Pain and tactile stimuli during arterial puncture in preterm neonates

Stress and self-regulation behaviors in preterm neonates hospitalized at open-bay and single-family room Neonatal Intensive Care Unit

The Neonatal Intensive Care Unit (NICU) could be a risk factor for the development of preterm neonates due to the stressful procedures they undergo. Stress-related behaviors must be managed through environmental strategies that support regulating the neonates' biobehavioural system to minimize the negative impact on their development. The study aimed to compare the NICU environment's stressful procedures and developmental care strategies and the stress and self-regulation behaviors of preterm neonates in groups differentiated by the NICU environmental design. The sample comprised 20 preterm neonates hospitalized in a NICU with an open-bay model (OB NICU) and 20 preterm neonates hospitalized in a single-family room model (SFR NICU). The stressful procedures were assessed by the Neonatal Infant Stressor Scale (NISS). The developmental care strategies and the preterm neonates' stress and self-regulation behaviors were assessed using a structured observational protocol. The between-group comparison was performed by the Mann-Whitney test, and the significance level was set at 5%. Both NICUs had similar stressful procedures and developmental care approaches. However, the preterm neonates hospitalized in the SFR NICU exhibited significantly fewer total stress behaviors, and specifically in the motor system, compared to those in the OB NICU. Additionally, the preterm neonates hospitalized in the SFR NICU exhibited significantly more total self-regulation behaviors, and specifically in the behavioral state system, compared to those in the OB NICU. The findings showed that the single-family room NICU model was consistent with the environmental protection of biobehavioural regulation in preterm neonates hospitalized in the NICU.

Effects of automatic heel lancet on invasiveness in neonates: A systematic review and meta-analysis

AIM

We conducted a meta-analysis comparing the invasiveness of automatic lancet devices, which can collect adequate amount of blood at shallow puncture depths, with conventional manual lance devices (lancet or needle) to statistically identify less invasive instruments for neonatal heel lance.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Ichushi databases for studies comparing the invasiveness between automatic lancet and manual lancet or needle in term and preterm neonates in neonatal intensive care unit.

RESULTS

This review included 9 out of 449 searched articles, with 673 neonates. Automatic lancet had significantly lower pain scores (standardised mean difference: -2.0, 95% confidence interval: -3.3 to -0.7), heart rate (mean difference: -8.0, 95% confidence interval: -13.8 to -2.1), cry duration (mean difference: -21.5, 95% confidence interval: -32.5 to -10.4), number of punctures (mean difference: -0.6, 95% confidence interval: -1.1 to -0.2), and duration of procedures (mean difference: -37.7, 95% confidence interval: -75.2 to -0.2) than manual lancet or needle. Furthermore, peripheral oxygen saturation was significantly higher in automatic lancet than in manual lancet or needle (mean difference: 4.5, 95% confidence interval: 0.5-8.5).

CONCLUSION

Automatic heel lancet devices were less invasive than manual heel lance devices (lancet or needle).

Effectiveness of Sucrose Used Routinely for Pain Relief and Neonatal Clinical Risk in Preterm Infants: A Nonrandomized Study

BACKGROUND

Preterm infants (PI) requiring the neonatal intensive care unit are exposed to early repetitive pain/distress. Little is known about how pain relief strategies interact with infants' clinical health status, such as severity of illness with pain responses. This study aimed to examine main and interactive effects of routine sucrose intervention and neonatal clinical risk (NCR) on biobehavioral pain reactivity-recovery in PI during painful blood collection procedures.

METHODS

Very low birth weight PI (<1500 g; n=104) were assigned to low and high clinical risk groups, according to the Clinical Risk Index for Babies. Sucrose group (n=52) received sucrose solution (25%; 0.5 mL/kg) 2 minutes before the procedures and control group received standard care. Biobehavioral pain reactivity-recovery was assessed according to the Neonatal Facial Coding System, sleep-wake state scale, crying time, and heart rate at 5 phases (baseline, antisepsis, puncture (P), recovery-dressing, and recovery-resting [R]). Repeated measure ANOVA with mixed-design was performed considering pain assessment phases, intervention group, and NCR.

RESULTS

Independent of NCR, sucrose presented main effect in decreasing neonates' facial activity pain responses and crying time, during P and R. Independent of NCR level or routine sucrose intervention, all neonates displayed activated state in P and decreased biobehavioral responses in R phase. Although no sucrose or NCR effects were observed on physiological reactivity, all neonates exhibited physiological recovery 10 minutes after P, reaching the same heart rate patterns as the baseline.

CONCLUSIONS

Independent of NCR level, sucrose intervention for pain relief during acute painful procedures was effective to reduce pain intensity and increase biobehavioral regulation.

Nociception and the neonatal brain

Measuring brain activity in infants provides an objective surrogate approach with which to infer pain perception following noxious events. Here we discuss different approaches which can be used to measure noxious-evoked brain activity, and discuss how these measures can be used to assess the analgesic efficacy of pharmacological and non-pharmacological interventions. We review factors that can modulate noxious-evoked brain activity, which may impact infant pain experience, including gestational age, sex, prior pain, stress, and illness.

Repeated touch and needle-prick stimulation in the neonatal period increases the baseline mechanical sensitivity and postinjury hypersensitivity of adult spinal sensory neurons

Neonatal abnormal noxious and tactile stimulations facilitate the activity of spinal neurons, which leads to an altered somatosensory and pain phenotype in adulthood.

Noxious stimulation at critical stages of development has long-term consequences on somatosensory processing in later life, but it is not known whether this developmental plasticity is restricted to nociceptive pathways. Here, we investigate the effect of repeated neonatal noxious or innocuous hind paw stimulation on adult spinal dorsal horn cutaneous mechanical sensitivity. Neonatal Sprague-Dawley rats of both sexes received 4 unilateral left hind paw needle pricks (NPs, n = 13) or 4 tactile (cotton swab touch) stimuli, per day (TC, n = 11) for the first 7 days of life. Control pups were left undisturbed (n = 17). When adult (6-8 weeks), lumbar wide-dynamic-range neuron activity in laminae III-V was recorded using in vivo extracellular single-unit electrophysiology. Spike activity evoked by cutaneous dynamic tactile (brush), pinch and punctate (von Frey hair) stimulation, and plantar receptive field areas were recorded, at baseline and 2 and 5 days after left plantar hind paw incision. Baseline brush receptive fields, von Frey hair, and pinch sensitivity were significantly enhanced in adult NP and TC animals compared with undisturbed controls, although effects were greatest in NP rats. After incision, injury sensitivity of adult wide-dynamic-range neurons to both noxious and dynamic tactile hypersensitivity was significantly greater in NP animals compared with TC and undisturbed controls. We conclude that both repeated touch and needle-prick stimulation in the neonatal period can alter adult spinal sensory neuron sensitivity to both innocuous and noxious mechanical stimulation. Thus, spinal sensory circuits underlying touch and pain processing are shaped by a range of early-life somatosensory experiences.

Non-pharmacological management of neonatal pain: Research and clinical practice in the Neonatal Intensive Care Unit

Abstract According to the World Health Organization and the International Association for the Study of Pain, pain is a relevant worldwide problem in the healthcare field. The present study aimed to describe the definition of pediatric pain and the main characteristics, and to examine the findings regarding the impact of pain on the development of the child. The best clinical practices in Neonatal Intensive Care Units should include developmental care and specifically implement pain management, aiming to protect the health and development of the infants. The efficacious non-pharmacological management of neonatal pain includes breastfeeding, skin-to-skin, non-nutritive sucking, facilitated-tucking and swaddling. Sweet solutions also have pain relief effects. Psychologists could actively participate in the implementation of non-pharmacological interventions and in the whole process to sensitize and train the professional teams, to alert parents to protection against pain and to support policymakers in the implementation of pain guidelines in the hospital.

Temperament and behavior in toddlers born preterm with related clinical problems

OBJECTIVE

The aim of this study was to compare temperament and behavior profiles among groups of preterm toddlers differentiated by level of prematurity and the presence of bronchopulmonary dysplasia (BPD) or retinopathy of prematurity (ROP), controlling for neonatal clinical conditions and chronological age.

METHOD

The sample comprised 100 preterm toddlers segregated according to level of prematurity (75 very preterm and 25 moderate/late preterm) and presence of BPD (n=36) and ROP (n=63). Temperament was assessed by the Early Childhood Behavior Questionnaire and behavior by the Child Behavior Checklist. The MANOVA was performed with a post-hoc univariate test.

RESULTS

The level of prematurity and the presence of BPD and ROP did not affect temperament and behavioral problems in toddlers born preterm. However, the covariates age and length of stay in NICU (Neonatal Intensive Care Unit) affected temperament and behavioral problems, respectively. The older toddlers showed higher inhibitory control and lower activity levels than younger toddlers (range of 18-36months-old). Additionally, toddlers who stayed in the NICU longer showed more pervasive development and emotionally reactive problems than toddlers who stayed in NICU for less time.

CONCLUSION

The level of prematurity and the presence of bronchopulmonary dysplasia and retinopathy of prematurity did not affect temperament and behavioral problems in toddlers born preterm. However, a longer stay in the NICU increased the risk for behavioral problems, and age enhanced the regulation of temperament at toddlerhood.

Non-pharmacological measures in preterm newborns submitted to arterial puncture

OBJECTIVE

to assess pain in preterm newborns and to compare the neonatal and therapeutic variables with the total scores of the Neonatal Facial Coding System of preterm newborns submitted to arterial puncture exposed to music and 25% oral glucose.

METHOD

a comparative study with 48 recordings of preterm newborns - Group 1, music (26); Group 2, glucose 25% (22) - individually analyzed by three trained nurses, after Kappa of at least 80%.

RESULTS

the variables and the pain scores of the groups did not present statistical significance (p < 0.05) according to the Neonatal Facial Coding System. 80.8% of the preterm infants in Group 1 had a higher quantitative score ≥ 3 in the neonatal variables (gender, type of delivery), and therapeutic variables (type of oxygen therapy, place of hospitalization, type of puncture).

CONCLUSION

There was no difference when comparing the music and glucose 25% groups and the variables studied.

Neurobehavioral development prior to term-age of preterm infants and acute stressful events during neonatal hospitalization

BACKGROUND

Neonatal Intensive Care Units (NICUs) protect preterm infants; otherwise, this is a stressful environment including painful stimuli.

AIMS

To compare early neurobehavioral development prior to term-age in preterm infants at 34-36weeks of post-conceptional age in different gestational ages, and to examine the effects of prematurity level and acute stressful events during NICU hospitalization on neurobehavioral development.

STUDY DESIGN

Cross-sectional design.

SUBJECTS

Forth-five preterm infants, 34-36weeks of post-conceptional age, were distributed into groups: extreme preterm (EPT; 23-28weeks of gestational age; n=10), moderate preterm (MPT; 29-32weeks of gestational age; n=10), late preterm (LPT; 34-36weeks of gestational age; n=25).

OUTCOME MEASURES

All of the neonates were evaluated using the Neurobehavioral Assessment of Preterm Infant (NAPI) prior to 37weeks of post-conceptional age. The Neonatal Infant Stressor Scale (NISS) was applied for EPT and MPT infants during NICU hospitalization, and medical charts were analyzed.

RESULTS

The EPT group experienced significantly more acute stressful events during NICU hospitalization than the MPT group. The MPT group had lower scores in motor development and vigor than the EPT and LPT group, and they exhibited poorer quality crying than the LPT group. Motor development and vigor and alertness and orientation in preterm infants were predicted by prematurity level and acute stressful events.

CONCLUSION

The extreme preterm was exposed to higher stressful experiences than moderate and late preterm infants. However, the moderate preterm infants presented more vulnerable than the other counterparts in motor and vigor outcomes.

Neonatal pain and developmental outcomes in children born preterm: a systematic review

BACKGROUND

Neonates cared for in neonatal intensive care units are exposed to many painful and stressful procedures that, cumulatively, could impact later neurodevelopmental outcomes. However, a systematic analysis of these effects is yet to be reported.

OBJECTIVES

The aim of this research was to review empirical studies examining the association between early neonatal pain experiences of preterm infants and the subsequent developmental outcomes of these children across different ages.

METHODS

The literature search was performed using the PubMed, PsycINFO, Lilacs, and SciELO databases and included the following key words: "pain," "preterm," and "development." In addition, a complementary search was performed in online journals that published pain and developmental studies to ensure all of the target studies had been found. The data were extracted according to predefined inclusion and exclusion criteria.

RESULTS

Thirteen studies were analyzed. In infants born extremely preterm (gestational age ≤29 wk) greater numbers of painful procedures were associated with delayed postnatal growth, with poor early neurodevelopment, high cortical activation, and with altered brain development. In toddlers born very preterm (gestational age ≤32 wk) biobehavioral pain reactivity-recovery scores were associated with negative affectivity temperament. Furthermore, greater numbers of neonatal painful experiences were associated with a poor quality of cognitive and motor development at 1 year of age and changes in cortical rhythmicity and cortical thickness in children at 7 years of age.

CONCLUSIONS

For infants born preterm, neonatal pain-related stress was associated with alterations in both early and in later developmental outcomes. Few longitudinal studies examined the impact of neonatal pain in the long-term development of children born preterm.

Alterações nos parâmetros fisiológicos dos recém-nascidos sob oxigenoterapia na coleta de gasometria

Objetivo: Identificar as alterações que ocorrem nos parâmetros fisiológicos dos recém-nascidos sob oxigenoterapia na coleta de gasometria arterial, comparando os momentos imediatamente antes, imediatamente depois, e cinco minutos depois do procedimento. Métodos: Estudo longitudinal, do tipo antes e depois,. Amostra composta por 67 recém-nascidos sob oxigenoterapia que receberam punção arterial para gasometria. Resultados: O grupo de recém-nascidos em Oxi-Hood sofreu alterações significativas (p<0,05) na frequência cardíaca, pulso e saturação de oxigênio. Os recém-nascidos em ventilação mecânica obtiveram alterações de frequência respiratória e pulso e aqueles sob CPAP nasal não mostraram instabilidade dos parâmetros fisiológicos. Conclusão: O estímulo doloroso causado pela coleta de gasometria nos recém-nascidos mostrou variações de todos os parâmetros fisiológicos, porém, para tal procedimento, as alterações foram diferentes em cada modalidade de oxigenoterapia.

Temperament and behavior problems in toddlers born preterm and very low birth weight

The purpose of the present study was to examine the temperament and behavior problems of 32 toddlers born preterm and very low birth weight and 25 toddlers born full-term without medical problems. Mothers completed the Early Childhood Behavior Questionnaire and the Child Behavior Checklist-1.5-5 for assessing toddler`s temperament and behavior problems, respectively. The results showed that, regarding temperament, toddlers born preterm exhibited higher scores on the temperament dimensions Motor Activation, Perceptual Sensitivity, and High Intensity Pleasure, and lower scores on the temperament dimension Cuddliness than toddlers born full-term. In regard to behavior problems, toddlers born preterm showed higher attention problems scores than the comparison group. These findings indicated that children born preterm presented developmental vulnerabilities in temperament dimensions related to behavior problems at toddlerhood. Early intervention programs for preventing psychological problems in at-risk children, especially those born preterm, could focus on children's temperament dispositions.

Examining the side effects of sucrose for pain relief in preterm infants: a case-control study

Sucrose solution is recommended as relevant pain relief management in neonates during acute painful procedures; however, only a few studies have analyzed the potentially adverse effects of sucrose administration to preterm neonates. The goal of this study was to examine the potential side effects of sucrose for pain relief in preterm infants, assessing feeding and weight gain during hospitalization and their feeding patterns postdischarge. The study sample consisted of 43 preterm neonates divided into two groups: a sucrose group (SG, n=18) and a control group (CG, n=25) in which no sucrose was administered. The SG received 0.5 mL/kg 25% oral sucrose for 2 min prior to all acute painful procedures during three consecutive days. A prospective review of medical charts was performed for all samples. The study was done prior to implementation of the institutional sucrose guidelines as a routine service, and followed all ethical requirements. There were no statistically significant differences between groups in terms of weight gain, length of stay with orogastric tubes, and parenteral feeding. Postdischarge, infant nutritional intake included feeding human milk to 67% of the SG and 74% of the CG. There were no statistically significant differences between groups regarding human milk feeding patterns postdischarge. Neonate feeding patterns and weight gain were unaffected following the short-term use of sucrose for pain relief.

Validation of the Premature Infant Pain Profile-Revised (PIPP-R)

OBJECTIVES

To examine the construct validity, inter-rater reliability, and feasibility of the Premature Infant Pain Profile-Revised in infants of varying gestational ages, diagnoses, and procedures.

METHODS

A prospective cross-over study with infants in three gestational age groups (26-31, 32-36, and ≥37 weeks) at three university-affiliated Neonatal Intensive Care Units in Canada. One hundred and ninety five bedside nurses and expert raters rated 202 hospitalized infants' pain during scheduled procedures using the measure. An expert rater and a nurse independently assessed infants' pain scores, using the Premature Infant Pain Profile-Revised, during 246 scheduled pairs of painful and non-painful procedures in the 202 infants. Nurses also completed a feasibility survey on using the measure in a clinical setting. To establish construct validity, pain scores were computed during painful and non-painful procedures. Inter-rater reliability between pain experts and nurses was calculated. A 5-point Likert scale was used to measure feasibility in terms of clarity, ease of use, and time to complete.

RESULTS

Irrespective of gestational age, Premature Infant Pain Profile-Revised scores were significantly higher during painful procedures (mean 6.7 [SD 3.0]) compared to non-painful procedures (mean 4.8 [SD 2.9]). There was a high degree of correlation between nurses' and experts' ratings for painful (all R(2)=0.92, p<0.001) and non-painful (all R(2)=0.87, p<0.001) procedures. Mean scores on all feasibility indicators were equal to or higher than 3.8.

DISCUSSION

The Premature Infant Pain Profile Revised has beginning construct validation, inter-rater reliability, and is considered feasible by clinicians. Concurrent validation studies should be considered.

Postnatal temporal, spatial and modality tuning of nociceptive cutaneous flexion reflexes in human infants

Cutaneous flexion reflexes are amongst the first behavioural responses to develop and are essential for the protection and survival of the newborn organism. Despite this, there has been no detailed, quantitative study of their maturation in human neonates. Here we use surface electromyographic (EMG) recording of biceps femoris activity in preterm (<37 weeks gestation, GA) and term (≥ 37 weeks GA) human infants, less than 14 days old, in response to tactile, punctate and clinically required skin-breaking lance stimulation of the heel. We show that all infants display a robust and long duration flexion reflex (>4 seconds) to a single noxious skin lance which decreases significantly with gestational age. This reflex is not restricted to the stimulated limb: heel lance evokes equal ipsilateral and contralateral reflexes in preterm and term infants. We further show that infant flexion withdrawal reflexes are not always nociceptive specific: in 29% of preterm infants, tactile stimulation evokes EMG activity that is indistinguishable from noxious stimulation. In 40% of term infants, tactile responses are also present but significantly smaller than nociceptive reflexes. Infant flexion reflexes are also evoked by application of calibrated punctate von Frey hairs (vFh), 0.8-17.2 g, to the heel. Von Frey hair thresholds increase significantly with gestational age and the magnitude of vFh evoked reflexes are significantly greater in preterm than term infants. Furthermore flexion reflexes in both groups are sensitized by repeated vFh stimulation. Thus human infant flexion reflexes differ in temporal, modality and spatial characteristics from those in adults. Reflex magnitude and tactile sensitivity decreases and nociceptive specificity and spatial organisation increases with gestational age. Strong, relatively non-specific, reflex sensitivity in early life may be important for driving postnatal activity dependent maturation of targeted spinal cord sensory circuits.

The effect of a familiar scent on the behavioral and physiological pain responses in neonates

There are adverse physiologic effects of pain in neonates, and effective pain management must be an essential aspect of neonatal care. In this study we assessed the effect of a nonmaternal familiar scent on the neonatal pain responses. This study included 135 neonates randomly assigned to one of three groups. During arterial puncture, one group was exposed to a vanillin scent on a gauze pad held next to their nose. They were familiarized with it the night before blood sampling by a scented gauze pad placed in the incubator next to their head for an average duration of 8.65 hours. The second group was not familiarized with the scent but was exposed to it during the procedure. The third group was neither familiarized nor exposed to the scent. The duration of crying in the familiar scent group was significantly lower than in the two other groups. Comparison of the physiologic parameters showed less variation in oxygen saturation level during arterial puncture in the familiar scent group. In this study, a familiar scent could reduce crying and oxygen consumption during arterial puncture.

Sevoflurane for central catheter placement in neonatal intensive care: a randomized trial

OBJECTIVE

To compare the efficacy and safety of sevoflurane deep sedation with glucose and nonnutritive sucking (GNNS) in reducing the duration of the procedure and in preventing pain-related effects during peripherally inserted central catheter (PICC) placement.

BACKGROUND

PICC placement in neonatal intensive care is a delicate and stressful procedure that requires pain prevention. GNNS has been recommended in this situation but remain often inefficient.

METHODS

We designed a randomized controlled study in a sixteen-bed pediatric and neonatal unit in a tertiary hospital. Fifty-nine neonates at >28 weeks of gestation with continuous positive airway pressure or invasive mechanical ventilation and requiring PICC placement were included. Patients were randomized to receive inhaled sevoflurane (IS) or glucose and non-nutritive sucking (GNNS). Procedural duration and conditions, hemodynamic and respiratory parameters, occurrence of movements and complications were compared (http://clinicaltrials.gov trial register no. NCT00420693).

RESULTS

The two groups had similar demographics. There were no between-group differences in procedural duration (P = 0.84) despite greater immobility in IS group (P = 0.017). IS was also associated with fewer episodes of hypertension (P = 0.003), tachycardia (P < 0.001), and bradycardia (P = 0.02). Occurrences of hypotension were not different between the groups (P = 0.06). The GNNS group showed more desaturation during the 4 h after the procedure (P = 0.03). Complications during intensive care stay did not differ between groups.

CONCLUSION

Inhaled sevoflurane does not make easier catheters placement but prevent pain-related symptoms. Because sevoflurane is responsible for hypotension, it requires careful monitoring and treatment adaptation.

Pain and distress reactivity and recovery as early predictors of temperament in toddlers born preterm

BACKGROUND

Pain reactivity may reflect underlying mechanisms of constitutional aspects of temperament.

AIM

To examine whether the neonatal biobehavioral reactivity and recovery responses from pain and distress, as well as the gestational age, the illness severity and the amount of painful procedures undergone the Neonatal Intensive Care Unit (NICU) stay, predict temperament later in toddlerhood, in vulnerable children born preterm.

STUDY DESIGN

Prospective-longitudinal study.

SUBJECTS

Twenty-six preterm and very low birth weight infants followed from birth to toddlerhood.

OUTCOME MEASURES

Illness severity was assessed with the Clinical Risk Index for Babies (CRIB) score. The medical charts were reviewed prospectively for obtaining the amount of pain exposure in NICU. For assessing the behavioral and cardiac reactivity and recovery from pain and distress, the neonates were evaluated during routine blood collection in the NICU in the first 10 days of life. Pain and distress reactivity and recovery was measured using the Neonatal Facial Coding System score, the duration of crying, and the magnitude of average heart rate. At toddlerhood, mothers answered the Early Childhood Behavior Questionnaire.

RESULTS

Higher biobehavioral reactivity to pain and distress predicted higher temperamental Negative Affect, above and beyond gestational age, illness severity and amount of pain exposure in NICU. However, we did not find a predictive relation between gestational age, CRIB score and number of painful procedures undergone NICU and toddler's temperament.

CONCLUSIONS

The findings highlight the relevance of the neonatal individual characteristics of reactivity for identifying more vulnerable infants for future problems in biobehavioral regulation.