Effect of repeated Kangaroo Mother Care on repeated procedural pain in preterm infants: A randomized controlled trial

Behavioral and physiological pain structures of PIPP-R and parental stress: structural equation modeling approach

BACKGROUND

Although most non-acute pain assessment tools are multi-dimensional (behavioral and physiological measures) in their approach, the outputs of such tools are considered unidimensional. This study aimed to explore and determine the behavioral and physiological pain structures of Premature Infant Pain Profile-Revised (PIPP-R) for neonates and its association with parental stress.

METHODS

This cross-sectional study was conducted in 2022-2023 in Isfahan, Iran. We recruited 400 pre-term infants, i.e. with gestational age (GA) of less than 37weeks who were admitted to the NICU of educational hospitals. PIPP-R and Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) were used for data gathering. The latent structures of pain and its association with parental stress were explored using latent variable modeling approach.

RESULTS

A two-factor model, i.e. behavioral and physiological pain factors, was extracted, explaining 65% of the total variance. The results of confirmatory factor analysis showed that the identified structures in the exploratory factor analysis could be nearly replicated (CFI = 0.99، TLI = 0.98, RMSEA = 0.001). Behavioral pain structure, independent from gestational age had a significant direct association with parental stress score (β = 0.005, SE = 0.002, p = 0.026).

CONCLUSIONS

The PIPP-R assesses both behavioral and physiological pain factors. We also found that behavioral pain factor was associated with parental stress.

IMPACT

These results may provide a potential clue for physicians, nurses, and parents to manage the pain in preterm infant. The PIPP-R scores in preterm infants consist of "Behavioral and Physiological" pain factors. Single dependence on behavioral indicators (such as facial expression) has some limitations. Multidimensional tools may be the optimal method in detecting pain in preterm infants. Parental stress can affect behavioral pain structure in preterm infants. Intensive care nurses play an effective role in reducing the parental stress and pain severity of these preterm infants by including the help of mothers in procedures and providing them with psychological support.

The Effect of Breast Milk Odor on the Pain and Stress Levels of the Newborn During the Endotracheal Suction Procedure

Objective: The study aimed to determine the effect of the breast milk odor on the pain and stress levels of the newborn during the endotracheal suction procedure. Method: The study was conducted in the randomized-controlled experimental design at the neonatal intensive care unit of the hospital in eastern Turkey between March 2022 and December 2023. The study population included newborns at the 37th to 41st gestational weeks who were receiving mechanical ventilation treatment in the neonatal intensive care unit of a hospital in eastern Turkey. All newborns who met the inclusion criteria during the data collection phase were included in the study. The study was completed with 88 newborns (44 in the intervention group and 44 in the control group). The Newborn Introductory Information Form, ALPS-Neo Newborn Pain and Stress Assessment Scale, and follow-up form were used to collect the study data. The breast milk odor of the mothers of the newborns was used as the intervention group in the study. The mothers of the newborns were contacted to obtain breast milk, and the information was obtained from the mother on the day of the procedure. One milliliter of breast milk was taken and dropped into a sterile sponge, and it was held 10 cm away from the baby's nose from 5 minutes before to 5 minutes after endotracheal suction. A routine endotracheal suction process was performed in the control group. Ethical principles were followed in the study. Results: We found that the intervention group's pain and stress score averages were lower than the control group during and after the endotracheal suction procedure (p < 0.05). Conclusion: We found that the breast milk odor reduced the pain, stress levels, and crying duration of newborns during the endotracheal suction process.

A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

Receiving touch is of critical importance, as many studies have shown that touch promotes mental and physical well-being. We conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review (n = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy. Included studies always featured a touch versus no touch control intervention with diverse health outcomes as dependent variables. Risk of bias was assessed via small study, randomization, sequencing, performance and attrition bias. Touch interventions were especially effective in regulating cortisol levels (Hedges' g = 0.78, 95% confidence interval (CI) 0.24 to 1.31) and increasing weight (0.65, 95% CI 0.37 to 0.94) in newborns as well as in reducing pain (0.69, 95% CI 0.48 to 0.89), feelings of depression (0.59, 95% CI 0.40 to 0.78) and state (0.64, 95% CI 0.44 to 0.84) or trait anxiety (0.59, 95% CI 0.40 to 0.77) for adults. Comparing touch interventions involving objects or robots resulted in similar physical (0.56, 95% CI 0.24 to 0.88 versus 0.51, 95% CI 0.38 to 0.64) but lower mental health benefits (0.34, 95% CI 0.19 to 0.49 versus 0.58, 95% CI 0.43 to 0.73). Adult clinical cohorts profited more strongly in mental health domains compared with healthy individuals (0.63, 95% CI 0.46 to 0.80 versus 0.37, 95% CI 0.20 to 0.55). We found no difference in health benefits in adults when comparing touch applied by a familiar person or a health care professional (0.51, 95% CI 0.29 to 0.73 versus 0.50, 95% CI 0.38 to 0.61), but parental touch was more beneficial in newborns (0.69, 95% CI 0.50 to 0.88 versus 0.39, 95% CI 0.18 to 0.61). Small but significant small study bias and the impossibility to blind experimental conditions need to be considered. Leveraging factors that influence touch intervention efficacy will help maximize the benefits of future interventions and focus research in this field.

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

Systematic Review of Kangaroo Care Duration's Impact in Neonatal Intensive Care Units on Infant-Maternal Health

Kangaroo care (KC), skin-to-skin contact between infants and caregivers, is encouraged in neonatal intensive care units (NICUs) to support health through improved weight, growth, and infant-maternal attachment while reducing the incidence of sepsis and infant pain. However, the optimal duration and frequency of KC to maximize health outcomes is unknown. Given parents' time stressors, identifying optimal KC time is critical. A literature review was undertaken on May 28, 2021 via querying the PubMed database from January 1, 1995, to May 28, 2021, regarding KC and NICUs with 442 results. Eleven studies met the eligibility criteria of (1) comparative KC between infants and adult caregivers in NICUs as a randomized controlled trial, (2) peer-reviewed articles in English, (3) study subjects ≥5, (4) health outcomes, and (5) KC sessions >1. Infant physical growth parameters, infant neurodevelopment, infant stress via salivary cortisol levels, and breastfeeding outcomes appear to increase with KC as compared with standard care (SC) without KC. Improvements were observed with longer KC duration, 2 h/d as compared with 1 h/d, for neurodevelopment and breastfeeding outcomes, but no greater improvement with longer KC duration was shown for reducing infant stress through salivary cortisol levels. Regarding maternal stress, the influence of KC duration showed mixed Parental Stressor Score: NICU scores. Further study on the impact of KC duration and frequency on health outcomes and dose-response relationship would help determine how much and how frequent KC is needed to improve specific health outcomes for infants and their mothers. KEY POINTS: · Data on kangaroo care duration's health impacts is lacking.. · Establishing dose-response for kangaroo care is needed.. · Kangaroo care for longer improves some but not all outcomes..

The impact of daily affective touch on cortisol levels in institutionalized & fostered children

Institutionalized children are often deprived of affective touch. Such tactile deprivation often leads to constant stress, as measured by the levels of salivary cortisol. We report here the impact of an affective touch program, optimized to activate a specific population of unmyelinated mechanosensitive nerves in the skin called c-tactile afferents (CT) on stress resistance. Two populations of children (age 4-10) were recruited: (i) a cohort living in an orphanage and (ii) a fostered cohort. Both groups received the affective touch program daily for 10-15 min for 5-6 weeks. A cohort of age-matched children living in a family environment acted as a control group and did not receive any instructions for tactile stimulation. Salivary cortisol was collected at the beginning (T1) and at the end (T2) of the study in all three groups. For institutionalized and fostered children there was a significant improvement in the level of cortisol (p < 0.0001) between T1 and T2, which is manifested in the balancing cortisol levels: a decrease where it was elevated and an increase, where the critically low level testified to the distress of the child. Balancing cortisol levels is a process of recovery to normal values, which indicates the restoration of neurohumoral mechanisms of stress regulation. The effect of balancing cortisol levels was more pronounced in the group of fostered children compared to the group of orphanage children (p = 0.0326). The children in the control group had no significant differences.

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.

Skin-to-skin contact-An effective intervention on pain and stress reduction in preterm infants

Introduction

The outcomes of pain and stress in preterm infants in the neonatal intensive care units (NICUs) compel the continued search for pain- and stress-reducing interventions.

The objective of the study

To investigate how skin-to-skin contact (SSC) influences chronic pain and stress in preterm infants in the NICU.

Materials and methods

The study included 140 preterm infants in the NICU with gestational age less than 34 weeks. The overall design was a baseline-response design. Urine and saliva were collected before (baseline) and after SSC to measure pain and stress markers by enzyme immunoassay method. The behavioral indicators of chronic pain were assessed using the EDIN (Échelle Douleur Inconfort Nouveau-Né-neonatal pain and discomfort).

Results

There was a significant decrease in the dopamine level in preterm infants after SSC in comparison with baseline values (85.99 [69.35; 112.20] pg/ml vs. 132.20 [104.80; 183.70] pg/ml), p < 0.001. The β-endorphin and serotonin levels increased after SSC (40.09 [26.81; 70.63] pg/ml vs. 29.87 [20.61; 46.94] pg/ml, p = 0.009 and 25.49 [20.45; 40.08] ng/ml vs. 22.30 [15.13; 31.65] ng/ml, p = 0.011, respectively). A significant decrease in cortisol levels in saliva and urine after SSC in comparison with baseline values (0.125 [0.079; 0.225] μg/dl vs. 0.371 [0.188; 1.002] μg/dl, p = 0.000 and 27.06 [14.59; 35.35] ng/ml vs. 35.25 [19.78; 61.94] ng/ml, p = 0.001, with a simultaneous increase of oxytocin level (57.00 [36.55; 88.49] pg/ml vs. 38.20 [28.78; 56.04] pg/ml, p = 0.009 were revealed. The total pain EDIN score in infants after SSC was below 6 points, significantly decreasing compared to the baseline (p < 0.05).

Conclusion

Preterm infants in the NICU experience stress and pain, which were confirmed by the EDIN pain scale and laboratory markers. The level of dopamine and cortisol as pain and stress hormones were reliably high, and normalized after regular SSC. Simultaneously, pain-relieving and anti-stress markers of oxytocin, β-endorphin and serotonin reliably increased in preterm infants in response to the SSC.

Kangaroo Care for Relieving Neonatal Pain Caused by Invasive Procedures: A Systematic Review and Meta-Analysis

Objective. Neonates develop significant pain responses during invasive procedures, and nonpharmacological interventions are better means of pain relief. An increasing number of studies have confirmed the effectiveness of kangaroo care (KC) in relieving neonatal pain caused by invasive procedures, but conclusions are inconsistent. In this study, a literature search and meta-analysis were performed to evaluate the effect of kangaroo care on relieving neonatal pain. Methods. The works of literature related to the application of KC in neonatal invasive procedures in the databases of Pubmed, Embase, Springer Link, Ovid, CNKI, and CBM were searched, and the RCT literature from database establishment to July 2022, was selected to evaluate the risk of bias, combined with statistical pain relief outcome indicators. Results. 12 pieces of literature were finally included in this study, with a total of 1172 newborns, including 585 newborns (49.9%) using KC and 587 newborns (50.1%) using the control group method. Meta-analysis showed that an infant’s heart rate during invasive procedures under KC intervention was significantly lower than that of other interventions (MD = −6.77, 95% CI (−13.03, −0.50), Z = −2.12, $P=0.03$ ), but compared to other nonpharmacological interventions, there was no clear advantage in the overall evaluation of pain reduction in infants (MD = −0.36, 95% CI (−0.80, 0.08), Z = −1.60, $P=0.11$ ). Conclusion. The heart rate of KC intervention during invasive procedures in infants is significantly lower than that of other interventions, and it can significantly relieve pain in infants, but the effect is not more than that of oral sucrose (or glucose) or standard care. KC combined with oral sucrose may achieve a better pain relief effect in infants, but more studies are still needed to verify it.

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

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

Effects of Kangaroo Mother Care in the NICU on the Physiological Stress Parameters of Premature Infants: A Meta-Analysis of RCTs

OBJECTIVE

The aim of this study was to analyze the randomised controlled trials that explored the effect of kangaroo mother care on physiological stress parameters of premature infants.

METHODS

Two independent researchers performed a systematic review of indexed studies in PubMed, Embase, CINAHL, Cochrane and Scopus. We included data from randomized controlled trials measuring the effects of kangaroo care compared to standard incubator care on physiological stress outcomes, defined as oxygen saturation, body temperature, heart rate and respiratory rate. The PRISMA model was used to conduct data extraction. We performed a narrative synthesis of all studies and a meta-analysis when data were available from multiple studies that compared the same physiological parameters with the kangaroo method as an intervention and controls and used the same outcome measures.

RESULTS

Twelve studies were eligible for inclusion in this meta-analysis. According to statistical analysis, the mean respiratory rate of preterm infants receiving KMC was lower than that of infants receiving standard incubator care (MD, -3.50; 95% CI, -5.17 to -1.83; p < 0.00001). Infants who received kangaroo mother care had a higher mean heart rate, oxygen saturation and temperature, although these results were not statistically significant.

CONCLUSIONS

Current evidence suggests that kangaroo care in the neonatal intensive care unit setting is a safe method that may have a significant effect on some of the physiological parameters of stress in preterm infants. However, due to clinical heterogeneity, further studies are needed to assess the effects of physiological stress in the neonatal intensive care unit on the development of preterm infants.

Systematic Review of the Effectiveness of Involving Parents During Painful Interventions for Their Preterm Infants

OBJECTIVE

To systematically review the literature related to the effectiveness of parents' active involvement during painful interventions for their preterm infants.

DATA SOURCES

We performed a systematic search of PubMed, EMBASE/Ovid, CINAHL, Livivio, and PsycInfo using the keywords "preterm infants," "pain," and "parents."

STUDY SELECTION

Articles were eligible for inclusion if they were published between 2000 and 2021 and reported randomized controlled trials (RCTs) in which preterm infants underwent painful interventions, and parents were present and actively involved in pain-reducing measures.

DATA EXTRACTION

We used the Consolidated Standards of Reporting Trials (CONSORT) checklist for RCTs for data extraction. We assessed methodologic quality using critical appraisal for RCTs according to the Joanna Briggs Institute.

DATA SYNTHESIS

In total, 22 articles met the inclusion criteria. These articles reported 19 studies focused on kangaroo/skin-to-skin care, one focused on breastfeeding, and two focused on facilitated tucking. The methods used to evaluate pain in the infant varied substantially. Overall, kangaroo/skin-to-skin care and facilitated tucking resulted in clinically and statistically significant decreases in pain. For breastfeeding, effectiveness was linked to a more mature sucking pattern of the preterm infant.

CONCLUSION

The current evidence suggests that involving parents in pain-reducing measures during painful interventions for their preterm infants is beneficial. However, more research is needed for the different methods of involving parents in pain-reducing measures.

Pain in Preterm Infants: Different Perspectives

In the last decades, there has been a tremendous change in approaching and managing neonates' pain. These changes began with rebutting the previous misconception about neonates' , particularly preterm infants' , pain. The development in neuroimaging has revealed that by 24 weeks of gestation the peripheral nervous system is mature and function fully. Researchers now know that neonates experience pain and premature infants have even lower pain thresholds. Since that time, a mounting amount of literature has addressed the issue of neonatal pain. Many pharmacological and non pharmacological pain reduction strategies have been investigated for their safety and analgesic effectiveness. Many interventions such as nonnutritive sucking (NNS), skin-to-skin contact (SSC), and facilitated tucking are effective in controlling neonates pain.

Revisions to the IASP definition of pain-What does this mean for children?

The complexity of the phenomenon of pain defies a simple and straightforward definition. Acute, chronic, nociplastic and neuropathic pain account for multiple pathologic mechanisms and forms of expression. Pain varies widely in intensity, duration and nature, often complicating description for those who are experiencing the pain and/ or those who are observing it. Assessment of pain in children can be challenging, especially in those who may be incapable of self-report report due to development immaturity or disability. In these children the responsibility of assessing pain often falls to the professional or lay care provider, whose knowledge, expertise and beliefs influence their judgements. The experience of pain includes not only the physiologic and behavioural indicators most frequently included in pain assessment measures but also encompasses the social and cognitive components that often go unrecognized. The 1979 IASP definition of pain has been praised for its brevity, simplicity and attention to the multidimensional nature of the phenomenon. It has also been criticized for ignoring mind-body interactions, disempowering and neglecting vulnerable populations, paying little attention to ethical dimensions, and excluding cognitive and social factors that are integral to the experience of pain. After four decades, the 1979 definition of pain and the accompanying notes were evaluated and revised by a 14-member IASP presidential task force with representation from basic and clinical research, geographical location and populations served (Pain, 2020, 161, 1976). These revisions resulted in decreasing the emphasis of pain associated with tissue damage in the definition, and, by removing the word 'described', allowing those who were nonverbal to be assessed using other validated pain indicators. Important revisions were also made to the Notes. The revisions that are most relevant for pain in children are discussed.

Effects of Kangaroo Mother Care on Repeated Procedural Pain and Cerebral Oxygenation in Preterm Infants

OBJECTIVE

 The study aimed to investigate the effects of kangaroo mother care (KMC) on repeated procedural pain and cerebral oxygenation in preterm infants.

STUDY DESIGN

 Preterm infants of 31 to 33 weeks of gestational age were randomly divided into an intervention group (n = 36) and a control group (n = 37). Premature infant pain profile (PIPP) scores, heart rate, oxygen saturation, regional cerebral tissue oxygenation saturation (rcSO₂), and cerebral fractional tissue oxygen extraction (cFTOE) were evaluated during repeated heel stick procedures. Each heel stick procedure included three phases: baseline, blood collection, and recovery. KMC was given to the intervention group 30 minutes before baseline until the end of the recovery phase.

RESULTS

 Compared with the control group, the intervention group showed lower PIPP scores and heart rates, higher oxygen saturation, and rcSO₂ from the blood collection to recovery phases during repeated heel sticks. Moreover, there were significant changes in cFTOE for the control group, but not the intervention group associated with repeated heel stick procedures.

CONCLUSION

 The analgesic effect of KMC is sustained over repeated painful procedures in preterm infants, and it is conducive to stabilizing cerebral oxygenation, which may protect the development of brain function.

KEY POINTS

· KMC stabilizes cerebral oxygenation during repeated heel sticks in preterm infants.. · The analgesic effect of KMC is sustained over repeated painful procedures in preterm infants.. · KMC may protect the development of brain function..

State of the Art in Parent-Delivered Pain-Relieving Interventions in Neonatal Care: A Scoping Review

Introduction: Parents' active involvement during painful procedures is considered a critical first step in improving neonatal pain practices. Of the non-pharmacological approaches in use, the biopsychosocial perspective supports parent-delivered interventions, in which parents themselves mediate pain relief, consistent with modern family-integrated care. This scoping review synthesizes the available research to provide an overview of the state of the art in parent-delivered pain-relieving interventions. Methods: A scoping review was performed to achieve a broad understanding of the current level of evidence and uptake of parent-driven pain- and stress-relieving interventions in neonatal care. Results: There is a strong evidence for the efficacy of skin-to-skin contact and breastfeeding, preferably in combination. These parent-delivered interventions are safe, valid, and ready for prompt introduction in infants' pain care globally. Research into parents' motivations for, and experiences of, alleviating infant pain is scarce. More research on combined parent-delivered pain alleviation, including relationship-based interventions such as the parent's musical presence, is needed to advance infant pain care. Guidelines need to be updated to include infant pain management, parent-delivered interventions, and the synergistic effects of combining these interventions and to address parent involvement in low-income and low-tech settings. Conclusions: A knowledge-to-practice gap currently remains in parent-delivered pain management for infants' procedure-related pain. This scoping review highlights the many advantages of involving parents in pain management for the benefit not only of the infant and parent but also of health care.

Systematic review and meta-analysis suggest that the duration of Kangaroo mother care has a direct impact on neonatal growth

AIM

A 2016 Cochrane review showed that Kangaroo mother care (KMC) had a moderate impact on preterm growth, with high heterogeneity among studies. This systematic review and meta-analysis considered new evidence on KMC, particularly the duration.

METHOD

Databases were searched for papers published in English, French, Spanish and Portuguese up to 2017. Randomised controlled trials (RCT) of preterm or low birth weight infants were included if they compared growth between KMC and conventional care. Anthropometric measures were related to duration.

RESULTS

We identified 1368 papers, and 13 RCTs covering 743 KMC infants and 718 controls met the selection criteria. Infants held in KMC for at least 6 h/d gained more weight than the controls, with a mean difference of 8.99 g/d (95% confidence interval 8.14-9.84, I²  = 0%). This difference persisted between 2 and 6 h/d and disappeared with 2 hours or less. When we used g/kg/d, the weight gain was higher when the duration was at least 8 h/d. Only babies who received 6 h/d gained more length and head circumference.

CONCLUSIONS

The effect of the KMC on growth was directly related to the duration.

The Effect of Caregiver-Facilitated Pain Management Interventions in Hospitalized Patients on Patient, Caregiver, Provider, and Health System Outcomes: A Systematic Review

CONTEXT

Alternative pain management interventions involving caregivers may be valuable adjuncts to conventional pain management interventions.

OBJECTIVES

Use systematic review methodology to examine caregiver-facilitated pain management interventions in a hospital setting and whether they improve patient, caregiver, provider, or health system outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus databases from inception to April 2020. Original research on caregiver-facilitated pain management interventions in hospitalized settings (i.e., any age) were included and categorized into three caregiver engagement strategies: inform (e.g., pain education), activate (e.g., prompt caregiver action), and collaborate (encourage caregiver's interaction with providers).

RESULTS

Of 61 included studies, most investigated premature (n = 27 of 61; 44.3%) and full-term neonates (n = 19 of 61; 31.1%). Interventions were classified as activate (n = 46 of 61; 75.4%), inform-activate-collaborate (n = 6 of 61; 9.8%), inform-activate (n = 5 of 61; 8.2%), activate-collaborate (n = 3 of 61; 4.9%), or inform (n = 1 of 61; 1.6%) caregiver engagement strategies. Interventions that included an activate engagement strategy improved pain outcomes in adults (18-64 years) (e.g., self-reported pain, n = 4 of 5; 80%) and neonates (e.g., crying, n = 32 of 41; 73.0%) but not children or older adults (65 years and older). Caregiver outcomes (e.g., pain knowledge) were improved by inform-activate engagement strategies (n = 3 of 3). Interventions did not improve provider (e.g., satisfaction) or health system (e.g., hospital length of stay) outcomes. Most studies were of low (n = 36 of 61; 59.0%) risk of bias.

CONCLUSION

Caregiver-facilitated pain management interventions using an activate engagement strategy may be effective in reducing pain of hospitalized neonates. Caregiver-facilitated pain management interventions improved pain outcomes in most adult studies; however, the number of studies of adults is small warranting caution pending further studies.

Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis

Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings.

METHODS

We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620.

FINDINGS

Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible.

INTERPRETATION

We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings.

FUNDING

Wellcome Trust Research Programme, and the Africa-Oxford Initiative.

Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive care unit hospitalization: a single-blind randomized controlled trial

Preterm neonates hospitalized in the neonatal intensive care unit undergo frequent painful procedures daily, often without pain treatment, with associated long-term adverse effects. Maternal-infant skin-to-skin contact, or kangaroo care (KC), and sweet-tasting solutions such as sucrose are effective strategies to reduce pain during a single procedure; however, evidence of sustained efficacy over repeated procedures is limited. We aimed to determine the relative sustained efficacy of maternal KC, administered alone or in combination with 24% sucrose, to reduce behavioral pain intensity associated with routine neonatal procedures, compared with 24% sucrose alone. Stable preterm infants (n = 242) were randomized to receive KC and water, KC and 24% sucrose, or 24% sucrose before all routine painful procedures throughout their neonatal intensive care unit stay. Pain intensity, determined using the Premature Infant Pain Profile, was measured during 3 medically indicated heel lances distributed across hospitalization. Maternal and neonatal baseline characteristics, Premature Infant Pain Profile scores at 30, 60, or 90 seconds after heel lance, the distribution of infants with pain scores suggesting mild, moderate, or severe pain, Neurobehavioral Assessment of the Preterm Infant scores, and incidence of adverse outcomes were not statistically significantly different between groups. Maternal KC, as a pain-relieving intervention, remained efficacious over time and repeated painful procedures without evidence of any harm or neurological impact. It seemed to be equally effective as 24% oral sucrose, and the combination of maternal KC and sucrose did not seem to provide additional benefit, challenging the existing recommendation of using sucrose as the primary standard of care.

Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled Trial

BACKGROUND

Premature infants hospitalized in the neonatal intensive care unit are routinely exposed to many painful procedures. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates, hence pain in infants should be reduced. Kangaroo care and oral sucrose are some of the methods that can help reduce pain.

AIM

This study aimed to compare the effects of kangaroo care and oral sucrose on pain relief in preterm infants during heel lancing.

METHODS

Our study involved 64 infants. The infants were randomly divided into two groups using a randomized block design of drawing out slips from a thick, non-transparent envelope. There were 64 slips in this envelope (32 for kangaroo care and 32 for oral sucrose). Kangaroo care was given to the preterm infants in the first group and oral sucrose to those in the second group. In both groups, heart rate and oxygen saturation were measured and pain score was evaluated by two observers using the Premature Infant Pain Profile (PIPP) before, during, and 2 minutes after blood sampling by heel lancing.

RESULTS

There was a statistically significant difference between the groups in favor of the kangaroo group in terms of change in the PIPP values after heel lancing. Kangaroo care is more effective than oral sucrose in pain relief during heel lancing in preterm infants.

CONCLUSIONS

In addition to many benefits it offers to infants, kangaroo care can be used to reduce pain during painful procedures in premature infants.

Revisiting the roots of attachment: A review of the biological and psychological effects of maternal skin-to-skin contact and carrying of full-term infants

During the early period of hypothesis building and empirical testing of attachment theory, a major emphasis was placed on mother-infant physical contact. In spite of this, mother-infant contact has received scant attention amongst attachment and child development researchers in the past decades. Here, a brief theoretical framework for mother-infant contact is presented, drawing on animal studies as well as human studies of preterm infants and neonates. Salient mechanisms may include an extended sensitive period during early infancy, requiring specific somatosensory stimuli for bio-behavioral homeorhesis; oxytocinergic and epigenetic pathways; kinesthetic stimuli and face-to-face proximity allowing for increased social interaction. Studies of extended human mother-full-term infant physical contact have demonstrated positive effects in multiple domains. For infants, these include sleep organization, temperature and heart rate regulation, behavioral response, crying/colic, socio-emotional development, attachment quality, speech development opportunities and mother-child interactions. For mothers, studies demonstrate improved depressive symptomatology, physiological stress regulation, contingent responsivity, breastfeeding and mother-child interactions. Parent-infant attachment quality has gained prominence as a trauma-resilience factor as well as a predictor of adult physical health. The potential role of mother-infant contact as an attachment promoting intervention as well as future research subjects are discussed. Current evidence supports the original attachment research that early maternal touch provision may influence infant socio-emotional development and attachment quality, with positive implications for mother-child relationship functioning.

Safety and feasibility of skin-to-skin care for surgical infants: A quality improvement project

BACKGROUND

Skin-to-skin care (SSC) for infants improves physiologic stability, pain perception, brain development, parental bonding, and overall survival. Using quality improvement (QI) methodology, this project aimed to increase SSC for surgical infants in the neonatal intensive care unit (NICU).

METHODS

A multidisciplinary working group composed of key NICU stakeholders instituted a needs assessment querying perceptions and concerns about SSC. Based on survey results, multiple system level interventions were implemented. Data for surgical infants receiving SSC during hospitalization were tracked over time using the electronic health record.

RESULTS

Overall, 315 infants requiring a surgical consult were admitted to the NICU in the first 12 months of the project. After six months, SSC rates in this group increased from 51% to 60.5% (p < 0.01) and were sustained for 12 months. After one year, nursing staff reporting that they were somewhat to very comfortable providing SSC for surgical infants increased from 44% to 75% (p = 0.001) and the percent of nurses providing SSC for a surgical infant increased from 12% to 37% (p = 0.001). Inadvertent extubation did not significantly increase after implementation of the QI project.

CONCLUSIONS

Using QI methodology and multidisciplinary engagement, SSC was integrated safely into the routine care of surgical infants in the NICU.

LEVEL OF EVIDENCE

Level V.

Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice

Infant medical trauma in the NICU is associated with serious and lasting consequences. Skin-to-skin contact (SSC) of infants with their parents is a nursing intervention that provides significant benefits and can mitigate the negative consequences of the infant's traumatic experiences in the NICU. The purpose of this article is to explain how SSC aligns with the concept of trauma-informed age-appropriate care (TIAAC) in the NICU. The evidence supporting SSC will be reviewed and discussed using TIAAC as a framework. SSC is an effective and evidence-based care strategy that reduces the infant's traumatic NICU experiences by improving parental proximity, attachment, and lactation; decreasing stress and pain; improving physiologic stability; supporting sleep; and enhancing neurologic outcomes.

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.

The biological embedding of neonatal stress exposure: A conceptual model describing the mechanisms of stress-induced neurodevelopmental impairment in preterm infants

The biological embedding of early life stress exposure may result in life-long neurodevelopmental impairment in preterm infants. Infants hospitalized in the neonatal intensive care unit are exposed to significant experiential, environmental, and physiologic stressors over the course of their extended hospitalization. Stress exposure during the sensitive period of brain development may alter biological processes, including functioning of the immune system, the autonomic nervous system, and the hypothalamic-pituitary-adrenal axis as well as gene expression. These alterations may subsequently affect brain structure and function. Changes to these processes may mediate the relationship between neonatal stress exposure and neurodevelopment in preterm infants and represent potential therapeutic targets to improve long-term outcomes. The purpose of this paper is to introduce a conceptual model, based on published research, that describes the mechanisms mediating stress exposure and neurodevelopment impairment in preterm infants and to provide the theoretical foundation on which to base future descriptive research, intervention studies, and clinical care.

Social touch during development: Long-term effects on brain and behavior

In this paper, our goal is to explore what is known about the role of social touch during development. We first address the neural substrates of social touch and the role of tactile experience in neural development. We discuss natural variation in early exposure to social touch, followed by a discussion on experimental manipulations of social touch during development and "natural experiments", such as early institutionalization. We then consider the role of other developmental and experiential variables that predict social touch in adults. Throughout, we propose and consider new theoretical models of the role of social touch during development on later behavior and neurobiology.

A Comparison of Breast Milk and Sucrose in Reducing Neonatal Pain During Eye Exam for Retinopathy of Prematurity

BACKGROUND

This double-blind randomized controlled experimental study aimed to determine the effects of breast milk and sucrose in reducing pain in preterm infants during retinopathy of prematurity (ROP) examination.

MATERIALS AND METHODS

This study was conducted with 60 preterm infants (breast milk group = 20, sucrose group = 20, and control/distilled water group = 20) meeting the inclusion criteria. The data were collected with the use of an Infant Evaluation Form, Procedure Monitoring Form, and Premature Infant Pain Profile (PIPP). The preterm infants were provided with 1 mL of breast milk, sucrose, and distilled water before the ROP examination. The pain level in preterm infants was measured by the PIPP 5 minutes before, during, and 5 minutes after the ROP examination. The ROP examinations were video recorded, and videos were evaluated by three observers blinded to the study.

RESULTS

No significant difference was determined between the three groups in terms of their postconceptional and postnatal ages, their body weights at birth and during the ROP examination. The PIPP scores of the preterm infants in the three groups were higher during the ROP examination and were not significantly different. The PIPP scores of the control group were significantly higher than those in the breast milk and sucrose groups after the ROP examination (p < 0.001). The preterm infants in the breast milk group recovered and returned to their initial values more quickly after the ROP examination than the infants in the sucrose group.

CONCLUSION

To reduce pain in preterm infants during ROP examination, breast milk is recommended.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonatesThe secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double- or single-blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Twenty-five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes.Seventeen studies (n = 810) compared SSC to a no-treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of -10.78 beats per minute (95% CI -13.63 to -7.93) favouring SSC. Meta-analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI -4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta-analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta-analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = -34.16, 95% CI -42.86 to -25.45), and two (n = 100) following IM injection (MD = -8.83, 95% CI -14.63 to -3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD -3.21, 95% CI -3.94 to -2.47), at 60 seconds (3 studies; n = 156) (MD -1.64, 95% CI -2.86 to -0.43), and at 90 seconds (n = 156) (MD -1.28, 95% CI -2.53 to -0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI -1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta-analysis findings.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother-providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions.

Kangaroo Mother Care 1: Alleviation of Physiological Problems in Premature Infants

Kangaroo mother care (KMC) involves placing the newborn infant into prolonged and continuous skin-to-skin contact with the mother as soon as possible after birth, exclusive breastfeeding, early discharge from the health facility, and supportive follow-up at home. Claimed benefits of KMC as an aid to the clinical mitigation of some detrimental features of prematurity need to be evidence based. This article, the first of two, provides an overview of the impact of prematurity on those features of neonates to which KMC may be directed. Specifically, the mitigation of some cardiorespiratory, neurophysiological, sensory, gastrointestinal, musculoskeletal, renal, metabolic, and immunological impacts are outlined. Relevant neurobehavioral, psychosocial, sociocultural, and economic perspectives are briefly reviewed in the companion article. These two articles provide scientific support for a wider upscaling of KMC education and its cautious use in physiologically stable preterm infants.

Management of acute pediatric pain in the emergency department

PURPOSE OF REVIEW

This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic.

RECENT FINDINGS

Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow.

SUMMARY

The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.