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McCarty DB, Clary-Williams E, LeBLond KD, Liu T, Zbornik-Thompson T, Ulrich JN, Go MS. Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project. Front Psychol 2024; 15:1354033. [PMID: 38770256 PMCID: PMC11102993 DOI: 10.3389/fpsyg.2024.1354033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/25/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes. Methods An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM. Results Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM. Discussion Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.
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Affiliation(s)
- Dana B. McCarty
- Division of Physical Therapy, Department of Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Erika Clary-Williams
- Pediatric Rehabilitation Services, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, United States
| | - Kristen D. LeBLond
- Department of Physical Therapy and Occupational Therapy, Duke University Hospital, Durham, NC, United States
| | - Tianyi Liu
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tika Zbornik-Thompson
- Department of Ophthalmology, University of North Carolina, Chapel Hill, NC, United States
| | - J. Niklas Ulrich
- Department of Ophthalmology, University of North Carolina, Chapel Hill, NC, United States
| | - Michelle S. Go
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, United States
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Cuddihee LJ, Giannulis P, Merriner S, Runge PE, Pringels V, McGill V, Johnson MA, Cobb LB, Arnold RW. Compared Methods for Reducing Stress in ROP Exams; Stake-Holding Examiner Perspective. Clin Ophthalmol 2023; 17:1953-1965. [PMID: 37465272 PMCID: PMC10350462 DOI: 10.2147/opth.s418150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/03/2023] [Indexed: 07/20/2023] Open
Abstract
Purpose To better understand the sensory impact of retinal exam components typically experienced by infants undergoing various retinopathy of prematurity staging examinations, adults concerned for infant welfare and exam quality underwent similar exams to compare their perceived stress. Patients and Methods Adults directly involved with ROP exams and infant stress reduction had cardiac monitoring and concomitant ordinal self symptom-score (1-10 Likert) during 15 components of the exam including lid speculum, various scleral depressors, indirect ophthalmoscopy, goniolens and direct ophthalmoscopy and retinal photography (Phoenix ICON) with or without topical anesthesia. Results Nine adults provided impressions and cardiac rhythm gathered supine over 15 minutes. Pain score for topical anesthetic 2 was less than for tropicamide 4. Lid specula numb scored a median 2 level (from 1 to 10) pain but without anesthetic scored 6. The goniolens numb scored 3. Scleral depression numb scored 3-4 but increased to 7 without topical anesthesia. Direct ophthalmoscope scored 3 through the goniolens and the retinal camera scored 4 pain. Brightness with low 350 Lux indirect scored 6-8 numb and 9 brightness without anesthetic. Full bright indirect, direct ophthalmoscope and the retinal camera all had Lux of 3000-4000 and were scored brightness 9, 7 and 10, respectively. Adults had minimal oculocardiac reflex during on-globe retinal examination methods (range 98% to 102%). Conclusion Topical anesthesia provided a moderate reduction in pain during on-globe lid-speculum, scleral depressed indirect examination. There was a synergistic augmented sensory response between pain and brightness. Adults did not show the bradycardia typically elicited by retinal examinations in premature infants.
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Affiliation(s)
- Laney J Cuddihee
- Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, USA
| | - Peter Giannulis
- Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, USA
| | - Sarah Merriner
- Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, USA
| | - Paul E Runge
- International Retinal Consultant, Lakewood Ranch, FL, USA
| | - Victoria Pringels
- Neonatal Intensive Care Unit, Providence Alaska Medical Center, Anchorage, AK, USA
| | - Virginia McGill
- Neonatal Intensive Care Unit, Providence Alaska Medical Center, Anchorage, AK, USA
| | - Mary-Alice Johnson
- Neonatal Intensive Care Unit, Providence Alaska Medical Center, Anchorage, AK, USA
| | - Lindsey B Cobb
- Anesthesiology Department, Central Peninsula Hospital, Soldotna, AK, USA
| | - Robert W Arnold
- Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, USA
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3
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Thirunavukarasu AJ, Hassan R, Savant S, Hamilton DL. Analgesia for retinopathy of prematurity screening: A systematic review. Pain Pract 2022; 22:642-651. [PMID: 35703418 PMCID: PMC9543288 DOI: 10.1111/papr.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/04/2022] [Accepted: 05/31/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Premature neonates require regular ophthalmological examination, generally indirect ophthalmoscopy, to screen for retinopathy of prematurity (ROP). Conventional analgesia is provided with topical anesthetic eyedrops and oral sugar solution, but neonates still experience significant pain. Here, the literature base was examined to evaluate the usefulness of other pharmacological analgesics. MATERIALS AND METHODS A systematic review was undertaken, adhering to a PROSPERO preregistered protocol in accordance with PRISMA guidelines (identifier CRD42022302459). Electronic databases were searched for primary research articles on pharmacological pain interventions used for ROP screening in neonates. The primary outcome measure was pain scores recorded using validated pain scoring tools, with and without pharmacological interventions in neonates during eye examination. For analysis, studies were separated into two categories: topical anesthesia and alternative pharmacological treatments. RESULTS Eleven studies met the inclusion criteria. Topical analgesia, oral paracetamol, and intranasal fentanyl were found to be effective in reducing the pain of eye examination. Oral morphine and inhaled nitrous oxide had no significant effect on premature infant pain profile (PIPP) scores during indirect ophthalmoscopy. DISCUSSION In addition to topical anesthesia, premedication with oral paracetamol is recommended during screening examination for ROP. The routine use of fentanyl is not recommended due to the risk of potential side effects. Non-pharmacological measures, such as sweet oral solutions and comfort techniques should also be employed. Further research is required to determine whether the use of nitrous oxide has a role, and to develop a safe and effective analgesic strategy to fully ameliorate the pain of ROP screening.
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Affiliation(s)
- Arun J. Thirunavukarasu
- School of Clinical MedicineUniversity of CambridgeCambridgeUK,Corpus Christi CollegeUniversity of CambridgeCambridgeUK
| | - Refaat Hassan
- School of Clinical MedicineUniversity of CambridgeCambridgeUK,Sidney Sussex CollegeUniversity of CambridgeCambridgeUK
| | - Shalom V. Savant
- School of Clinical MedicineUniversity of CambridgeCambridgeUK,St John's CollegeUniversity of CambridgeCambridgeUK
| | - Duncan L. Hamilton
- James Cook University HospitalMiddlesbroughUK,School of MedicineUniversity of SunderlandSunderlandUK
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Akbari N, Mutlu B, Nadali J. Effect of Non-nutritive Sucking during Heel-stick Procedure in Pain Management of Term Infants in the Neonatal Intensive Care Unit: A Systematic Review and Meta-analysis. Curr Pediatr Rev 2022; 19:90-98. [PMID: 35410609 DOI: 10.2174/1573396318666220410225908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study aimed to evaluate the efficacy of non-nutritive sucking for analgesia in term infants undergoing heel-stick procedures. METHODS Randomized controlled trials and non-randomized studies based on the PICO framework were included in the study. Review articles, commentary, pilot, and non-English articles were excluded. Databases, such as PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane, were searched until January 31st, 2021, using the keywords "Pain management", 'Non-nutritive sucking", and "Heel stick". All studies were reviewed and retrieved by two authors independently using a standardized form according to the inclusion criteria, and any disagreements were examined by a third scholar. Quality assessment was evaluated by using the ROB-2 tool. Data were analyzed using Stata version 12.0 software, and a random-effects model was used for analysis. RESULTS A total of 5,629 articles were retrieved from all databases, and after the screening, finally, 6 relevant articles were included in the analysis. The tools used to control pain in infants in the articles included PIPP, NFCS, NIPS, and NPASS. The results showed that the pain scores were significantly lower in the NNS group compared to the control group (MD, -1.05; 95% CI, -1.53 to -0.57) and NNS had a significant effect on oxygen saturation (O2 Sat) increasing in newborns compared to the control group, but no significant reduction in the heart rate (HR) between two groups was observed. CONCLUSION NNS effectively provides analgesia in full-term neonates undergoing heel-stick procedures; however, its effects on the long-term outcomes of infants are unclear. The results showed that NNS was effective in improving heel-stick pain in infants.
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Affiliation(s)
- Negarin Akbari
- Pediatric Nursing Doctorate Program, Institute of Graduate Studies, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Birsen Mutlu
- Pediatric Nursing Department, Florence Nightingale Nursing Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Javad Nadali
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
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5
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Mangalesh S, Sarin N, McGeehan B, Prakalapakorn SG, Tran-Viet D, Cotten CM, Freedman SF, Maguire MG, Toth CA. Preterm Infant Stress During Handheld Optical Coherence Tomography vs Binocular Indirect Ophthalmoscopy Examination for Retinopathy of Prematurity. JAMA Ophthalmol 2021; 139:567-574. [PMID: 33792625 DOI: 10.1001/jamaophthalmol.2021.0377] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Binocular indirect ophthalmoscopy (BIO) examination for retinopathy of prematurity (ROP) is a well-known cause of repeated preterm infant stress. Objective To compare stress during investigational optical coherence tomography (OCT) imaging to that during BIO for ROP. Design, Setting, and Participants This cross-sectional study examined infants at the bedside in the intensive care nursery. Consecutive preterm infants enrolled in Study of Eye Imaging in Preterm Infants (BabySTEPS) who had any research OCT imaging as part of the study. Patients were recruited from June to November 2019, and analysis began April 2020. Main Outcomes and Measures Infant stress was measured using modified components of a neonatal pain assessment tool before (baseline) and during OCT imaging and BIO examination of each eye. Results For 71 eye examinations of 16 infants (mean [SD] gestational age, 27 [3] weeks; birth weight, 869 [277] g), change from baseline to each eye examination was lower during OCT imaging than during BIO and the difference between OCT imaging and BIO at each eye examination was significant for the following: infant cry score (first eye examination: mean [SD], 0.03 [0.3] vs 1.68 [1.2]; -1.65 [95% CI, -1.91 to -1.39]; second eye examination: mean [SD], 0.1 [0.3] vs 1.97 [1.2]; -1.87 [95% CI, -2.19 to -1.54]), facial expression (first eye: 3 [4%] vs 59 [83%]; -79% [95% CI, -87% to -72%]; second eye: 4 [6%] vs 61 [88%]; -83% [95% CI, -89% to -76%]), and heart rate (first eye: mean [SD], -7 [16] vs 13 [18]; -20 [95% CI, -26 to -14]); second eye: mean [SD], -3 [18] vs 20 [20] beats per minute; -23 [95% CI, -29 to -18]) (P < .001 for all). Change in respiratory rate and oxygen saturation did not differ between OCT imaging and BIO. Conclusions and Relevance While the role of OCT alone or in combination with BIO is currently unknown for ROP, these findings suggest that investigational OCT imaging of ROP is less stressful than BIO examination by a trained ophthalmologist.
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Affiliation(s)
- Shwetha Mangalesh
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Neeru Sarin
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Brendan McGeehan
- Department of Ophthalmology, University of Pennsylvania, Philadelphia
| | - S Grace Prakalapakorn
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Du Tran-Viet
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Sharon F Freedman
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Maureen G Maguire
- Department of Ophthalmology, University of Pennsylvania, Philadelphia
| | - Cynthia A Toth
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina.,Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, North Carolina
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Reducing discomfort of eye drops prior to retinal examination in the neonatal intensive care unit. J Perinatol 2020; 40:1857-1862. [PMID: 33060779 DOI: 10.1038/s41372-020-00852-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 09/07/2020] [Accepted: 09/26/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the effectiveness in reducing pain by giving oral sucrose and non-pharmacological comfort measures prior to topical administration of mydriatic eye drops on premature infants undergoing retinopathy of prematurity (ROP) screening eye exams in a neonatal intensive care unit (NICU). STUDY DESIGN A prospective quality improvement study was conducted in the NICU where infants were given oral sucrose prior to administration of mydriatic eye drops while a second person performed facilitated tucking and containment. Premature Infant Pain Profile (PIPP) scores were recorded during eye drop administration and compared to a group that did not receive any comfort measures. RESULT Sixty-eight infants were enrolled. Mean PIPP scores increased an average of 1.5 (SD = 1.5) during administration of mydriatic drops without comfort measures compared to 0.6 (SD = 0.8) when comfort measures were used. This difference was statistically significant (p < 0.001). CONCLUSIONS Oral sucrose and simple comfort measures can be effective in reducing pain associated with mydriatic eye drops.
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7
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Metreş Ö, Yıldız S. Pain Management with ROP Position in Turkish Preterm Infants During Eye Examinations: A Randomized Controlled Trial. J Pediatr Nurs 2019; 49:e81-e89. [PMID: 31495577 DOI: 10.1016/j.pedn.2019.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/22/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effects of infant positioning on pain, heart rate, oxygen saturation and crying time during examination. DESIGN & METHODS The randomized controlled experimental study was carried out on 70 preterm infants. ROP position + pacifier was used in the experimental group (n = 35) while only the pacifier was used in the control group. Heart rates, oxygen saturation, crying duration and pain score (Premature Infant Pain Profile-PIPP) were evaluated before, during and after the screening. RESULTS The preterm infants in the experimental group recorded lower pain scores at the beginning of the screening (p = 0.01), at the end of the screening (p = 0.01) and after screening (p = 0.01) than those in the control group. The heart rate was higher in the control group during screening (p = 0.010) and after screening (p = 0.008) than in the preterm infants in the experimental group. Oxygen saturation was not significantly different between the groups before, during or after screening. Crying duration was lower in the experimental group than in the control group (p = 0.010). CONCLUSIONS Positioning of the infant to support behavioral organization was found to be effective in reducing pain and shortening crying time during eye examination, and had favorable effects on physiological variables with ROP position during eye examinations. PRACTICE IMPLICATIONS ROP position is a practical and effective non-pharmacological method during eye examinations by neonatal nurses.
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Affiliation(s)
- Özlem Metreş
- The Turkısh Republıc of Demiroglu Bilim University, Faculty of Health Scıences, İstanbul, Turkey.
| | - Suzan Yıldız
- Istanbul University-Cerrahpasa, Florence Nightingale Faculty of Nursing, Department of Child Health and Diseases Nursing, İstanbul, Turkey.
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8
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Differential effects of the retinopathy of prematurity exam on the physiology of premature infants. J Perinatol 2019; 39:708-716. [PMID: 30755719 PMCID: PMC6483876 DOI: 10.1038/s41372-019-0331-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/31/2018] [Accepted: 01/15/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the differential effects of the retinopathy of prematurity (ROP) examination on the physiology of premature infants with and without oxygen support. STUDY DESIGN We collected data from 42 premature infants (room air = 19, oxygen support = 23) and compared physiological metrics including heart rate (HR), systemic peripheral saturation (SpO2), mesenteric tissue oxygen saturation (StO2) and clinical events (oxygen desaturation episodes, bradycardia events, and gastric residuals). RESULTS We found significant differences between groups in HR during and briefly after the exam, and in mesenteric StO2, during eye drop administration, eye exam, and up to 8 min after the exam. SpO2 was significantly different between the groups at all time points. Gastric residuals were higher after the exam in infants on oxygen support, compared to baseline. CONCLUSION Premature infants on oxygen support may be at a higher risk of adverse physiologic effects in response to the ROP exam.
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9
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Pirelli A, Savant Levet P, Garetti E, Ancora G, Merazzi D, Bellieni CV, Lago P. Literature review informs clinical guidelines for pain management during screening and laser photocoagulation for retinopathy of prematurity. Acta Paediatr 2019; 108:593-599. [PMID: 30054933 DOI: 10.1111/apa.14523] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 06/29/2018] [Accepted: 07/25/2018] [Indexed: 01/12/2023]
Abstract
AIM The aim of this study was to carry out a literature review and develop clinical guidelines for pain prevention and control during screening and laser photocoagulation for retinopathy of prematurity (ROP) in neonatal intensive care units (NICUs). METHODS The Italian Society of Neonatology assessed papers published between 1986 and June 2017 and used the Grading of Recommendations, Assessment, Development and Evaluation approach, to develop new guidelines on pain and ROP. RESULTS The Society's pain experts assessed the full texts of 47 papers, including randomised or quasi-randomised controlled trials and case-control studies on nonpharmacological and pharmacological measures used in NICUs during the screening and laser photocoagulation of neonates for ROP. The literature suggested methods for reducing the stress and pain associated with ROP screening procedures. The panel concluded that the literature showed that it was feasible to provide laser photocoagulation for ROP in spontaneously breathing patients with adequate analgesia. CONCLUSION This literature review on managing pain in infants with ROP in NICUs led to the development of national guidelines, which will help physicians and nurses to reduce the stress and pain experienced by premature newborn infants during unavoidable screening and treatment for ROP.
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Affiliation(s)
- Anna Pirelli
- NICU; Women's and Children's Health Department; ASST Rhodense; Ospedale of Rho; Rho Italy
| | | | - Elisabetta Garetti
- NICU; Women's and Children's Health Department; Azienda Ospedaliera-University of Modena; Modena Italy
| | - Gina Ancora
- Women's and Children's Health Department; Infermi Hospital; Azienda Ospedaliera of Rimini; Rimini Italy
| | - Daniele Merazzi
- NICU; Mother's and Infant's Department; Valduce Hospital; Como Italy
| | | | - Paola Lago
- NICU; Women's and Children's Health Department; Azienda Ospedaliera-University of Padova; Padova Italy
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10
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Şener Taplak A, Erdem E. A Comparison of Breast Milk and Sucrose in Reducing Neonatal Pain During Eye Exam for Retinopathy of Prematurity. Breastfeed Med 2017; 12:305-310. [PMID: 28414522 DOI: 10.1089/bfm.2016.0122] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Ayşe Şener Taplak
- 1 Department of Pediatric Nursing, Health School, Bozok University , Yozgat, Turkey
| | - Emine Erdem
- 2 Department of Pediatric Nursing, Faculty of Health Sciences, Erciyes University , Kayseri, Turkey
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11
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Liu Y, Huang X, Luo B, Peng W. Effects of combined oral sucrose and nonnutritive sucking (NNS) on procedural pain of NICU newborns, 2001 to 2016: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e6108. [PMID: 28178172 PMCID: PMC5313029 DOI: 10.1097/md.0000000000006108] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Both oral sucrose (OS) and nonnutritive sucking (NNS) are effective nonpharmacological methods to alleviate procedures pain in neonatal intensive care unit (NICU) newborns when they were used alone, but the combined effect of OS+NNS remains controversial. So, we conducted this study to evaluate the efficiency of NNS combined with oral sucrose on pain relief in NICU newborns undergoing painful procedures. METHODS We searched PubMed, Ovid (Medline), Embase (Medline), Cochrane Central Library, and other resources such as Google Scholar, bibliographies of included literatures for all available articles. Two reviewers screened literatures and extracted data independently. The fixed effects model was used to pool the results using Reviewer Manager (RevMan) 5.3. As each study included in our meta-analysis had been approved by Ethics Committee or institutional review board, thus our study did not need ethical approval. RESULTS Seven randomized controlled trials, including 599 participants, were contained in our meta-analysis. The combination of oral sucrose and NNS is associated with reduced pain scores (mean difference [MD], -0.52; 95% confidence interval [CI], -0.68 to -0.36); shortened crying time (MD,-0.92; 95% CI, -1.39 to -0.44); but the 2 groups did not differ significantly in reducing bradycardia (MD, 0.73; 95% CI, 0.32-1.68), tachycardia (MD, 0.65; 95% CI, 0.38-1.10), or desaturations (MD, 0.73; 95% CI, 0.32-1.68). CONCLUSION The pooled evidence indicates that the combination measures may serve as an evidence-based guideline for pain relief among patients having minor pain. Besides, it also indicates that OS combined with NNS can be an alternative for better prevention and management of procedure pain in NICU newborns. Nevertheless, the results may be limited due to incomplete data, and thus, more randomized controlled trials or well-designed studies are required to determine the effects of OS+NNS in the future.
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Affiliation(s)
- Yi Liu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu
| | - Xinchun Huang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education
- Research Center of Combine Traditional Chinese and Western Medicine, Affiliated Traditional Medicine Hospital, Southwest Medical University, Luzhou
| | - Biru Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education
- Department of Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Wentao Peng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education
- Department of Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
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12
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016; 1:7. [PMID: 28066825 PMCID: PMC5218543 DOI: 10.12688/wellcomeopenres.10005.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016. [PMID: 28066825 DOI: 10.12688/wellcomeopenres.10005.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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Jefferies AL. Retinopathy of prematurity: An update on screening and management. Paediatr Child Health 2016; 21:101-8. [PMID: 27095887 DOI: 10.1093/pch/21.2.101] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Retinopathy of prematurity is a proliferative disorder of the developing retinal blood vessels in preterm infants. The present practice point reviews new information regarding screening and management for retinopathy of prematurity, including the role of risk factors in screening, optimal scheduling for screening examinations, pain management, digital retinal photography and antivascular endothelial growth factor therapy.
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Jefferies AL. La rétinopathie du prématuré : mise à jour sur le dépistage et la prise en charge. Paediatr Child Health 2016. [DOI: 10.1093/pch/21.2.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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The effect of erythropoietin on the severity of retinopathy of prematurity. Eye (Lond) 2014; 28:814-8. [PMID: 24763242 DOI: 10.1038/eye.2014.95] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/25/2014] [Indexed: 01/18/2023] Open
Abstract
AIMS Exogenous human erythropoietin (EPO) artificially synthesised through recombinant DNA technology (rHuEPO) is currently used as a substitute for blood transfusion in preterm and low birth weight neonates. The objective of this study is to determine whether the use of rHuEPO is associated with an increased severity of retinopathy of prematurity (ROP) in preterm neonates. METHOD This retrospective review studies neonates who were admitted to a tertiary perinatal unit and screened for ROP during the 10-year period from January 2003 to December 2012. RESULTS : During the 10-year period, 688 preterm neonates underwent ROP screening, with 198 identified as having ROP. The incidence of stage 1 ROP was 51.5% (102/198), followed by 35.9% (71/198) for stage 2, and 12.6% (25/198) for stage 3 and greater. Plus disease was seen in 14 neonates (7.1%). Treatment (laser photocoagulation) was administered in 64% of neonates (16/25) with stage 3 of the disease and above because of progression to threshold ROP. Twenty-six (13%) of the neonates received rHuEPO treatment. There were no statistically significant differences in birth weight (910.4 vs 885 g; P=0.71), gestational age (26.5 vs 25.8 weeks; P=0.09), and duration of ventilation (512 vs 501.4 h; P=0.92) between neonates who did not receive rHuEPO compared with those who were treated with rHuEPO. Multivariate regression analysis showed that the use of EPO was associated with increased severity of ROP. CONCLUSIONS EPO therapy appears to increase the risk of development and worsening of ROP.
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Piyasena C, Dhaliwal C, Russell H, Hellstrom A, Löfqvist C, Stenson BJ, Fleck BW. Prediction of severe retinopathy of prematurity using the WINROP algorithm in a birth cohort in South East Scotland. Arch Dis Child Fetal Neonatal Ed 2014; 99:F29-33. [PMID: 23985883 DOI: 10.1136/archdischild-2013-304101] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE We tested the ability of the 'Weight, IGF-1, Neonatal Retinopathy of Prematurity (WINROP)' clinical algorithm to detect preterm infants at risk of severe Retinopathy of Prematurity (ROP) in a birth cohort in the South East of Scotland. In particular, we asked the question: 'are weekly weight measurements essential when using the WINROP algorithm?' STUDY DESIGN This was a retrospective cohort study. Anonymised clinical data were uploaded to the online WINROP site, and infants at risk of developing severe ROP were identified. The results using WINROP were compared with the actual ROP screening outcomes. Infants with incomplete weight data were included in the whole group, but were excluded from a subgroup analysis of infants with complete weight data. In addition, data were manipulated to test whether missing weight data points in the early neonatal period would lead to loss of sensitivity of the algorithm. RESULTS The WINROP algorithm had 73% sensitivity for detecting infants at risk of severe ROP when all infants were included and 87% when the complete weight data subgroup was analysed. Manipulation of data from the complete weight data subgroup demonstrated that one or two missing weight data points in the early postnatal period lead to loss of sensitivity performance by WINROP. IMPLICATIONS The WINROP program offers a non-invasive method of identifying infants at high risk of severe ROP and also identifying those not at risk. However, for WINROP to function optimally, it has to be used as recommended and designed, namely weekly body weight measurements are required.
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Affiliation(s)
- Chinthika Piyasena
- Neonatal Unit, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, , Edinburgh, UK
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Inhalation anesthesia with sevoflurane during intravitreal bevacizumab injection in infants with retinopathy of prematurity. BIOMED RESEARCH INTERNATIONAL 2013; 2013:435387. [PMID: 23841070 PMCID: PMC3690215 DOI: 10.1155/2013/435387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 05/26/2013] [Indexed: 12/02/2022]
Abstract
Bacground. To investigate the anesthetic management in premature infants with retinopathy of prematurity (ROP) treated with intravitreal bevacizumab (IVB) injections. Methods. A retrospective chart review was performed for the patients with ROP who had IVB injection. Clinical characteristics, demographic variables, anesthetic medications, operation techniques, time intervals, and complications were recorded. Results. Sixty-six eyes of 33 patients (23 males, 10 females) with type 1 ROP who were treated with IVB were included. A total of 66 anesthetic applications were performed. Mean gestational age at birth was 28.3 weeks (range 25–33). Mean birth weight was 1300 g (range 600–1850). Serious ocular and systemic complications were not observed in any infant. Conclusion. Inhalation anesthesia with sevoflurane during IVB treatment in premature infants with ROP may be appropriate for anesthetic management.
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Costa MCD, Eckert GU, Fortes BGB, Fortes Filho JB, Silveira RC, Procianoy RS. Oral glucose for pain relief during examination for retinopathy of prematurity: a masked randomized clinical trial. Clinics (Sao Paulo) 2013; 68:199-204. [PMID: 23525316 PMCID: PMC3584268 DOI: 10.6061/clinics/2013(02)oa13] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 10/23/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Ophthalmologic examination for retinopathy of prematurity is a painful procedure. Pharmacological and non-pharmacological interventions have been proposed to reduce pain during eye examinations. This study aims to evaluate the analgesic effect of 25% glucose using a validated pain scale during the first eye examination for retinopathy of prematurity in preterm infants with birth weight <1,500 g and/or gestational age <32 weeks. METHODS A masked, randomized clinical trial for one dose of 1 ml of oral 25% glucose solution 2 minutes before the first ophthalmologic examination for retinopathy of prematurity was conducted between March 2008 and April 2010. The results were compared to those of a control group that did not receive oral glucose solution. Pain was evaluated using a Neonatal Infant Pain Scale immediately before and immediately after the ophthalmologic examination in both groups. Clinicaltrials.gov: NCT00648687 RESULTS One hundred and twenty-four patients who were examined for the first time for retinopathy of prematurity were included. Seventy were included in the intervention group and 54 in the control group. The number of patients with pain immediately before the procedure was similar in both groups. The number of patients with pain after ophthalmologic examination was 15.7% in the intervention group and 68.5% in the control group (p<0.001). CONCLUSIONS One ml of oral 25% glucose solution given 2 minutes before an ophthalmologic examination for retinopathy of prematurity was an effective measure for pain relief.
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Affiliation(s)
- Marlene Coelho da Costa
- Newborn Section, Departments of Pediatrics and Ophthalmology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Abstract
PURPOSE OF REVIEW Although many publications have documented the use of complementary and alternative medicine (CAM) in children and adolescents, most have lacked the scientific rigor to establish clear benefits over so-called conventional medicine. We reviewed the literature published in the past year to identify the types of CAM most often studied in children, the variety of conditions to which these modalities are applied, and the methodologies used in the articles exploring the most prevalent CAM modalities. RECENT FINDINGS We identified 111 published articles on CAM use in children in 2011. The most common modalities were herbal/dietary supplements, acupuncture, massage, chiropractic, and homeopathy. The most commonly studied conditions were pain, headache, attention deficit hyperactivity disorder (ADHD), asthma, and colic. Although a majority of the articles consisted of reviews, case reports, and other nonhypothesis-driven methodologies, we did find that several were randomized controlled trials, meta-analyses, or systematic reviews. These methodologies, however, rarely accounted for the majority of publications on a particular therapy or condition. SUMMARY The use of CAM in children continues to occupy a niche area of interest for many providers and families, but only a minority of articles published in the past year utilized methods of sufficient rigor to provide a useful comparison to more conventional therapies.
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Pain assessment in premature infants treated with intravitreal antiangiogenic therapy for retinopathy of prematurity under topical anesthesia. Graefes Arch Clin Exp Ophthalmol 2012; 251:491-4. [PMID: 22619071 DOI: 10.1007/s00417-012-2060-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/01/2012] [Accepted: 05/03/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To evaluate the physiological and behavioral pain response in premature infants receiving intravitreal bevacizumab injection (IVB) for retinopathy of prematurity (ROP) under topical anesthesia. METHODS A prospective interventional non-comparative case series. Premature infants with high-risk prethreshold or threshold ROP received IVB using topical anesthesia with tetracaine eye drops. A Premature Infant Pain Profile was used to assess the pain response during the procedure. RESULTS Nine premature infants requiring bilateral IVB therapy were included in the study. Mean gestational age was 28.7 ± 1.3 weeks, and birth weight was 1,200 ± 194 grams. The mean total pain score was found to be 8.7 ± 2.4 (range 5-14), indicating generally mild pain during the procedure. Eye squeeze was the most prominent indicator of pain. Most changes occurred at the beginning, with the insertion of the lid speculum and were hardly noted during the rest of the procedure including the injection itself. CONCLUSION Topical anesthesia with tetracaine is an effective method for the relief of pain associated with intravitreal injections in premature infants with ROP.
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Wong RK, Ventura CV, Espiritu MJ, Yonekawa Y, Henchoz L, Chiang MF, Lee TC, Chan RVP. Training fellows for retinopathy of prematurity care: a Web-based survey. J AAPOS 2012; 16:177-81. [PMID: 22525176 PMCID: PMC3338950 DOI: 10.1016/j.jaapos.2011.12.154] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To characterize the training received by pediatric ophthalmology and retina fellows in retinopathy of prematurity (ROP) management. METHODS Pediatric ophthalmology and retina fellowship programs were emailed a Web-based survey to assess fellowship training in ROP management. RESULTS Of 140 programs contacted, 42 (30%) participated, resulting in 87 surveys for analysis. Of the 87 respondents, 25 (29%) reported that two-thirds or less of ROP examinations performed by fellows were also seen by an attending. When stratified by specialty, this trend was statistically different between pediatric ophthalmology and retina fellows (P = 0.03). Additionally, pediatric ophthalmology fellows performed fewer laser photocoagulation procedures than retina fellows (P < 0.001). Regarding fellows' perceived competency in ROP management, 3 of 51 (6%) felt competent at the start of their fellowship and 43 of 51 (84%) felt competent at the time of the survey. Only 7% of respondents reported the use of formal evaluations at their programs to assess fellow competence in ROP examination. CONCLUSIONS Training programs for fellows in pediatric ophthalmology and retina vary greatly with respect to ROP training and the quality of clinical care. Many clinical ROP examinations are being performed by pediatric ophthalmology and retina fellows without involvement and/or direct supervision by attending ophthalmologists. Our findings have important implications for the development of a future workforce for ROP management.
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Affiliation(s)
- Ryan K Wong
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut, USA
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