Effects of white noise on procedural pain-related cortical response and pain score in neonates: A randomized controlled trial

The effect of music on pain, comfort, and physiological parameters during premature retinopathy examination

AIM

To determine the effect of music applied during the ROP examination on pain, comfort, and physiological parameters in preterm infants.

METHODS

The sample of this prospective randomized controlled double-blind experimental study consisted of 28 preterm infants who were examined for ROP of a tertiary hospital in the Neonatal Unit. Data were collected with a Questionnaire, Physiological Parameters Observation Form (PPOF), Revised-Premature Infant Pain Profile (PIPP-R), and Premature Infant Comfort Scale (PICS).

RESULTS

The results revealed that the crying times of the infants in the experimental group were shorter than the infants in the control group. The preterm infants in the experimental group had statistically lower PIPP-R scores during and after the procedure than the PIPP-R scores of the infants in the control group (p < 0.001) and the music applied to the preterm infants resulted in a mean decrease of 3.857 in the post-procedure and pre-procedure PIPP-R scores (p < 0.05). While there was no statistical difference between the pre-procedure and pre-procedural PICS scores of the preterm infants in the experimental and control groups (p = 0.599; p = 117), the post-procedure PICS values of the preterm infants in the experimental group were found to be lower than those of the control group (p < 0.001). It was found that the music applied to preterm infants during the ROP examination resulted in a mean decrease of 1.286 in PICS scores after the procedure and before the procedure (p < 0.05).

CONCLUSION

It was determined that the music listened to during the ROP examination decreased the PIPP-R pain scores of preterm infants, had a positive effect on the PICS scores after the procedure, but did not affect the physiological parameters positively.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05263973.

The effects of white noise and swaddling methods on orogastric tube insertion-related pain in preterm infants: A randomized controlled trial

AIM

This study aims to investigate the effects of the white noise, swaddling and white noise + swaddling methods on pain and physiological parameters associated with orogastric tube insertion procedure.

METHODS

This was a randomized controlled trial. A total of 132 preterm infants were randomly assigned to four groups as white noise group (n = 33), swaddling group (n = 33), white noise + swaddling group (n = 33) and control group (n = 33). Interventions were initiated 5 min before the orogastric tube insertion procedure and continued during and up to 5 min after the procedure.

RESULTS

White noise intervention alone did not have a significant effect on reducing pain associated with orogastric tube insertion (p > 0.05). Compared with the control group, the preterm infants in the swaddling group experienced 0.587 times less pain, and those in the white noise + swaddling group experienced 0.473 times less pain.

CONCLUSIONS

Findings indicate the swaddling and the combination of white noise + swaddling may be a useful intervention in reducing the invasive pain experienced by preterm infants during and after orogastric tube insertion and in improving the physiological parameters associated with pain.

Effects of White Noise on Pain Scores and Salivary Cortisol Levels in Surgical Neonates: A Randomized Controlled Trial

BACKGROUND

Neonates experience varying intensities of pain after surgery. While white noise has been used for postoperative pain relief in infants, its effects on neonates after surgery need further exploration.

PURPOSE

This study aimed to evaluate the effects of white noise on pain scores and salivary cortisol levels in surgical neonates.

METHODS

In this randomized controlled trial, 64 neonates scheduled for surgery were recruited and assigned by block randomization into 2 groups. The intervention group listened to white noise at 50 dB, while the control group listened to white noise at 0 dB, for 30 minutes 6 times for 48 hours postoperatively. Pain scores, measured by the COMFORTneo Scale, and salivary cortisol levels were compared.

RESULTS

Although pain scores decreased after surgery in all subjects, no statistically significant difference was observed between the 2 groups (P = .937). There was a significant difference between pre- and postintervention pain scores in the intervention group only (P = .006). Salivary cortisol levels decreased after intervention in the intervention group, but there was no significant difference between pre- and postintervention levels in the 2 groups (P = .716).

IMPLICATIONS FOR PRACTICE

Given the reduction in pain scores and salivary cortisol concentrations after white noise intervention, white noise shows potential as an adjunctive soothing measure for neonates after surgery.

IMPLICATIONS FOR RESEARCH

Future studies are needed to confirm the efficacy and utility of white noise intervention in clinical settings.

Intervention strategies for white noise alleviating procedural pain in newborns: A systematic review

AIMS AND OBJECTIVE

To systematically evaluate the current intervention strategies of white noise alleviating procedural pain in newborns.

METHODS

This review was conducted following the PRISMA guideline. Seventeen databases National Guideline Clearinghouse, up to date, Clinical Evidence, BMJ best practice, Cochrane library, OVID, PubMed, Medline, EMBASE, Web of Science, CHINHAL, Medlive, China Biology Medicine disc, Chinese Clinical Trial Registry, China National Knowledge Infrastructure, China Science and Technology Journal Database, Wanfang Data Knowledge Service Platform were employed, and the studies about pain-relieving with white noise in newborns published before June 2022 was included. Quality of studies was evaluated by using the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

18 studies were included, with sample sizes ranging from 32-296 cases. Intervention indices included duration, distance, volume, music type and outcome measure. Duration varies from study to study, from 5 min before to 5 min after the procedures. The distance was controlled at 10-60 cm, volume was controlled at 45-60 dB and music type was selected from Orhan Osman's album "Kolic" in most studies. Outcome measures included physiological indicators, neurophysiological indicators, behavioural indicators and pain score. Differences in duration leading to different white noise effects was found, but no studies have shown whether there is an effect of different volume, distance or music type.

CONCLUSIONS

Based on this review, we recommend the following intervention strategies: the duration is set from 1 min before to 3 min after the procedures, the distance is decided according to the actual clinical situation, the volume is controlled at 45-55 dB (55 dB is optimal), the music type is selected to simulate intrauterine sounds, and outcome measures can choose physiological indicators, neurophysiological indictors, behavioural indicators and pain score depending on specific department and population. It is important to further explore the best intervention strategies.

RELEVANCE TO CLINICAL PRACTICE

In addition to providing a set of intervention strategies, this review could be used as evidence for relieving procedural pain in newborns.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution. Data were obtained from others' literature.

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.

The missing mechanistic link: Improving behavioral treatment efficacy for pediatric chronic pain

Pediatric chronic pain is a significant global issue, with biopsychosocial factors contributing to the complexity of the condition. Studies have explored behavioral treatments for pediatric chronic pain, but these treatments have mixed efficacy for improving functional and psychological outcomes. Furthermore, the literature lacks an understanding of the biobehavioral mechanisms contributing to pediatric chronic pain treatment response. In this mini review, we focus on how neuroimaging has been used to identify biobehavioral mechanisms of different conditions and how this modality can be used in mechanistic clinical trials to identify markers of treatment response for pediatric chronic pain. We propose that mechanistic clinical trials, utilizing neuroimaging, are warranted to investigate how to optimize the efficacy of behavioral treatments for pediatric chronic pain patients across pain types and ages.