. The LLLT group received laser therapy to the heel lance site for 20 s before heel lance. The BM group received 5 mL expressed BM via a syringe before heel lance. The primary outcomes were behavioral responses. The secondary outcomes were physiological responses and levels of salivary cortisol and α-amylase. A total of 125 neonates were included, of whom 55 in the LLLT group and 59 in the BM group completed the study. There were no significant differences in latency to first cry and cry duration between the two groups. The squeeze time was significantly shorter in the LLLT group than in the BM group (p = 0.047). There were no significant differences in pain scores, heart rate, respiratory rate, oxygen saturation, and blood pressure before and after heel lance between the two groups. There were no significant differences in salivary cortisol and α-amylase levels in the LLLT group before and after heel lance; however, the differences were significant in the BM group. These findings suggest that the analgesic effect of LLLT is similar to that of BM during heel lance in healthy term neonates. LLLT has potential as an analgesic treatment.

Effect of Acupressure on Procedural Pain in Children: A Systematic Review

PURPOSE

Acupressure is a complementary treatment method performed using fingers and hands to maintain the body's energy balance by stimulating acupuncture points. In recent studies, acupressure has been widely used for minimally invasive procedural (venous assess, intravenous (IV) cannulation, intramuscular injection, heel lancing) pain management in children. This study aims to systematically review the studies that evaluate the effectiveness of acupressure on minimally invasive procedural pain in children.

DESIGN

This study is a systematic review of literature.

METHODS

Studies were obtained by screening literature on this topic using the databases PubMed, EBSCO, Scopus, Google Scholar and Cochrane Central Register of Controlled Trials. The keywords "Acupressure," "Child," "Pain," and "Procedural" were used when screening the literature. The studies selected were those published from January 1, 2000 to January 1, 2022 that met the inclusion and exclusion criteria. The PRISMA checklist was used when performing this systematic review. The Oxford Center for Evidence-Based Medicine Levels of Evidence Working Group (2011) table was used to assess the level of evidence. The procedures for this systematic review were preregistered in the PROSPERO (CRD42022320155) database.

FINDINGS

Of the 12,624 records identified, 10 nursing studies that met the research selection criteria were included in the advanced analysis. These papers were further reviewed for their study design, adequacy of randomization and concealment of allocation, blinding of participants, interventions, and outcome measurements.

CONCLUSIONS

Acupressure has been shown to be effective in relieving minimally invasive procedural pain in children. This review begins to establish a credible evidence base for the use of acupressure in minimally invasive procedural pain relief in pediatric age groups. The implication for nurses includes incorporating acupressure into their practice as an alternative therapy for children who suffer from minimally invasive procedural pain.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

AUTHORS' CONCLUSIONS

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

Effect of Acupoint Stimulation on Controlling Pain from Heel Lance in Neonates: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To evaluate the effect of acupoint stimulation compared to other interventions on pain control in neonates who underwent heel lance, we searched for randomized controlled trials across six databases (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, and Web of Science) published up to January 2023. Studies comparing acupoint stimulation and other interventions for controlling heel lance pain in neonates were included. These reports measured at least one of the following variables: pain score, crying time, oxygenation saturation, heart rate, respiration rate, and duration of the procedure. The data were independently extracted by two authors, and the PRISMA guidelines for study selection were followed. A total of 79 articles were screened, and 10 studies, with results on 813 neonates, were included in the final selection. The pain scores recorded during the heel lance procedure were not significantly different between the acupoint stimulation cohort and the control cohort (SMD of -0.26, 95% confidence interval (CI) from -0.52 to 0.01; p = 0.06; I² = 68%). After processing the subgroup analyses, significant differences were found in the comparisons of acupuncture vs. usual care (SMD of -1.25, 95% CI from -2.23 to 0.27) and acupressure vs. usual care (SMD of -0.62, 95% CI from -0.96 to -0.28); nonsignificant differences were found in other comparisons. Our results demonstrate that acupoint stimulation may improve pain score during the heel lance procedure.

A Randomized Controlled Trial: The Effect of Acupressure and Foot Reflexology on Pain During Heel-Lancing in Neonates

This randomized controlled study aimed to determine the effects of acupressure and foot reflexology on procedural pain during heel-lancing in newborns. This study was conducted with 105 neonates (35 foot reflexology group, 35 acupressure group, and 35 control group) who met the inclusion criteria and who were delivered by cesarean section between October 2017 and March 2018 at a state hospital in Turkey. A "Newborn Information Form" and a "Neonatal Pain, Agitation, and Sedation Scale" (N-PASS) were used to collect data. The study found a significant intergroup difference between pain scores of neonates during the procedures (p < .05). Advanced analyses found that the pain scores in the acupressure and foot reflexology groups were similar, whereas the pain scores in the control group were higher than in the other two groups. Acupressure and foot reflexology administered during heel lancing in newborns are effective methods for reducing pain.

Massage for pain relief in newborns submitted to puncture: systematic review

ABSTRACT Objective To analyze in the scientific literature the effects of massage on pain relief in newborns submitted to puncture. Method Systematic review with meta-analysis performed in October 2020, using PubMed, Web of Science, CINAHL, Scopus, Cochrane and Gale databases. Studies without time frame were included, which used massage as the main technique for relieving neonatal pain during puncture. Data were extracted using standardized forms and the synthesis of results occurred in a descriptive way. Results From the 12 studies included, massage was effective in pain relief in 83.3% of the studies. The comparative meta-analysis of massage versus routine care that assessed duration of crying obtained a statistically significant result (p = 0.0002; 95% CI -85.51 to -27.09). Conclusion Massage contributes to neonatal pain relief by reducing pain score and reducing crying time in newborns submitted to puncture.

Massagem para alívio da dor em recém-nascidos submetidos a punção: revisão sistemática

RESUMO Objetivo Analisar na literatura científica os efeitos da massagem no alívio da dor em recém-nascidos submetidos a punção. Método Revisão sistemática com meta-análise realizada em outubro de 2020, utilizando as bases PubMed, Web of Science, CINAHL, Scopus, Cochrane e Gale. Incluíram-se estudos sem delimitação de recorte temporal, que utilizaram massagem como principal técnica para o alívio da dor neonatal durante a punção. Os dados foram extraídos através de formulários padronizados e a síntese dos resultados ocorreram de forma descritiva. Resultados Dos 12 estudos incluídos, a massagem foi eficaz no alívio da dor em 83,3% dos estudos. A meta-análise comparativa da massagem versus cuidados de rotina que avaliou duração do choro obteve resultado estatisticamente significativo (p = 0,0002; IC 95% -85,51 a -27,09). Conclusão A massagem contribui para o alívio da dor neonatal através da redução do escore de dor e redução do tempo de choro em recém-nascidos submetidos a punção.

Psychosocial and Neurobiological Vulnerabilities of the Hospitalized Preterm Infant and Relevant Non-pharmacological Pain Mitigation Strategies

Background: Preterm pain is common in the Neonatal Intensive Care Unit (NICU), with multiple invasive procedures occurring daily. Objective: To review the psychosocial and neurobiological vulnerabilities of preterm infants and to provide an updated overview of non-pharmacological strategies for acute procedural pain in hospitalized preterm infants. Methods: We utilized a narrative review methodology, which also included a synthesis of key pieces of published systematic reviews that are relevant to the current work. Results and Conclusions: Preterm infants are uniquely susceptible to the impact of painful procedures and prolonged separation from caregivers that are often inherent in a NICU stay. Non-pharmacological interventions can be efficacious for mitigating procedural pain for preterm infants. Interventions should continue to be evaluated with high quality randomized controlled trials, and should endeavor to take into account the neurobiological and psychosocial aspects of preterm vulnerability for pain prevention and management strategies.

Laser acupuncture versus oral glucose administration for pain prevention in term neonates: an observer-blinded non-inferiority randomized controlled clinical trial

BACKGROUND

Neonates undergoing intensive care are routinely submitted to minor painful procedures such as heel lances. Pharmacological treatment is limited in neonatal care and not recommended for minor painful interventions. Hence, non-pharmacological acute pain management is an important subject. Acupuncture could be a new strategy for neonatal pain prevention. Accordingly, the aim of the present study was to investigate whether laser acupuncture is non-inferior to oral sweet solutions in pain prevention.

METHODS

In total, 96 healthy term neonates were randomly assigned to receive either laser acupuncture with 10 mW at LI4 bilaterally (AG, acupuncture group) or 30% oral glucose solution (GG, glucose group) before heel lance for metabolic screening. The primary outcome was the difference in premature infant pain profile (PIPP) score between groups in a non-inferiority concept. Secondary outcomes were changes in heart rate and crying time.

RESULTS

Median (interquartile range) PIPP scores were comparable in the AG and GG (12 (10-14) vs 12 (9-14), p = 0.981). Nevertheless, the 95% confidence interval (CI) of location shift exceeded the predefined margin for non-inferiority of 1 (95% CI: -1.000006 to 1.000059). Heart rate was found to be significantly lower after intervention (p = 0.048) and after heel lance (p = 0.015) in the AG versus GG. There was no difference in crying time between groups (p = 0.890).

CONCLUSION

Laser acupuncture was not shown to be non-inferior to an oral glucose solution, possibly due to the higher than expected variability in PIPP scores within the studied groups. Future neonatal laser acupuncture studies for pain prevention with higher sample sizes are therefore warranted.

Feasibility of auricular acupressure as an adjunct treatment for neonatal opioid withdrawal syndrome (NOWS)

BACKGROUND

The opioid epidemic in the United States continues to threaten public health. As a result of this crisis, neonatal opioid withdrawal syndrome (NOWS) has risen exponentially and requires a multitude of non-pharmacologic treatments to ensure healthy neonatal outcomes. Methods: This feasibility study implemented an acupressure protocol as informed by the Near-Term Infant (NTI) conceptual framework for the treatment of NOWS. Aims of this study were to assess provider training, effective integration of acupressure within the standard of care, and acceptance of this treatment by mothers and healthcare providers. Results: With maternal consent, a total of 12 participants were enrolled and underwent auricular acupressure. Nurse Practitioners were credentialed (75%) and effectively administered neonatal acupressure (100%) in accordance with the study protocol. Mothers were very satisfied with acupressure for the treatment of NOWS (Client Satisfaction Questionaire-8 mean scores 3.8-4.0 of a possible 4.0), and the majority of healthcare providers were supportive (66%, mean scores 3.6 to 4.0 out of possible 5). Conclusions: Auricular acupressure was successfully implemented within the standard of care for NOWS. Future studies should incorporate outlined suggestions and include qualitative measures of acceptance as well as randomized controlled trials to evaluate efficacy.

Magnetic Non-invasive Auricular Acupuncture During Eye-Exam for Retinopathy of Prematurity in Preterm Infants: A Multicentre Randomized Controlled Trial

Background: Eye exam for Retinopathy of prematurity (ROP) is a painful procedure and pharmacological analgesia might be ineffective. We hypothesized that magnetic auricular acupuncture (MAA) compared to placebo will decrease pain during ROP exam in preterm infants. Methods: Multicentre randomized controlled trial conducted in three hospitals (Australia, Canada, and Malaysia). Eligibility: >32 weeks, ROP exam, not sedated, and parental consent. A total of 100 infants were randomized (1:1) to MAA (n = 50) or placebo (n = 50). MAA stickers or placebo were placed on both ears by an unblinded investigator. Pain was assessed using the Premature Infant Pain Profile. Primary analyses were by intention-to-treat. ClinicalTrials.gov:NCT03650621. Findings: The mean (standard deviation, SD) gestation, birthweight, and postnatal age were (MAA 28(3) vs. placebo 28(2) weeks; MAA 1,057(455) vs. placebo 952(273) g; MAA 7(3) vs. placebo 7(3) weeks. Placebo infants had significantly higher PIPP scores during [mean difference 1.6 points (95%CI 0.1-3.1)] and 1 h mean difference 1.5 points (95%CI 0.7-2.2) after the procedure (p < 0.03). Heart rate was lower (173(22) vs. 184(18)/min) and oxygen saturations were higher (93.8(6.2) vs. 91.7(6.1)%, p = 0.05) in MAA infants. No adverse effects. Interpretation: MAA may reduce physiological pain responses during and after ROP exam in preterm infants. Assessment of long-term effects are warranted. Clinical trial registration: www.ClinicalTrials.gov, identifier: NCT03650621.

Culturally Based Practice in Neonatal Procedural Pain Management: A Mini Review

Cultural factors have gradually become important considerations in health services, including in pain management for adult and pediatric patients. However, research on culturally based pain management in neonates remains limited. This mini review aims to provide an overview of procedural pain management in neonates based on cultural approaches from various countries. The review found that there are several analyses of pain management procedures for neonates developed from cultural practices, namely, acupuncture, foot massage and reflexology, Yakson touch therapy, and aromatherapy. The acupuncture method (invasive and non-invasive) is more widely studied using randomized controlled trials (RCTs) than the other methods because the techniques applied can be standardized and measured. There are indications of the positive impact of all the methods examined in this review, but the results of studies have not been consistent because of the diversity of outcome measurement methods used and because of the difficulty of creating standardized procedures to measure pain management methods that are based on cultural practices.

Acupuncture for pediatric pain: The trend of evidence-based research

Background and aim

Acupuncture is part of thousand years Traditional Chinese Medicine. There was promising evidence to support the efficacy of acupuncture in reducing postoperative surgery and dental pain, as well as chemotherapy-related nausea and vomiting. The US National Health Statistics Report indicated that there was significant increase in the use of acupuncture. Research on acupuncture has allowed for its integration into common adult pain practice. Acupuncture can also be utilized in pediatric patients.

Experimental procedure

We evaluate the evidence-based acupuncture for pediatric pain research from 2008 to 2017.

Results

and Conclusions: Acupuncture treatment is well supported to be effective treatment for pediatric procedural pain, infantile colic, adolescent pelvic pain, and headaches under specific intervention methods. There is increasing interest in using acupuncture and related techniques for pediatric pain management. However, the evidence-based randomized controlled trials using acupuncture for pediatric pain management is very limited. Further randomized controlled trial research in pediatric pain is urgently needed.

Effect of acupressure on post tonsillectomy pain in adolescents: a randomized, single-blind, placebo-controlled trial study

Introduction Tonsillectomy is one of the most common pediatric surgeries in the world and pain control following tonsillectomy is very important. Objective The aim of this study is to investigate the effect of acupressure on the amount of pain following tonsillectomy in children. Method One hundred and forty-four children aged 5-12 years old were assigned into one of three groups: interventions, control and placebo. In the intervention group, acupressure was applied at three acupoints and in the placebo group, sham acupressure was applied. In the control group routine care only was applied. Results There was a significant difference between an average of changes in pain score before and after the intervention during the 3 time periods after the tonsillectomy operation in the acupressure group (p = 0.002). Conclusion The results showed that acupressure had a positive effect on pain reduction after tonsillectomy in children in the intervention group.

Invasive and non-invasive acupuncture techniques for pain management in neonates: a systematic review

BACKGROUND

Neonatal pain is an extensive research field and there are many possibilities to treat pain in neonates. Acupuncture is one new and non-pharmacological option and a promising tool to reduce pain in neonates undergoing minor painful interventions during routine medical care.

OBJECTIVES

This review summarises trials of acupuncture for pain reduction in neonates undergoing painful interventions during routine medical care.

DATA SOURCE

MEDLINE, Embase, CINAHL, electronic clinical trials registry platforms and reference lists were systematically screened for trials from their dates of inception to February 2017 (English language database search).

STUDY SELECTION

Inclusion criteria were (1) preterm or term neonates, (2) acupuncture for painful medical interventions and (3) formal pain assessment as a primary or secondary study outcome. We included only randomised controlled trials.

DATA EXTRACTION

Data were extracted using a standardised protocol and individual risk of bias was assessed.

RESULTS

The literature search revealed a total of 12 196 records. After application of inclusion criteria, five studies were included in this review. Two studies demonstrated significant pain reduction, one found equal outcomes in comparison to standard care, and two showed significantly higher pain scores with acupuncture alone.

LIMITATIONS

The main limitation of the results is the heterogeneity across trials in acupuncture modality, acupuncture point selection, control groups and pain assessment (heterogeneity: I²=87%).

CONCLUSION

The results of this review suggest that acupuncture may have a positive pain-relieving effect in neonates. However, due to the low number of available high-quality trials and heterogeneity across the studies it is not possible to state clear recommendations.

Neonatal Abstinence Syndrome: An Integrative Review of Neonatal Acupuncture to Inform a Protocol for Adjunctive Treatment

BACKGROUND

The current opioid epidemic in the United States has given rise to a growing incidence of neonatal abstinence syndrome (NAS). Treatments for this condition optimize nonpharmacologic therapies in an effort to improve withdrawal symptoms and reduce or eliminate the need for opioid medications, thereby reducing hospital length of stay and improving healthy neonatal outcomes.

PURPOSE

The purpose of this review was to evaluate the current evidence for neonatal acupuncture treatments and identify essential characteristics that must be included in a treatment protocol for NAS.

METHODS/SEARCH STRATEGY

An integrative review was conducted under the guidance of the Whittemore and Knafl methodology and near-term infant conceptual framework. An evaluation of the quality and levels of evidence was also included.

FINDINGS/RESULTS

A total of 10 studies were identified in this review. Four of these studies were randomized controlled trials, and utilized acupuncture in the neonatal population to evaluate impact on pain, NAS, and weight gain.

IMPLICATIONS FOR PRACTICE

This review provided the essential elements for the development of a complementary acupuncture treatment protocol for the management of NAS.

IMPLICATIONS FOR RESEARCH

Future research should include the identified essential characteristics in high-quality, blinded, randomized controlled trials to assess the treatment effect of acupuncture on neonates experiencing withdrawal symptoms.

A Scoping Review of Acupuncture as a Potential Intervention for Neonatal Abstinence Syndrome

Objective: Neonatal abstinence syndrome (NAS) has risen drastically over the past decade. Infants with NAS experience extreme discomfort and developmental delays when going into withdrawal. Management includes multiple supportive and nonpharmacologic therapies as first-line treatments in an effort to reduce or prevent the need for medication management. Acupuncture has demonstrated efficacy in adults experiencing withdrawal from addictions, as well as for treating many other conditions in pediatric patients who have similar symptoms to withdrawal. The purpose of this review is to evaluate the safety and efficacy of acupuncture for neonates in withdrawal. Materials and Methods: This review was guided by the Arksey and O'Malley methodological framework, and analysis was performed based on a social ecological model. The PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] statement was used to organize selected publications, and a flow chart was created to display the search process. PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Databases were searched for relevant publications. Results: Acupuncture appears to be safe and effective for reducing withdrawal symptoms in infants, and, thus, should be considered as an additional nonpharmacologic treatment option for NAS.

A Systematic Review of Behavioral and Environmental Interventions for Procedural Pain Management in Preterm Infants

PROBLEM

Current research suggests behavioral and environmental interventions to prevent neonatal pain prior to an invasive procedure are rarely administered and seldom documented. The aim of this study was to systematically review findings from published randomized controlled trials that tested the effects of behavioral and environmental procedural pain management interventions on behavioral pain response in preterm infants.

ELIGIBILITY CRITERIA

Randomized controlled trials examining the effects of behavioral and environmental pain management interventions on behavioral pain response in preterm infants were identified. Articles accepted for inclusion met the following criteria: English language, original, peer refereed, randomized controlled clinical trials published within the past 5 years, study sample: preterm infants, setting: neonatal intensive care units, study intervention behavioral and environmental, outcome pain measurement score from valid and reliable pain scale.

SAMPLE

Fourteen randomized controlled trials from a literature search of PubMed and Medline databases were included in this review.

RESULTS

Across all age groups, facilitated tucking, oral sucrose, and kangaroo care decreased behavioral and physiologic pain response alone and in combination with other behavioral and environmental interventions.

CONCLUSION

Among preterm infants, facilitated tucking, oral sucrose, and kangaroo care significantly mitigates biobehavioral pain response associated with acutely painful procedures.

IMPLICATIONS

Evidence suggests that behavioral and environmental interventions can decrease biobehavioral pain response associated with acutely painful procedures in preterm infants. This review highlights the need for rigorous studies to help healthcare providers to build a tailored pain treatment plan for preterm infants.

A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants

Pain is a major problem in sick newborn infants, especially for those needing intensive care. Pharmacological pain relief is the most commonly used, but might be ineffective and has side effects, including long-term neurodevelopmental sequelae. The effectiveness and safety of alternative analgesic methods are ambiguous. The objective was to review the effectiveness and safety of non-pharmacological methods of pain relief in newborn infants and to identify those that are the most effective. PubMed and Google Scholar were searched using the terms: “infant”, “premature”, “pain”, “acupuncture”, “skin-to-skin contact”, “sucrose”, “massage”, “musical therapy” and ‘breastfeeding’. We included 24 studies assessing different methods of non-pharmacological analgesic techniques. Most resulted in some degree of analgesia but many were ineffective and some were even detrimental. Sucrose, for example, was often ineffective but was more effective than music therapy, massage, breast milk (for extremely premature infants) or non-invasive electrical stimulation acupuncture. There were also conflicting results for acupuncture, skin-to-skin care and musical therapy. Most non-pharmacological methods of analgesia provide a modicum of relief for preterm infants, but none are completely effective and there is no clearly superior method. Study is also required to assess potential long-term consequences of any of these methods.

Minimally invasive non-surgical management of plantar fasciitis: A systematic review

BACKGROUND

Minimally invasive non-surgical techniques have been widely used worldwide to treat musculoskeletal injuries. Of these techniques, injectable pharmaceutical agents are the most commonly employed treatments, with corticosteroids being the most widely used drugs. The aim of this article is to review current scientific evidence as well as the effectiveness of minimally invasive non-surgical techniques, either alone or combined, for the treatment of plantar fasciitis.

METHODS

This systematic review was conducted from April 2016 until March 2017, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and was registered with PROSPERO. Randomized controlled trials (RCTs) of adult patients diagnosed with plantar fasciitis were included as well as intervention studies, with a minimal sample size of 20 subjects per study (10 per group). Assessment of study eligibility was developed by three reviewers independently in an unblinded standardized manner. The physiotherapy evidence database (PEDro) scale was used to analyse the methodological quality of studies.

RESULTS

Twenty-nine full-text articles on minimally invasive techniques were reviewed. These articles focused on corticosteroid injections, platelet-rich plasma, Botox, dextrose injections, as well as comparative studies with dry needling vs sham needling.

CONCLUSION

The treatment of plantar fasciitis has dramatically improved in the past decade with minimally invasive techniques becoming increasingly available. Research findings have shown that the long term effects of minimally invasive (non-surgical) treatments such as shock wave therapy, botulinum toxin type-A injections, platelet-rich plasma injections and intratissue percutaneous electrolysis dry needling show similar and sometimes better results when compared to only corticosteroid injections. The latter have been the mainstay of treatment for many years despite their associated side effects both locally and systemically. To date, there is no definitive treatment guideline for plantar fasciitis, however the findings of this literature review may help inform practitioners and clinicians who use invasive methods for the treatment of plantar fasciitis regarding the levels of evidence for the different treatment modalities available.

Pediatric Tuina for promoting growth and development of preterm infants: A protocol for the systematic review of randomized controlled trail

BACKGROUND

Preterm infants are babies born alive before 37 weeks. Many survived infants concomitant with defects of growth and development, a lifetime of disability usually as following when insufficient intervention. In early intervention of preterm infants, pediatric Tuina shows good effect in many Chinese and some English clinical trials. This systematic review is aimed to evaluate the efficacy and safety of pediatric Tuina for promoting growth and development of preterm infants.

METHODS

The electronic databases of Cochrane Library, MEDLINE, EBASE, Web of Science, Springer, World Health Organization International Clinical Trials Registry Platform, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Wan-fang database, Chinese Scientific Journal Database, and other databases will be searched from establishment to April 1, 2018. All published randomized controlled trials (RCTs) about this topic will be included. Two independent researchers will operate article retrieval, screening, quality evaluation, and data analyses by Review Manager (V.5.3.5). Meta-analyses, subgroup analysis, and/or descriptive analysis will be performed based on included data conditions.

RESULTS

High-quality synthesis and/or descriptive analysis of current evidence will be provided from weight increase, motor development, neuropsychological development, length of stay, days of weight recovery to birthweight, days on supplemental oxygen, daily sleep duration, and side effects.

CONCLUSION

This study will provide the evidence of whether pediatric Tuina is an effective early intervention for preterm infants.

ETHICS AND DISSEMINATION

There is no requirement of ethical approval and informed consent, and it will be in print or published by electronic copies.

TRAIL REGISTRATION NUMBER

This systematic review protocol has been registered in the PROSPERO network (No. CRD42018090563).

Laser Acupuncture at Large Intestine 4 Compared with Oral Glucose Administration for Pain Prevention in Healthy Term Neonates Undergoing Routine Heel Lance: Study Protocol for an Observer-Blinded, Randomised Controlled Clinical Trial

Background

Nonpharmacological strategies have actually become more important in neonatal pain management during routinely applied minor painful procedures. However, commonly used nonpharmacological strategies are inferior to orally administered sweet solutions. Therefore, we will compare laser acupuncture, as a recent nonpharmacological method, with the standard care of oral glucose solution for pain prevention.

Methods

Ninety-five healthy term neonates will be allocated into one of two groups. Before routine heel lance for metabolic screening, one group will receive laser acupuncture at acupuncture point Large Intestine 4 (LI 4) bilaterally for 60 seconds per point (acupuncture group) and the other will receive the standard care with orally administered glucose solution (glucose group). The complete procedure of blood sampling will be recorded on video, excluding the intervention before heel lance. A paediatric nurse, blinded with respect to the allocation, will evaluate these video recordings and determine the Premature Infant Pain Profile (PIPP) for each neonate. Primary outcome will be the mean difference in PIPP scores between groups.

Discussion

This observer-blinded randomised controlled trial has been designed to explore potential advantages of laser acupuncture in the management of neonatal pain because more data are required to provide information about its efficacy and safety.

Trial Registration

This trial is registered with DRKS00010122.

Magnetic noninvasive acupuncture for infant comfort (MAGNIFIC) - a single-blinded randomised controlled pilot trial

AIM

To determine the safety and feasibility of auricular noninvasive magnetic acupuncture (MA) to decrease infant pain during heel pricks.

METHODS

Infants requiring heel pricks for blood collection were randomised to either MA (n = 21) or placebo (P) (n = 19) after parental informed consent. MA or placebo stickers were placed on both ears according to the Battlefield Protocol by an unblinded investigator and left on for 3 days. Pain was assessed with the Premature Infant Pain Profile (PIPP) by blinded clinicians.

RESULTS

Mean gestation (MA:34.1, P:34.4 weeks) and age of infants (MA:5.3, P:4.5 days) were similar as were mean (SD) pre (MA:1.7(1.4), P:2.1(1.9)) and post (MA:1.6(1.4), P: 2.1(1.7)) heel prick PIPP scores. PIPP scores were significantly lower in MA infants during heel pricks (MA:5.9(3.7), P: 8.3(4.7), p = 0.04). One-way ANCOVA modelling showed that MA was significantly associated with lower PIPP scores after controlling for analgesic use (p = 0.043). No differences in heart rate, oxygen saturation, analgesic use or adverse effects (e.g. local skin reactions) noted.

CONCLUSION

This pilot study shows that auricular MA is feasible in neonates and may reduce PIPP scores during heel pricks. Further study is required to determine the impact of MA on other painful or stressful conditions and on neurodevelopment.

Acupuncture in the neonatal intensive care unit-using ancient medicine to help today's babies: a review

Acupuncture has been used for thousands of years in Eastern medicine for a variety of conditions and illnesses, including pain. Neonatal intensive care, on the other hand, is a relatively new branch of medicine that has emerged as the pivotal influence in increasing survival of critically ill newborn infants only within the last 50 years. Unfortunately, pain is an inevitable part of treatment in a neonatal intensive care unit (NICU). The control and prevention of pain remains a major issue for clinicians despite recognition and understanding of the myriad of short- and long-term problems that are associated with both pain and its treatment within the NICU environment. In this review, we examine the potential role of acupuncture to decrease and treat pain in babies requiring neonatal intensive care and discuss future therapeutic and research implications for the use of this ancient therapy within the modern environment of the NICU.

Does noninvasive electrical stimulation of acupuncture points reduce heelstick pain in neonates?

AIM

Noninvasive electrical stimulation at acupuncture points (NESAP) for analgesia is used in children, but has not been widely studied in neonates. The purpose of this study was to determine whether NESAP alone or in combination with sucrose relieved heelstick pain in neonates.

METHODS

Term neonates (n = 162) receiving routine heelsticks for newborn screening were enrolled following parental consent. All infants received facilitated tucking and non-nutritive sucking. Neonates were randomised to standard care, sucrose, NESAP or sucrose plus NESAP. NESAP (3.5 mA, 10 Hz) or sham was administered over four acupuncture points. The Premature Infant Pain Profile (PIPP), heart rate variability (HRV) and salivary cortisol were used to measure heelstick pain.

RESULTS

PIPP scores among all four treatment groups increased during heelstick, F (9,119) = 1.95, p = 0.05 and NESAP therapy had no significant effect on PIPP scores. However, PIPP scores from baseline to heelstick increased the most in the two groups not receiving sucrose (p < 0.01). Mean PIPP scores remained below five during the heelstick in all four groups, indicating minimal or no pain. Differences in HRV and salivary cortisol among groups were insignificant.

CONCLUSION

NESAP at 3.5 mA, 10 Hz is not effective in relieving pain during heelsticks in neonates.

Laser acupuncture before heel lancing for pain management in healthy term newborns: a randomised controlled trial

BACKGROUND

Healthy term newborns commonly undergo painful procedures during routine follow-up visits. Non-pharmacological strategies have currently become more important than pharmacological analgesic agents in neonatal pain management. Acupuncture is a new non-pharmacological method for preventing pain in newborns.

OBJECTIVE

We aimed to investigate the effect of laser acupuncture (LA) at the Yintang point before heel lancing as a non-pharmacological intervention for procedural pain management in infants.

METHODS

Forty-two term newborns, who were undergoing heel lancing between postnatal days 3 to 8 as part of routine neonatal screening, were randomly assigned to the LA group or the oral sucrose group. In the LA group, 2 min before the heel lancing, 0.3 J of energy was applied to the Yintang point using a Laser PREMIO-30 unit for 30 s. In the sucrose group, each infant received 0.5 mL of 24% sucrose orally via syringe 2 min before the heel lancing. Each baby's behaviour was scored using the Neonatal Infant Pain Scale (NIPS), assessed blinded to group.

RESULTS

There were no significant differences between the LA and oral sucrose groups with respect to means for gestational week of age at birth, birth weight, actual weight, or Apgar score. Mean procedure time was significantly shorter in the LA group; however, mean crying time was longer and NIPS score was lower compared to the oral sucrose group.

CONCLUSIONS

Our results indicate that 0.3 J of LA at the Yintang point before heel lancing is less effective than oral sucrose for reducing the discomfort of this procedure.

TRIAL REGISTRATION NUMBER

KA14/09.