Non-nutritive sucking, oral breast milk, and facilitated tucking relieve preterm infant pain during heel-stick procedures: A prospective, randomized controlled trial

Effectiveness of an atraumatic orogastric tube insertion protocol for the combined use of swaddling, facilitated tucking, breast milk and sucrose

AIM

The study aims to develop a protocol for the combined use of swaddling, facilitated tucking, expressed breast milk and sucrose administration methods in the orogastric tube (OGT) insertion procedure and evaluate its effectiveness.

METHODS

The randomized controlled trial was conducted in the Neonatal Intensive Care Unit between 15 February 2022 and 15 September 2022, with 175 preterms. Preterms at 32-34 gestational weeks were randomly allocated to five groups: routine care, swaddling + expressed breast milk, swaddling + sucrose, facilitated tucking + expressed breast milk and facilitated tucking + sucrose groups. The data were collected using the Preterm Descriptive Information Form, the Physiological Measurement Form, the COMFORTneo scale and the Premature Infant Pain Profile (PIPP).

RESULTS

The facilitated tucking + expressed breast milk method was found to be more effective than the routine care (pdistress < 0.001; ppain = 0.031) and swaddling + expressed breast milk (pdistress = 0.004; ppain = 0.015) methods in reducing the estimated distress and PIPP pain level of preterms during the procedure. Two minutes after the procedure, the facilitated tucking + expressed breast milk method was more effective than the routine care (p < 0.001), swaddling + expressed breast milk (p = 0.011) and swaddling + sucrose (p = 0.002) methods in reducing the comfort level score.

CONCLUSIONS

The facilitated tucking + expressed breast milk method is effective in reducing pain and distress and providing comfort during the OGT procedure. Clinical Trials ID: NCT05180058.

The effect of facilitated tucking and white noise on stress and sleep of newborns receiving nasal continuous positive airway pressure

OBJECTIVE

To investigate the effects of facilitated tucking and white noise on stress and sleep in neonates receiving nasal continuous positive airway pressure (CPAP).

METHOD

This study was conducted as a randomised controlled experimental study of neonates receiving nasal CPAP in neonatal intensive care units. The study sample consisted of 108 newborns (facilitated tucking (n = 36), white noise (n = 36) and control (n = 36)) receiving nasal CPAP support in the NICU. The neonates' sleep parameters were recorded by actigraphy for 24 h. Data were collected using the Neonatal Descriptive Information Form, the Sleep Tracking Form and the Neonatal Stress Scale. Percentage, mean, chi-squared and one-way ANOVA were used for data analysis.

RESULTS

It was found that 50.9% of the newborns were female, their mean gestational age was 33.54 ± 3.38, their mean height was 43.56 ± 5.12, and their mean weight was 2139.23 ± 827.82. The total sleep time of the neonates in the facilitated tucking and white noise group increased by 3 h, their sleep efficiency increased by 20% and their mean stress scores decreased (p < 0.05).

CONCLUSION

Facilitated tucking and white noise each showed a similar improvement in sleep duration and sleep efficiency and a reduction in stress scores in neonates receiving nasal CPAP. Close monitoring of sleep in this population and supportive care practices are recommended.

PRACTICE IMPLICATIONS

The findings of this study may help to reduce sleep problems and stress levels in the clinical care of neonates in the NICU through developmental nursing practices.

Effect of combining oral glucose solutions with supportive positions on pain during heel puncture blood sampling in premature infants: A randomized quadruple-blinded experimental study

PURPOSE

The trial aimed to assess the impact on pain scores of the administration of oral glucose solutions at different concentrations and in combination with supportive positions during heel puncture procedures.

DESIGN & METHODS

This trial was structured as a quadruple-blinded experimental study conducted at a single center - a Level II and IVa NICU between June 2022-2023. Included in the study were 128 premature infants born with a gestational age of between 33 and 36 weeks and a postnatal age of <7 days. For the heel puncture procedures, four distinct interventions were employed, each involving supportive positions and oral solutions. All interventions were recorded on video for analysis, and data were collected using the "Infant Information and Observation Form" and "Neonatal Pain, Agitation and Sedation Scale (N-PASS)". The N-PASS was rated by two independent nurses. The data were analyzed with the two-way repeated measures ANOVA and post-hoc Bonferroni tests.

RESULTS

The descriptive and clinical characteristics were similar in all groups (p > 0.05). The pain scores, physiological variables and total crying times of the premature infants differed significantly depending on the interventional groups and times, and the interaction between the groups and times (p < 0.05).

CONCLUSIONS

Combining glucose solutions with supportive positions led to a reduction in pain scores, a decrease in total crying time when compared to the use of supportive positions alone.

PRACTICE IMPLICATIONS

Combining an oral 20% glucose solution with supportive positions can be recommended to reduce pain during unplanned heel puncture procedures in the absence of a parent in the unit.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Breastfeeding or breast milk for procedural pain in neonates

BACKGROUND

Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in neonates experiencing pain or stress. Non-pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012.

OBJECTIVES

The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one-third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin-to-skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin-to-skin contact (low-certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin-to-skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate-certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin-to-skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin-to-skin contact (low-certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate-certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low-certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau-né (DAN) score compared to positioning, holding or placebo (low-certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low-certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate-certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low-certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low-certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low-certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low-certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies.

AUTHORS' CONCLUSIONS

Moderate-/low-certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non-pharmacological interventions. Low-certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population.

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.

Sensorial saturation improves infants' procedure-related pain behaviour in the cardiac intensive care unit: A quasi-experimental study

BACKGROUND

Painful procedures are unavoidable when providing critical care to infants in intensive care units. These adverse experiences during infancy can lead to later hyperalgesia and poor neurodevelopmental outcomes. Thus, appropriate interventions are required to relieve infant pain during these procedures.

OBJECTIVES

This study evaluated the effectiveness of sensorial saturation in reducing pain for infants during jugular central venous catheter removal procedures in intensive care units.

METHODS

This study involved a quasi-experimental, repeated-measures design. Data were collected from participants sequentially recruited from April to June 2019 (control period) and July to September 2019 (experimental period). Participants included 78 infants younger than 1 year with congenital heart disease. The control group (n = 38) received a general nursing intervention using swaddling, a common child-care practice that consists of wrapping infants to restrict movements, whereas the experimental group (n = 40) received sensorial saturation using oral sugar, body massage, and verbal interaction. Infants' physiological reactions to procedural pain were measured by changes in heart rate, oxygen saturation, and respiratory rate. Infants' procedural pain and behavioural indicators were measured using the Modified Behavioural Pain Scale. Data were analysed using descriptive statistics, independent t-tests, χ² tests, and repeated-measures analysis of variance.

RESULTS

Compared with the control group, the experimental group had lower heart rates (F = 53.15, p < .001), respiratory rates (F = 15.19, p < .001), and behavioural pain scores (F = 45.21, p < .001), both during and after the procedure.

CONCLUSIONS

Sensorial saturation can be used as a nursing intervention in infants. Given the many invasive procedures that are part of infant clinical care, sensorial saturation may be a safe analgesic alternative. The findings of this study could lead to the development of evidence-based clinical practice guidelines for the nonpharmacological management of acute pain in infants.

The effect of swaddling method applied to preterm infants during the aspiration procedure on pain

PURPOSE

The study was carried out to determine the effect of the swaddling method on pain in preterm infants (between 27 and 36 weeks) hospitalized in the Neonatal Intensive Care Unit during the aspiration procedure. Preterm infants were recruited by convenience sampling from level III neonatal intensive care units in a city in Turkey.

METHOD

The study was conducted in a randomized controlled trial manner. The study consisted of preterm infants (n = 70) receiving care or treatment at a neonatal intensive care unit. While swaddling was applied to the infants in the experimental group before the aspiration process. The pain was assessed before, during, and after the nasal aspiration using the Premature Infant Pain Profile.

RESULTS

No significant difference was found in terms of pre-procedural pain scores whereas a statistically significant difference was detected in terms of pain scores during and after the procedure between the groups.

CONCLUSION

It was determined in the study that the swaddling method reduced the pain of the preterm infants during the aspiration procedure.

IMPLICATIONS FOR PRACTICE

This study emphasized that swaddling had pain-reducing during the aspiration procedure in the neonatal intensive care unit in preterm infants. It is recommended that future studies be conducted using different invasive procedures in preterm infants born earlier.

Effect of Non-Pharmacological Methods in the Reduction of Neonatal Pain: Systematic Review and Meta-Analysis

In neonatology, neonates have traditionally been considered incapable of feeling pain, due to the immaturity of their nervous system. Currently, there is sufficient information on the perception of pain in neonates; however, this treatment at this crucial stage for development requires a better approach. For this reason, the aim of this study was to analyse the efficacy of non-pharmacological analgesia interventions during heel prick, and to assess their effects on heart rate (HR), premature infant pain profile (PIPP) and O2 saturation. A systematic review and meta-analysis was performed following the guidelines of the preferred reporting items for systematic reviews and meta-analyses (PRISMA), and the Cochrane collaboration handbook. The databases PubMed, Cochrane Library, Web of Science, Scopus, CINAHL and Science Direct were searched until the end of January 2022. The DerSimonian and Laird methods were used to estimate the effect size with a 95% confidence interval (CI95%). Effect size estimates were 0.05 (95% CI: -0.19, 0.29) for HR, -0.02 (95% CI: -0.24, 0.21) for PIPP scale, and -0.12 (95% CI: -0.29, 0.05) for O2 saturation. The non-pharmacological interventions analysed (breastfeeding, kangaroo-mother care method, oral sucrose and non-nutritive sucking) were not statistically significant in reducing neonatal pain, but did influence the decrease in pain score and a faster stabilisation of vital signs.

The effect of using maternal voice, white noise, and holding combination interventions on the heel stick sampling

BACKGROUND

Heel stick sampling, a common procedure in newborns, causes acute pain.

AIMS

This study aims to measure the outcome of five various non-pharmacologic pain relief groups; maternal voice, white noise, holding, maternal voice+holding, and white noise+holding.

METHODS

The study is an open label, randomized controlled trial. A total of 178 newborns were included in this study. Newborns were randomly allocated to each group; white noise (n = 31), maternal voice (n = 31), holding (n = 30), white noise+holding (n = 29), maternal voice+holding (n = 28), and control (n = 29) interventions. Newborns' pain responses were evaluated using the Neonatal Infant Pain Scale (NIPS), and the Premature Infant Pain Profile (PIPP). The primary measured outcomes were the newborns' pain levels, while the secondary outcomes were the heart rate and changes in oxygen saturation. The mean values of pain in neonates between groups were evaluated one minute before (Phase1), during (Phase2), and one minute after (Phase3) the procedure.

RESULTS

The research results are given with comparisons in three time periods (Phase1, Phase2 and Phase3). White noise and white noise+holding were found to have the lowest mean NIPS and PIPP score (p < 0.001). The mean heart rate was found to be the lowest in the white noise+holding group (p < 0.001). There was no significant difference between the groups in terms of oxygen saturation score (p = 0.453).

CONCLUSION

The white noise+holding applied to newborns during heel stick sampling were effective in pain reduction. Nurses and midwives can use white noise+holding method.

IMPLICATIONS TO PRACTICE

These results contribute to the pain management of newborns.

Analgesic Role of Breastfeeding: Analysis of Effectiveness, Implementation Barriers, and Strategies to Promote Evidence-Based Practice

Objective:

Exposure to painful stimuli serves as toxic stress for infants, increasing their subsequent pain sensitivity and resulting in neurodevelopmental impairments. Besides offering nutritional, psychological, immunological, and economic benefits, breastfeeding is reported as the most effective analgesia for the management of minor procedural pain in infants. Although breastfeeding holds several advantages, implementation of this nonpharmacological intervention is still uncommon in many clinical settings.

Methods:

This scoping review presents an analysis of 29 clinical trials that compare the effectiveness of breastfeeding with other nonpharmacological methods.

Findings:

Breastfeeding is an efficacious analgesia compared with sucrose, sweet solutions, and other nonpharmacological methods. When used alone or in combination with other nonpharmacological interventions, breastfeeding reduces infants’ biobehavioral responses to pain and promotes faster physiologic recovery after painful procedures. Breastfeeding is recommended as the first choice whenever feasible. Barriers to the uptake of this effective pain management method in clinical practice include misinformation/inconsistent use of evidence, an infant’s impaired sucking reflex, maternal–child separation, the workload of healthcare professionals, a lack of parental involvement, assumptions of healthcare providers, and a lack of adequate information/guidance for parents. Strategies to promote the uptake of breastfeeding for the management of procedural pain in infants include an effective partnership between healthcare providers and breastfeeding mothers, knowledge mobilization resources in multiple languages, informational support and media campaigns, and experiential learning opportunities for breastfeeding mothers.

Conclusions:

Successful implementation of baby-friendly hospital initiatives, a patient-centered approach, family-centered care, and the collaborative efforts of healthcare providers in all healthcare settings is recommended to promote the uptake of breastfeeding as analgesia.

Efficacy of 2 Nonpharmaceutical (Non-nutritive Sucking and Human Care Contact) Pain Relief Measures for Idiopathic Clubfoot Casted Using Ponseti Technique

PURPOSE

This study aimed at exploring the pain and physiological responses exhibited during Ponseti manipulation and casting in clubfoot infants. In addition, we compared the efficacy of 2 nonpharmaceutical techniques (non-nutritive sucking and human care contact) for tackling these responses.

METHODS

The study included children with unilateral and bilateral idiopathic clubfeet between 15 days to 6 months of age. For comparisons, children were divided into control group without any intervention (group A), non-nutritive sucking group (group B), and human care contact group (group C). Pain score (Neonatal Infant Pain Score), heart rate (HR), and oxygen saturation (SpO2) was assessed before, during and 1 minute after casting. These measurements were compared using statistical methods.

RESULTS

There were 16 children (11 bilateral) in group A, 17 (10 bilateral) in group B, and 18 (8 bilateral) in group C. Before casting, the baseline parameters (Neonatal Infant Pain Score, HR, and SpO2) of the 3 groups were comparable. Groups B and C had a significant reduction in pain score at casting and in postcasting period when compared with group A (P<0.05). Group B (at casting-mean: 174.1/min, postcasting-mean: 168.2/min) had the lowest HR both during and after cast application. Group B had the highest SpO2 among all the 3 groups, both during casting (mean: 95.7%) and after casting (mean: 97.4%) (P<0.05).

CONCLUSIONS

Infants exhibit moderate pain response and altered physiological responses during and after Ponseti casting. Non-nutritive sucking emerged as a better method to lessen these parameters when compared with the conventional technique and human care contact.

LEVEL OF EVIDENCE

Level II.

The effect of breastfeeding, breast milk odour and mother's heartbeat sound on pain level in newborns: A randomized trial

AIM

This study aimed to compare the effects of breastfeeding, breast milk odour and mother's heartbeat sounds on perceived pain during heel lance procedures in term newborns.

DESIGN

This was a randomized three-group experimental study.

METHODS

The sample of the study consisted of 90 newborns. The data were collected using pulse oximeter, fetal hand doppler, voice recorder, loudspeaker, a data collection form and the ALPS-Neo Pain and Stress Assessment Scale for Newborn Infants.

RESULTS

During the procedure, newborns in the breast milk odour group had high levels of pain and stress, those in the mother's heartbeat sounds group had mild pain and stress, and those in the breastfeeding group had no pain and stress. Additionally, a statistically significant difference was found between their crying times. This difference was the highest for newborns in the breast milk odour group, followed by the mother's heartbeat sounds and breastfeeding groups, respectively.

CONCLUSION

Breastfeeding and mother's heartbeat sounds, which are non-pharmacological pain relief methods, are effective in neonatal pain management. However, breast milk odour is not effective for pain control in newborns. Further studies should examine the efficacy combinations of these methods.

Summary and Analysis of Relevant Evidence for Nondrug Nursing Programs in Neonatal Operational Pain Management

Purpose

To summarize the relevant evidence for nondrug nursing programs in neonatal operational pain management.

Methods

Computer search for the literature on neonatal procedural pain from 2015 to 2020 in Up To Date, JBI, NICE, SIGN, RNAO, NGC, PubMed, Cochrane Library, CNKI, and Wanfang database was conducted. All literature works that may meet the inclusion criteria were independently evaluated by two researchers to determine the quality grade of the articles.

Results

Finally, 9 literature works were extracted, including 4 guidelines, 3 systematic reviews, and 2 evidence summaries. The relevant contents of the literature were extracted and summarized, and 20 pieces of the best evidence were obtained.

Conclusion

Breast feeding, sweetener, Kangaroo mother care, sensory stimulation, nonnutritive sucking, and other nondrug nursing programs can reduce the neonatal operational pain, which has guiding significance in neonatal operational pain management.

Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis

Background

Pain management is currently important in neonatal intensive care unit (NICU). The superiority in pain relief of the combined oral sucrose (OS) and nonnutritive sucking (NNS) to other single intervention has not been well established. The administration of sucrose has been considered to potentially induce adverse events, which has been controversial. This study aims to investigate the combined effects and safety in comparison with other single intervention methods, including NNS, OS alone, breast milk and oral glucose.

Methods

We searched databases including Medline (via Pubmed), Embase (via Ovid), web of science, and Cochrane Library for randomized controlled trials from Jan 1, 2000 to Mar 31, 2021. The data were analyzed in the meta-analysis using Review manager Version 5.3. Pain score was the primary outcome in this meta-analysis. The adverse events were assessed qualitatively.

Results

A total of 16 studies were eligible in the meta-analysis. The results demonstrated a significant reduction in pain score in the NNS+OS group compared with NNS alone (SMD = -1.69, 95%CI, -1.69,-0.65) or sucrose alone (SMD = -1.39, 95% CI, -2.21,-0.57) during the painful procedures. When compared NNS+OS with breast milk, no significant difference was detected (SMD = -0.19, 95% CI: -0.5, 0.11).

Conclusion

The combined effects of NNS and OS might be superior to other single intervention method. However, the effects might be mild for moderate-to-severe pain.

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.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Efficacy of Breast Milk Olfactory and Gustatory Interventions on Neonates’ Biobehavioral Responses to Pain during Heel Prick Procedures

This study aimed to evaluate the efficacy of breast milk odor either alone or in combination with breast milk taste (via syringe-feeding) to alleviate neonates’ biobehavioral responses to pain during heel-prick procedures. This prospective randomized controlled trial recruited 114 neonates by convenience sampling from a newborn unit of a medical center in Taiwan. Neonates were randomly assigned to three groups: control (gentle touch + human voice), control + breast milk odor, and control + breast milk odor + breast milk taste. Heart rate, oxygen saturation, and voice recordings of crying were measured across heel-prick procedures: baseline, no stimuli (stage 0); during heel prick (Stages 1–4); and recovery (Stages 5–10). Generalized estimating equations and Kaplan–Meier survival analysis compared differences in changes between groups for heart rate, oxygen saturation, and time to crying cessation. Changes in mean heart rate and oxygen saturation in neonates receiving breast milk odor or breast milk odor + breast milk taste were significantly less than those at the corresponding stage for the control group. Among neonates receiving breast milk odor or breast milk odor + breast milk taste, hazard rate ratios for crying cessation were 3.016 and 6.466, respectively. Mother’s breast milk olfactory and gustatory interventions could stabilize the biobehavioral responses to pain during heel prick procedures in neonates.

Effects of a tripartite intervention on biological stress in preterm infants during heel pricks for newborn screening: A randomized controlled trial

This prospective randomized trial examined the effects of a tripartite intervention (behavioral state modulation + nonnutritive sucking + tucking) on stress from procedural pain during heel pricks. Blood samples for routine screening were collected by heel pricks 48 h after birth (Stage 1) and at ≥37 weeks' gestation (Stage 2); salivary cortisol levels (SCLs) pre-prick (T0) and 20 min post-prick (T1) assessed stress. Preterm infants (n = 64) sampled by convenience at Level III neonatal care units were randomly assigned to the control condition (usual care) or intervention condition (tripartite intervention). Generalized estimating equations examined differences in salivary cortisol between conditions. After adjusting for effects of gestational age, postmenstrual age, and baseline SCLs, (1) at Stage 1, the change in salivary cortisol from T0 to T1 in preterm infants who received the tripartite intervention was, on average, significantly lower by 0.431 units (log scale) than the change in preterm infants who received the control condition (p < 0.001); (2) in the tripartite intervention condition, the difference between the change in mean SCLs from T0 to T1 at Stages 1 and 2 was significantly lower by 0.287 units (log scale), on average than between the change at Stages 1 and 2 in the control condition (p = 0.026). The provision of a tripartite intervention during heel prick significantly decreased the raise of SCLs compared with infants receiving usual care, suggesting lower stress. Clinicians could easily implement the tripartite intervention for heel-stick support; however, replication is needed before recommending its incorporation into routine heel stick and other stressful procedures.

Breastmilk as a Multisensory Intervention for Relieving Pain during Newborn Screening Procedures: A Randomized Control Trial

The study aim was to explore the effects of multisensory breastmilk interventions on short-term pain of infants during newborn screening. This is a randomized controlled trial. A total of 120 newborns were recruited and assigned by randomization to one of three treatment conditions: Condition 1 = routine care (gentle touch + verbal comfort); Condition 2 = breastmilk odor + routine care; or Condition 3 = breastmilk odor + taste + routine care. Pain was scored with the Neonatal Infant Pain Scale (NIPS). Data were collected from video recordings at 1 min intervals over the 11 phases of heel sticks: phase 1, 5 min before heel stick without stimuli (baseline); phase 2 to phase 6 (during heel stick); and phase 7 to phase 11 (recovery). Generalized estimating equations compared differences in pain scores for newborns over phases among the three conditions. Compared with the routine care, provision of the odor and taste of breastmilk reduce NIPS scores during heel sticks (B = −4.36, SE = 0.45, p < 0.001 [phase₆]), and during recovery (B = −3.29, SE = 0.42, p < 0.001 [phase₇]). Our findings provide new data, which supports the use of multisensory interventions that include breastmilk odor and taste in combination with gentle touch and verbal comfort to relieve pain in infants undergoing newborn screening.

The Effect of Breastfeeding, Kangaroo Care, and Facilitated Tucking Positioning in Reducing the Pain During Heel Stick in Neonates

PURPOSE

Invasive intervention can negatively affect prognosis, behavior, environmental adaptation in neonates. Some nonpharmacological pain management methods are used for effective pain treatment. This study investigated the effect of breastfeeding, kangaroo care, and facilitated tucking positioning on heel-stick pain in neonates.

DESIGN

A quasi-experimental design was employed. The study was conducted in three family health centers in Kütahya/Turkey. The sample consisted of 140 healthy neonates with the gestational age of 37 weeks or more, birth weight greater than 2500 g, and no sucking problems. The sample was divided into four groups (breastfeeding, kangaroo care, facilitated tucking position, and control). Data were collected using a Baby-Mother Characteristics Questionnaire, a Physiological Parameter Follow-up Form, and the Neonatal Infant Pain Scale. Data were analyzed using chi-square, the one-way analysis of variance (ANOVA), Kruskal-Wallis, Student t-test, and Mann-Whitney U tests. The research adhered to ethical principles.

RESULTS

The facilitated tucking position group cried less and experienced less pain during heel stick than the other groups (p < 0.05). Breastfeeding, kangaroo care, and facilitating tucking help reduce heel-stick pain but facilitating tucking causes less crying and imposes less pain on neonates than the other methods.

CONCLUSION

Facilitated tucking position may be preferred to reduce pain during heel stick.

PRACTICE IMPLICATIONS

Using facilitated tucking positions and breastfeeding methods can assist healthcare professionals as supportive methods in pain management.

Event-related potentials evoked by skin puncture reflect activation of Aβ fibers: comparison with intraepidermal and transcutaneous electrical stimulations

Background

Recently, event-related potentials (ERPs) evoked by skin puncture, commonly used for blood sampling, have received attention as a pain assessment tool in neonates. However, their latency appears to be far shorter than the latency of ERPs evoked by intraepidermal electrical stimulation (IES), which selectively activates nociceptive Aδ and C fibers. To clarify this important issue, we examined whether ERPs evoked by skin puncture appropriately reflect central nociceptive processing, as is the case with IES.

Methods

In Experiment 1, we recorded evoked potentials to the click sound produced by a lance device (click-only), lance stimulation with the click sound (click+lance), or lance stimulation with white noise (WN+lance) in eight healthy adults to investigate the effect of the click sound on the ERP evoked by skin puncture. In Experiment 2, we tested 18 heathy adults and recorded evoked potentials to shallow lance stimulation (SL) with a blade that did not reach the dermis (0.1 mm insertion depth); normal lance stimulation (CL) (1 mm depth); transcutaneous electrical stimulation (ES), which mainly activates Aβ fibers; and IES, which selectively activates Aδ fibers when low stimulation current intensities are applied. White noise was continuously presented during the experiments. The stimulations were applied to the hand dorsum. In the SL, the lance device did not touch the skin and the blade was inserted to a depth of 0.1 mm into the epidermis, where the free nerve endings of Aδ fibers are located, which minimized the tactile sensation caused by the device touching the skin and the activation of Aβ fibers by the blade reaching the dermis. In the CL, as in clinical use, the lance device touched the skin and the blade reached a depth of 1 mm from the skin surface, i.e., the depth of the dermis at which the Aβ fibers are located.

Results

The ERP N2 latencies for click-only (122 ± 2.9 ms) and click+lance (121 ± 6.5 ms) were significantly shorter than that for WN+lance (154 ± 7.1 ms). The ERP P2 latency for click-only (191 ± 11.3 ms) was significantly shorter than those for click+lance (249 ± 18.6 ms) and WN+lance (253 ± 11.2 ms). This suggests that the click sound shortens the N2 latency of the ERP evoked by skin puncture. The ERP N2 latencies for SL, CL, ES, and IES were 146 ± 8.3, 149 ± 9.9, 148 ± 13.1, and 197 ± 21.2 ms, respectively. The ERP P2 latencies were 250 ± 18.2, 251 ± 14.1, 237 ± 26.3, and 294 ± 30.0 ms, respectively. The ERP latency for SL was significantly shorter than that for IES and was similar to that for ES. This suggests that the penetration force generated by the blade of the lance device activates the Aβ fibers, consequently shortening the ERP latency.

Conclusions

Lance ERP may reflect the activation of Aβ fibers rather than Aδ fibers. A pain index that correctly and reliably reflects nociceptive processing must be developed to improve pain assessment and management in neonates.

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.

Development of an Interprofessional Policy on the Use of Human Milk and Breastfeeding for Pain Relief

BACKGROUND

Infants are subjected to painful procedures as part of routine care. Evidence suggests human milk (HM) has pain-relieving qualities; however, nurses may not be aware of this evidence.

PURPOSE

This article presents the evidence for HM and breastfeeding for pain management, as well as describes using the evidence to create an interprofessional enterprise-wide policy on the topic.

METHODS/SEARCH STRATEGY

Cochrane, PubMed, CINAHL, and Medline were searched for full-length articles published in peer-reviewed journals between 2012 and 2020. Articles using HM as an independent variable during a painful procedure, or discussing benefits of HM for pain management, were analyzed.

FINDINGS/RESULTS

Ten articles were selected for evaluating use of HM for pain relief in term and preterm infants. There is statistically significant evidence that expressed HM has pain-relieving abilities, especially when combined with other soothing interventions such as rocking. HM reduces crying time, and lowers pain scores during painful procedures. Seven articles recommend breastfeeding for effective pain management. Breastfeeding reduces crying time, heart rate, and pain scores compared with oral sucrose, holding, nonnutritive sucking, swaddling, and topical anesthetics.

IMPLICATIONS FOR PRACTICE

Breastfeeding and HM should be offered as primary pain management options. Having an interprofessional enterprise-wide policy for the use of breastfeeding and HM for pain management during painful procedures, such as vaccination, will provide safe, effective pain management.

IMPLICATIONS FOR RESEARCH

Further understanding of effective HM dosing for pain management and use of pasteurized donor HM in place of expressed HM is required.

Sedoanalgesia in neonatal units

Pain recognition and management continues to be a challenge for health professionals in Neonatal Intensive Care Units. Many of the patients are routinely exposed to repeated painful experiences with demonstrated short- and long-term consequences. Preterm babies are a vulnerable high-risk population. Despite international recommendations, pain remains poorly assessed and managed in many Neonatal Intensive Care Units. Due to there being no general protocol, there is significant variability as regards the guidelines for the approach and treatment of pain between the different Neonatal Intensive Care Units. The objective of this article is to review and assess the general principles of pain in the initial stages of development, its recognition through the use of standardised scales. It also includes its prevention and management with the combination of pharmacological and non-pharmacological measures, as well as to establish recommendations that help alleviate pain in daily clinical practice by optimising pain and stress control in the Neonatal Intensive Care Units.

Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: Team Education and Family Engagement

The number of babies born extremely low birth weight surviving to be discharged home after experiencing the NICU continues to improve. Unfortunately, early sensory development for these babies occurs in an environment vastly different from the intended in-utero environment and places them at high risk of long-term neurodevelopmental and neurocognitive challenges. Our goal in the NICU must transition from simply discharge home to supporting the neurosensory development necessary for a thriving lifetime. To accomplish a goal of thriving families and thriving babies, it is clear the NICU interprofessional team must share an understanding of neurosensory development, the neuroprotective strategies safeguarding development, the neuropromotive strategies supporting intended maturational development, and the essential nature of family integration in these processes. We share the educational endeavors of 11 center collaboratives in establishing the foundational knowledge necessary to support preterm babies and their families.

Assessment of four pain scales for evaluating procedural pain in premature infants undergoing heel blood collection

BACKGROUND

Procedural pain is underestimated in hospitalized preterm infants. The aim of this study was to assess the reliability, validity, and clinical utility of the Neonatal Facial Coding System (NFCS), Douleur Aiguë du Nouveau-né (DAN) scale, Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP) in premature infants undergoing heel blood collection. We assume that the four scales were similar in reliablility and validity (but different in clinical utility).

METHODS

The pain assessments were performed on 111 premature infants using the four scales. Internal consistency was determined by Cronbach's α, and the reliability was determined by the intraclass correlation coefficients. Concurrent validity was evaluated by Spearman's rank correlations. Bland-Altman plots were used to investigate the convergent validity.

RESULTS

The internal consistency and their reliability of the scales were high (p < 0.001). Scores were significantly higher at the time of blood collection (p < 0.001). Mean scores of clinical utility of PIPP were significantly higher than NFCS and DAN (p < 0.05) but not higher than the NIPS (p > 0.05).

CONCLUSIONS

The four scales were reliable and valid. This study suggests that the PIPP and NIPS has good clinical utility and are better choice for evaluating procedural pain in premature infants.

IMPACT

The aim of this study was to assess the reliability, validity, and clinical utility of NFCS, DAN, NIPS, and PIPP in premature infants undergoing heel blood collection. The results showed that the four scales have high reliability and internal consistency; the PIPP and NIPS have good clinical utility and are better choice for evaluating procedural pain in premature infants. Our study results provided a reference for clinical workers in choosing pain assessment scales and conduction intervention.

Can Event-Related Potentials Evoked by Heel Lance Assess Pain Processing in Neonates? A Systematic Review

To clarify the possibility of event-related potential (ERP) evoked by heel lance in neonates as an index of pain assessment, knowledge acquired by and problems of the methods used in studies on ERP evoked by heel lance in neonates were systematically reviewed, including knowledge about Aδ and C fibers responding to noxious stimuli and Aβ fibers responding to non-noxious stimuli. Of the 863 reports searched, 19 were selected for the final analysis. The following points were identified as problems for ERP evoked by heel lance in neonates to serve as a pain assessment index: (1) It is possible that the ERP evoked by heel lance reflected the activation of Aβ fibers responding to non-noxious stimuli and not the activation of Aδ or C fibers responding to noxious stimulation; (2) Sample size calculation was presented in few studies, and the number of stimulation trials to obtain an averaged ERP was small. Accordingly, to establish ERP evoked by heel lance as a pain assessment in neonates, it is necessary to perform a study to clarify ERP evoked by Aδ- and C-fiber stimulations accompanied by heel lance in neonates.

A complex interprofessional intervention to improve the management of painful procedures in neonates

During hospitalization, neonates are exposed to a stressful environment and a high number of painful procedures. If pain is not treated adequately, short‐ and long‐term complications may develop. Despite evidence about neonatal pain and available guidelines, procedural pain remains undertreated. This gap between research and practice is mostly due to limited implementation of evidence‐based knowledge and time constraints. This study describes in detail the development process of a complex interprofessional intervention to improve the management of procedural pain in neonates called NEODOL© (NEOnato DOLore). The framework of the Medical Research Council (MRC) for the development and evaluation of complex interventions was used as a methodological guide for the design of the NEODOL© intervention. The development of the intervention is based on several steps and multiple methods. To report this process, we used the Criteria for Reporting the Development of Complex Interventions in Healthcare (CReDECI 2). Additionally, we evaluated the content of the intervention using a Delphi method to obtain consensus from experts, stakeholders, and parents. The complex interprofessional intervention, NEODOL©, is developed and designed for three groups: healthcare professionals, parents, and neonates for a level IIb neonatal unit at a regional hospital in southern Switzerland. A total of 16 panelists participated in the Delphi process. At the end of the Delphi process, the panelists endorsed the NEODOL© intervention as important and feasible. Following the MRC guidelines, a multimethod process was used to develop a complex interprofessional intervention to improve the management of painful procedures in newborns. Complex interprofessional interventions need theoretical bases, careful development, and integration of stakeholders to provide a comprehensive approach. The NEODOL intervention consists of promising components and has the potential to improve the management of painful procedures and should facilitate the knowledge translation into practice.

Effects of Combined Use of Mother's Breast Milk, Heartbeat Sounds, and Non-Nutritive Sucking on Preterm Infants' Behavioral Stress During Venipuncture: A Randomized Controlled Trial

PURPOSE

Even routine procedures can cause pain and stress, and can be harmful to the fast-growing brain of preterm infants. Mitigating pain and stress with sucrose and analgesics has side effects; thus, an alternate choice is the use of natural breast milk and infants' sensory capabilities. Therefore, this study examined the effects of different integrations of sensory experiences-mother's breast milk odor and taste (BM-OT), heartbeat sounds (HBs), and non-nutritive sucking (NNS)-on preterm infant's behavioral stress during venipuncture.

DESIGN

This study was a prospective, randomized controlled trial.

METHODS

Infants born preterm (<37 weeks' gestational age) were enrolled in the study through convenience sampling, and randomly assigned to the following conditions: (condition 1) routine care (n = 36); (condition 2) BM-OT (n = 33); (condition 3) BM-OT + HBs (n = 33); or (condition 4) BM-OT + HBs + NNS (n = 36). Crying duration from puncture to recovery period was recorded using a voice recorder. Facial actions and body movements were measured using an infant behavioral coding scheme and transformed into frequencies during seven stages: baseline (stage 0), disinfecting (stage 1), venipuncture (stage 2), and the recovery period for 10 minutes (stages 3-6).

FINDINGS

Data were analyzed for 138 preterm infants. The corresponding median times to stop crying for conditions 1, 2, 3, and 4 were 137, 79, 81, and 39 s, respectively; the instantaneous occurrence rates of stopping crying for conditions 2, 3, and 4 were 1.469, 1.574, and 2.996 times greater than for condition 1, respectively. Infants receiving conditions 3 and 4 had significantly fewer occurrences of facial actions (stage 6 and stages 4-6, respectively) and body movements (stages 3-6 for both); however, there were no significant reductions in stress behaviors for condition 2 (BM-OT).

CONCLUSIONS

The combination of BM-OT, HBs, and NNS could be provided to preterm infants as interventions to prevent and reduce behavioral stress, and facilitate pain recovery during venipuncture procedures.

CLINICAL RELEVANCE

Clinicians should be educated about how to recognize preterm infants' behavioral stress, and to incorporate different sensory combinations of respective mothers' BM, HBs, and NNS into painful procedures to help preterm infants recover from distress.

Establishing a Foundation for Optimal Feeding Outcomes in the NICU

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.

The effect of facilitated tucking position during painful procedure in pain management of preterm infants in neonatal intensive care unit: a systematic review and meta-analysis

We performed a systematic review and meta-analysis to investigate the effects of facilitated tucking position during painful procedure in pain management of preterm infants. We searched MEDLINE, PEDro, SciELO and the Cochrane Library (until June 2019) for randomized controlled trials. An α value ≤ 0.05 was considered significant. Heterogeneity among studies was examined with Cochran's Q and I² statistic, in which values greater than 40% were considered indicative of high heterogeneity and random-effects model was chosen. Analyses were performed with Review Manager 5.3. Fifteen studies met the eligibility criteria, including 664 preterm infants. The meta-analyses showed a significant reduction in pain of - 1.02 (95% CI - 1.7 to - 0.4, N = 216) during endotraqueal suctioning for participants in the facilitated tucking position group (FTPG) compared with routine care group. The meta-analyses showed a non-significant difference in pain - 0.3 (95% CI - 2.05 to - 1.4, N = 88) during heel stick for participants in the FTPG compared with oral glucose group. The meta-analyses showed a non-significant difference in pain for participants in the FTPG compared with oral opioid group 0.2 (95% CI - 1.4 to 1.8, N = 140).Conclusion: Facilitated tucking position may improve the pain during painful procedures.What is Known:• Exposure of premature babies to painful procedures is associated with changes in brain development, regardless of other factors.• Facilitated tucking reduces the expression of pain in premature infants.What is New:• Facilitated tucking position was efficient in pain management of preterm infants when compared to routine care.• Facilitated tucking compared to opioid or oral glucose did not achieve a significant reduction in pain intensity.

Comparing the Analgesic Effects of 4 Nonpharmacologic Interventions on Term Newborns Undergoing Heel Lance: A Randomized Controlled Trial

This randomized trial compared the analgesic effect of 4 nonpharmacologic interventions (breastfeeding, oral sucrose, nonnutritive sucking, and skin-to-skin contact) on term newborns between 24 and 48 hours of age who underwent a heel lance. The Neonatal Pain, Agitation, and Sedation Scale was used to evaluate pain. The newborns (N = 226) were assigned to one of 4 intervention groups (n = 176) or a control group without pain intervention (n = 50). The results indicate that all intervention groups showed decreased pain levels when compared with the control group (P < .01). The oral sucrose group experienced a superior analgesic effect when compared with the skin-to-skin contact group (P < .01), but no difference was observed when compared with the breastfeeding group (P > .05) or the nonnutritive sucking group (P > .05). All intervention groups showed a shortened crying time (P < .01) and reduced procedural duration (P < .01) compared with the control group. All of these interventions are clinically applicable and acceptable when caring for a newborn during a minor painful procedure.

Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update

Infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available that may be used for these painful procedures, including swaddling/containment, pacifier/non-nutritive sucking, rocking/holding, breastfeeding and breastmilk, skin-to-skin care, sweet tasting solutions, music therapy, sensorial saturation, and parental presence. Adoption these interventions into routine clinical practice is feasible and should be a standard of care in quality health care for infants. This review summarizes the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions.

Integration of Different Sensory Interventions From Mother's Breast Milk for Preterm Infant Pain During Peripheral Venipuncture Procedures: A Prospective Randomized Controlled Trial

PURPOSE

To compare the effects of integrating mother's breast milk (BM) with three different combinations of sensory stimuli on preterm infant pain during peripheral venipuncture procedures.

DESIGN

A prospective, repeated-measures randomized controlled trial.

METHODS

Preterm infants (gestational age between 28 and 37 weeks, and in stable condition) needing venipuncture were recruited by convenience sampling (N = 140) and randomly assigned to four treatment conditions: (a) routine care (condition 1); (b) BM odor or taste (condition 2); (c) BM odor or taste + heartbeat sounds (HBs; condition 3), and (d) BM odor or taste + HBs + non-nutritive sucking (NNS; condition 4). Pain scores were assessed based on the Premature Infant Pain Profile-Revised (PIPP-R) over nine phases: baseline (phase 0, 5 min without stimuli before venipuncture), disinfecting (phase 1), during venipuncture (phase 2), and a 10-min recovery (phases 3-8).

FINDINGS

Infants who received BM odor or taste + HBs + NNS had significantly lower increases in pain scores from baseline compared with controls across phases 1 through 8. Infants treated with either condition 2 or 3 demonstrated significant reductions in mild pain during disinfecting and recovery phases, as compared with the controls. When condition 2 was used as the reference, there were no significant differences in pain scores between the infants receiving condition 3 across the nine phases, suggesting mothers' HBs have only mild analgesic effects on venipuncture pain.

CONCLUSIONS

Integration of mother's BM odor or taste, HBs, and tactile NNS should be considered as an intervention for alleviation of procedural pain for preterm infants.

CLINICAL RELEVANCE

Clinicians should incorporate the integrated sensory intervention into caregiving support for preterm infants undergoing short painful procedures.

Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach

PURPOSE

Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain.

FINDINGS

After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking.

IMPLICATIONS

The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.

Efficacy of facilitated tucking combined with non-nutritive sucking on very preterm infants' pain during the heel-stick procedure: A randomized controlled trial

BACKGROUND

Reducing acute pain in premature infants during neonatal care improves their neurophysiological development. The use of pharmacological and non-pharmacological analgesia, such as sucrose, is limited per day, particularly for very preterm infants. Thus, the usual practice of non-nutritive sucking is often used alone. Facilitated tucking could be an additional strategy to non-nutritive sucking for reducing pain. To the best of our knowledge, no randomized trial has compared the combination of facilitated tucking and non-nutritive sucking to non-nutritive sucking alone.

OBJECTIVES

To compare the efficacy of facilitated tucking in combination with non-nutritive sucking (intervention group) to non-nutritive sucking alone (control group) in reducing pain during the heel-stick procedure in very preterm infants.

DESIGN

Prospective, randomized controlled trial.

SETTINGS

Level III and II neonatal care units, including the neurosensory care management program.

METHODS

Very preterm infants (gestational age between 28 and 32 weeks) were randomly assigned by a computer programme to the intervention or control group during a heel-stick procedure within the first 48 h of life. In both groups, infants were placed in an asymmetric position on a cushion; noise and light were limited following routine care. A heel-stick was performed first in the care sequence. In the intervention group, facilitated tucking was performed by a nurse or nursing assistant. The procedure was video recorded from 15 s (T-15 s) before the procedure until three minutes (T + 3 min) after the end of the procedure. Pain was blindly assessed by two independent specialist nurses. The primary outcome was the pain score evaluated 15 s before the procedure and 30 s immediately after by the premature infant pain profile (PIPP) scale. The secondary outcome was the pain score evaluated between T-15 s and T + 3 min by the DAN scale (a French acronym for the acute pain of a newborn).

RESULTS

Sixty infants were included (30 in each group). The PIPP pain scores did not differ between the intervention group (median: 8.0; interquartile range (IQR): 6.0-12.0) and the control group (median: 9.5; IQR: 7.0-13.0, p = 0.32). Pain assessed by the DAN scale at T + 3 min was lower in the intervention group than in the control group (median: 0.3; IQR: 0.0-1.0 and 2.0; IQR: 0.5-3.0, respectively, p = 0.001).

CONCLUSIONS

The combined use of facilitated tucking and non-nutritive sucking did not significantly alleviate pain during the heel-stick procedure. However, the addition of facilitated tucking facilitated faster pain recovery following the heel-stick procedure.