A Systematic Review of Behavioral and Environmental Interventions for Procedural Pain Management in Preterm Infants

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.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project

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.

The effectiveness of the therapeutic toys on the comfort level and vital signs of the neonates during intravenous cannula insertion (Comfiestudy): A randomized controlled trial

PURPOSE

This study was planned to determine the effect of the therapeutic toy used during IV cannula insertion on the comfort level, crying time and vital signs of neonates.

METHODS

The sample (n = 38) was randomized to the Control and the Comfie Groups. Vital signs were measured before, during, and after the IV cannula insertion. Comfort levels and the duration of crying were measured during the insertion.

RESULTS

Neonates in the Comfie Group had lower pulse and higher saturation levels during the insertion, and they had lower respiration rates and pulse but higher oxygen saturation levels at the post 1st-5th minute. They were more comfortable than the neonates in the control group.

DISCUSSION

The result of this research reveals that therapeutic toys applied during the IV cannula insertion in neonates increase the comfort level and stabilize the vital signs.

APPLICATION TO PRACTICE

The use of toys during IV cannula insertion could be an effective nonpharmacological method to improve outcomes.

The effect of maternal voice and non-nutritional sucking on repeated procedural pain of heel prick in neonates: a quasi-experimental study

BACKGROUND

Neonates in the neonatal intensive care unit undergo frequent painful procedures. It is essential to reduce pain using safe and feasible methods.

PURPOSE

To evaluate the effects of non-nutritional sucking, mother's voice, or non-nutritional sucking combined with mother's voice on repeated procedural pain in hospitalized neonates.

METHODS

A quasi-experimental study was conducted in which 141 neonates were selected in a hospital in Changsha, China. Newborns were divided into four groups: non-nutritional sucking (NNS) (n = 35), maternal voice (MV) (n = 35), NNS + MV (n = 34), and control (n = 37) groups. The Preterm Infant Pain Profile-Revised Scale (PIPP-R) was used to assess pain.

RESULTS

During the heel prick, the heart rate value and blood oxygen saturation were significantly different between the groups (P < 0.05). Both non-nutritional sucking and maternal voice significantly reduced PIPP-R pain scores of hospitalized newborns (P < 0.05). The pain-relief effect was more robust in the combined group than in other groups.

CONCLUSIONS

This study showed that both non-nutritional sucking and the mother's voice alleviated repeated procedural pain in neonates. Therefore, these interventions can be used as alternatives to reduce repeated procedural pain.

Intertemporal Improvement in Physicians' Perceptions of the Short-Term Adverse Outcomes of Neonatal Pain: Results of a Two-Time-Point National Survey

Pain in early life may seriously impact neonatal outcomes. This study aimed to evaluate whether the perceptions of physicians working in neonatal intensive care units (NICUs) of the short-term adverse outcomes associated with neonatal pain have changed over a 20-year period. Self-administered questionnaires were distributed to 117 and 145 neonatologists, pediatricians, and fellows working in level III NICUs in 2000 (T1) and 2019 (T2), respectively. The questionnaire consisted of four domains, including the central nervous, cardiovascular, and respiratory systems, as well as "other systems" (metabolic/endocrine system, growth, and general condition), with 21 total items overall. Although the proportion of positive (correct) responses to the total and system-specific domain scores was significantly higher at T2 than T1, the knowledge of certain short-term adverse outcomes was suboptimal even at T2. Adjustment for cofactors confirmed the independent association of the survey time-point with the total and system-specific domain scores. Moreover, NICU type was an independent significant factor associated with the adjusted total and central nervous system scores, while young doctors had a better knowledge of adverse cardiovascular effects. Conclusions: The perceptions of NICU physicians concerning the short-term outcomes associated with neonatal pain have significantly improved over the past 20 years, although remaining knowledge gaps mandate ongoing efforts to achieve an improvement in neonatal care.

The challenges of nursing care for patients with lumbar discectomy: A qualitative study

AIM

Patients with lumbar disc surgery experience many different problems during their hospital stay. Nurses also face different challenges in providing care to them. Nonetheless, no study has yet specifically addressed these challenges to the best of our knowledge. This study aimed at exploring the challenges of nursing care for patients with lumbar discectomy.

DESIGN

This qualitative study was conducted in 2022 using content analysis.

METHODS

Eight nurses, three patients with lumbar discectomy, and one physician were purposively selected from the neurosurgery wards of the hospitals affiliated to Golestan University of Medical Sciences, Gorgan, Iran. Semi-structured interviews were conducted for data analysis and the content analysis method recommended by Elo and Kyngas was used for data analysis. The main phases of this method are open coding, grouping, categorization, and abstraction. The MAXQDA 10 software was employed to facilitate data management. Data collection continued to reach data saturation.

RESULTS

The challenges of nursing care for patients with lumbar discectomy were categorized into eleven subcategories and three main categories, namely dominant routine-based practice in the healthcare system, futile attempt for team-based care, and shortages as a major barrier to quality care. There are different personal, professional, financial, structural, and organizational challenges in nursing care for patients with lumbar discectomy which can negatively affect postoperative patient recovery.

The effect of music on pain management in preterm infants during daily painful procedures: a systematic review and meta-analysis

Background

The present systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to investigate the effects of music on pain management in preterm neonates during painful procedures.

Methods

The PubMed, Embase, Web of Science, EBSCO and Cochrane Library databases were searched to identify relevant articles published from their inception to September 2023. The study search strategy and all other processes were implemented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

Four RCTs that satisfied the inclusion criteria were included in this meta-analysis. The music group had significantly lower Premature Infant Pain Profile (PIPP) scores during (RR = -1.21; 95% CI = -2.02--0.40, p = 0.0032) and after painful procedures (RR = -0.65; 95% CI = -1.06--0.23, p = 0.002). The music group showed fewer changes in PIPP scores after invasive operations than did the control group (RR = -2.06; 95% CI -3.16--0.96; p = 0.0002). Moreover, our results showed that music improved oxygen saturation during (RR = 3.04, 95% CI = 1.64-4.44, p < 0.0001) and after painful procedures (RR = 3.50, 95% CI = 2.11-4.90, p < 0.00001). However, the change in peak heart rate during and after painful procedures was not statistically significant (RR = -12.14; 95% CI = -29.70-5.41 p = 0.18; RR = -10.41; 95% CI = -22.72-1.90 p = 0.10).

Conclusion

In conclusion, this systematic review demonstrated that music interventions are effective for relieving procedural pain in preterm infants. Our results indicate that music can reduce stress levels and improve blood oxygen saturation. Due to the current limitations, large-scale, prospective RCTs should be performed to validate the present results.

Exploring the Knowledge Structures of Korean and International Nursing Research on Premature Infants Using Text Network Analysis

This study aimed to identify the knowledge structures of Korean and international nursing studies on premature infants using text network analysis, which represents a text as a network graph that describes how keywords are linked. This network graph refers to a knowledge structure. International and Korean journal databases were searched to extract nursing studies regarding premature infants published in academic journals from 1998 to 2020. Abstracts from the selected studies were analyzed using the following four steps: word extraction and refinement, keyword extraction, co-occurrence matrix generation, and text network visualization. The results demonstrated that 182 Korean and 2502 international studies were published. The common keywords of Korean and international studies were "kangaroo mother care," "stress," and "child." The keywords of the international studies had more branches linking to other keywords than those of the Korean studies. Thus, the knowledge structure of international studies included diverse concepts. These findings will serve as important guidance for future research worldwide. Furthermore, studies to develop a more comprehensive knowledge structure of international research on premature infants are needed. The knowledge structure of Korean studies mainly included concepts related to mothers. Korean studies regarding hospitalized premature infants and communication with parents need to be conducted.

Effect of non-pharmacological interventions on pain in preterm infants in the neonatal intensive care unit: a network meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of different non-pharmacological interventions for pain management in preterm infants and provide high-quality clinical evidence.

METHODS

Randomized controlled trials (RCTs) of various non-pharmacological interventions for pain management in preterm infants were searched from PubMed, Web of Science, Embase, and the Cochrane Library from 2000 to the present (updated March 2023). The primary outcome was pain score reported as standardized mean difference (SMD). The secondary outcomes were oxygen saturation and heart rate reported as the same form.

RESULTS

Thirty five RCTs of 2134 preterm infants were included in the meta-analysis, involving 6 interventions: olfactory stimulation, combined oral sucrose and non-nutritive sucking (OS + NNS), facilitated tucking, auditory intervention, tactile relief, and mixed intervention. Based on moderate-quality evidence, OS + NNS (OR: 3.92, 95% CI: 1.72, 6.15, SUCRA score: 0.73), facilitated tucking (OR: 2.51, 95% CI: 1.15, 3.90, SUCRA score: 0.29), auditory intervention (OR: 2.48, 95% CI: 0.91, 4.10, SUCRA score: 0.27), olfactory stimulation (OR: 1.80, 95% CI: 0.51, 3.14, SUCRA score: 0.25), and mixed intervention (OR: 2.26, 95% CI: 0.10, 4.38, SUCRA score: 0.14) were all superior to the control group for pain relief. For oxygen saturation, facilitated tucking (OR: 1.94, 95% CI: 0.66, 3.35, SUCRA score: 0.64) and auditory intervention (OR: 1.04, 95% CI: 0.22, 2.04, SUCRA score: 0.36) were superior to the control. For heart rate, none of the comparisons between the various interventions were statistically significant.

CONCLUSION

This study showed that there are notable variations in the effectiveness of different non-pharmacological interventions in terms of pain scores and oxygen saturation. However, there was no evidence of any improvement in heart rate.

Effects of white noise on preterm infants in the neonatal intensive care unit: A meta-analysis of randomised controlled trials

AIM

To critically assess the effects of white noise on the pain level, weight gain and vital signs (heart rate, respiratory rate and oxygen saturation) of preterm infants in neonatal intensive care units (NICUs).

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

Ten databases (PubMed, Cochrane Library, Embase, Web of Science, CINAHL, PsycINFO, SinoMed, China National Knowledge Infrastructure, VIP and Wanfang Data) were systematically reviewed from inception to July 2022. Two reviewers evaluated the risk of bias separately using the Cochrane Collaboration criteria and extracted data using a predesigned information form.

RESULTS

The meta-analysis included eight eligible RCTs. According to statistical analysis, white noise significantly affected the pain level, weight gain, heart rate, respiratory rate and oxygen saturation in preterm infants. Regardless of the outcome measurement timing, gestational age and birth weight of preterm infants, subgroup analysis demonstrated that white noise reduced the pain level, heart rate and respiratory rate and promoted weight gain in preterm infants in NICUs.

CONCLUSION

White noise is a practical and potentially useful therapy for premature neonates in NICUs. No Patient or Public Contribution.

Development of educational videos about bathing in bed newborns admitted to a neonatal unit

OBJECTIVE

to develop and analyze evidence of content validity of educational videos about bathing newborns in bed in a neonatal unit.

METHOD

applied and methodological research, carried out from December/2020 to February/2022, in three phases: pre-production, production, post-production. Validity was carried out by nurses specializing in social communication and nursing professionals, including the Brazilian Sign Language and assessment by nursing students. The Content Validity Index and Cronbach's alpha above 0.8 were considered for analysis.

RESULTS

the videos were entitled "Best practices: bathing newborns in the heated crib" and "Best practices: bathing newborns in the incubator", lasting seven minutes each, divided into six scenes that demonstrated the approach to parents, environment and material organization, preparing newborns, bathing and after-bath care.

CONCLUSION

the videos will support permanent education processes, academic training and professional training in nursing.

Physiological responses and behavioural organization of very low birth weight infants during swaddled versus traditional weighing

AIM

Despite the consequences of neonatal distress and agitation, preterm infants undergo stress owing to weighing procedures. The objective of this study was to enable very low birth weight infants to maintain adequate self-regulation during weighing.

DESIGN

This prospective crossover study utilizes a within-subjects design, where intervention days were compared to control days.

METHOD

Infants were exposed to both swaddled and unswaddled weighing in an intensive care nursery setting. Nineteen very low birth weight infants were weighed on two consecutive days. Variables of heart rate, respiratory rate and ALPS-Neo score were recorded.

RESULTS

Stress score decreased significantly from 1.65 (pre-weight) to 0.23 (weight measurement) in swaddled-intervention periods; conversely, it increased significantly from 1.26 (pre-weight) to 4.97 (weight measurement) in control periods. During weight measurement, heart and respiratory rate were significantly lower for swaddled-intervention days when compared to control days. Given the significant impact of swaddled weighing in reducing stress, this method can be used as an appropriate weighing procedure in intensive care. This research has no patient or public contribution.

Validity and Reliability of Pain and Behavioral Scales for Preterm Infants: A Systematic Review

OBJECTIVE

To systematically review the instruments used to assess behavior, stress, and/or pain in preterm newborns in the neonatal intensive care unit (NICU) and verify the validity and reliability of these instruments.

DATA SOURCES

Electronic searches were conducted in PubMed/MEDLINE, Cochrane Library, Web of Science, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature on Health Sciences (LILACS), and EBSCOhost Research Platform. 12,295 records were found.

REVIEW/ANALYSIS METHODS

37 studies met the inclusion and exclusion criteria.  The COnsensus-based Standards for selecting health Measurement INstruments (COSMIN) checklist was used to assess the quality assessment and measurement properties.

RESULTS

We identified 25 scales that assessed behavior, pain, and/or stress in preterm newborns. The Behavioral Indicators of Infant Pain (BIPP), Crying, Requires Oxygen, Increased Vital Signs, Expression, Sleeplessness (CRIES), Premature Infant Pain Profile (PIPP), and Premature Infant Pain Profile-Revised (PIPP-R) had scored "very good" in quality data. The PIPP and PIPP-R scales received the "very good" classification in validity assessment. The Evaluation Enfant Douleur (EVENDOL), Children's and Infants Postoperative Pain Scale (CHIPPS), PIPP-R, Neonatal Pain Agitation and Sedation Scale (N-PASS), Bernese Pain Scale for Neonates (BPSN), Faceless Acute Neonatal Pain Scale (FANS), BIIP, and Pain Assessment Scale for Preterm Infants (PASPI) obtained an assessment classified as excellent on reliability, both for inter-rater reliability and internal consistency, and the BPSN demonstrated a very strong value to intra-rater reliability.

CONCLUSIONS

Considering the assessments of inter-rater reliability, internal consistency, and quality of scales by COSMIN, the BIPP, and PIPP-R, were the scales considered appropriate.

[Evidence-based guideline for neonatal pain management in China (2023)]

Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.

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.

Improving Consistency in the Use of Sucrose With Comfort Measures During Minor Painful Procedures

BACKGROUND

Inconsistent pain management practices can have negative physiologic and neurodevelopmental consequences in the neonate. Low rates of oral sucrose use with comfort measures for pain management during minor painful procedures were identified at a level III neonatal intensive care unit. Underutilization of pain management resources occurs despite the availability of evidence-based pain management interventions.

PURPOSE

To improve consistency in the use of oral sucrose solution with comfort measures during peripheral intravenous catheter insertion attempts in the neonatal intensive care unit in patients greater than or equal to 32 0/7th weeks postmenstrual age.

METHODS

Quality improvement methods were used to implement an evidence-based procedural pain algorithm for minor painful procedures and optimize pain management processes over a 15-week period in a 26-bed, level III neonatal intensive care unit.

RESULTS

There was an increase in the average percentage of documented use of sucrose with comfort measures during peripheral intravenous catheter insertion attempts from 20% to 27%. There was a 41% increase in the average presence of a sucrose order indicated for procedural pain. There were improvements in staff knowledge of sucrose dosing and perceived behavior of staff after completing the education.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Procedural pain management should be used as a quality indicator and guidelines should be established with the support of key stakeholders in neonatal intensive care settings. Future projects should address barriers related to workflow and accessibility of sucrose, include other common needlestick procedures, and expand the role of parent participation in pain management practices.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/pages/video.aspx?v=60 .

Touch Experiences of Preterm Infants During Essential Nursing Care

Purpose: To characterize and quantify touch experienced by preterm infants in the NICU during essential nursing care, identify instances of skin-to-skin touch between infants and caregivers, and identify clinical/demographic variables associated with touch experiences. Design: Cross-sectional study. Sample: Preterm infants (N = 20) born 27-32 weeks post-menstrual age. Main Outcome Variable: Categories of touch during observations. Results: Touch experienced by infants during day and night shifts was primarily direct touch that was further categorized as general handling. During day shifts, 30 percent of direct touch was provided for comfort, but only 9.7 percent of touch was provided exclusively for comfort (i.e., without more intrusive touch). During night shifts, 10.6 percent of direct touch was provided for comfort, and 3 percent was categorized as exclusive comforting touch. Caregivers wore gloves for >89 percent of infant touch. Only the level of respiratory support was associated with touch categories during both shifts.

Quantification of stress exposure in very preterm infants: Development of the NeO-stress score

BACKGROUND

Stress during treatment at the Neonatal Intensive Care Unit (NICU) has long-term negative consequences on preterm infants' development.

AIMS

We developed an instrument suited to validly determine the cumulative stress exposure for preterm infants in a NICU.

STUDY DESIGN

This survey study made use of two consecutive questionnaires.

SUBJECTS

NICU nurses and physicians from the nine NICUs in the Netherlands.

OUTCOME MEASURES

First, respondents rated the relevance of 77 items encompassing potentially stressful procedures, commented on their comprehensibility and the comprehensiveness of the list. We calculated the content validity per item (CVI-I) and included only the relevant items in a second questionnaire in which the participants rated the stressfulness from 0 (not stressful) to 10 (extremely stressful). A stressfulness index - representing the median score - was calculated for each included item.

RESULTS

Based on the CVI-I of the 77 items, step 1 resulted in 38 items considered relevant to quantify stress in preterm infants during the first 28 days of life. This list of 38 items exists of 34 items with a CVI-I if 0.78 or higher, one of these items was split into two items, and three items were added to improve comprehensiveness. The stressfulness index ranged from five to nine.

CONCLUSIONS

The NeO-stress score consists of stressful items including their severity index and was developed to determine cumulative stress exposure of preterm infants. Evaluating the cross-cultural validity, correlating it to behavioural and biological stress responses, and evaluating its ability to predict preterm infants at risk for the negative effects following stress might expand the possibilities for this instrument.

An integrative review of clinician-administered comforting touch interventions and acute stress responses of preterm infants

PROBLEM

Preterm infants experience numerous stressors in the neonatal intensive care unit. Non-pharmacological interventions, including maternal comforting touch, reduce stress responses of preterm infants; however, the effects of clinician-administered comforting touch are unclear. The purpose of this integrative review was to synthesize findings from clinical trials to determine the effect of clinician-administered comforting touch on preterm infants' acute stress responses.

ELIGIBILITY CRITERIA

Eligible clinical trials were published in English between 2001 and October 2021 and reported effects of clinician-administered comforting touch on acute stress responses in preterm infants.

SAMPLE

Thirty clinical trials were included.

RESULTS

Researchers tested the effect of comforting static touch, massage, massage with kinesthetic stimulation, sensorial saturation, and Yakson. There was significant heterogeneity in study design, comparison condition, and context of intervention delivery. Results varied; some studies demonstrated efficacy of comforting touch in reducing acute stress responses and others showed no effect. Generally, comforting touch provided during stressful procedures was associated with lower stress responses compared to standard care and was an effective adjunct to other stress management strategies. However, comforting touch alone was insufficient for managing pain, especially during skin-breaking procedures.

CONCLUSIONS

While comforting touch may be a useful part of stress management plans for preterm infants, additional research is needed to determine when comforting touch is appropriate and effective.

IMPLICATIONS

Comforting touch is beneficial to preterm infants and should be provided for stress management. For highly intrusive or painful procedures, comforting touch can be provided as part of a comprehensive stress management plan.

Effects of kangaroo care on pain relief in premature infants during painful procedures: A meta-analysis

AIM

This study aimed to evaluate effects of kangaroo care on pain relief in premature infants during painful procedures.

DESIGN

A meta-analysis.

METHODS

Eight databases (Cochrane Library, PubMed, Embase, Web of Science, China Biology Medicine [CBM], China Science and Technology Journal Database [CSTJ], China National Knowledge Infrastructure [CNKI], and WanFang Data) were systematically reviewed from inception to November 2021 for randomized controlled and crossover trials.

RESULTS

Thirteen studies, including 2311 infants (kangaroo care: 1153, control: 1158) were analyzed. Kangaroo care had a moderate effect on pain relief during painful procedures in premature infants at a gestational age of 32-36 + 6 weeks but no effect at 28-31 + 6 weeks. Furthermore, 15 or 30 min of kangaroo care had a moderate effect and could markedly relieve pain at the instant of and 30/60 s after, had a small effect at 90 s after, and no effect at 120 s after the procedure.

PRACTICE IMPLICATIONS

Kangaroo care may be an effective nonpharmacologic alternative therapy to relieve procedural pain in premature infants born at a gestational age of 32-36 + 6 weeks.

Efficacy and safety of non-pharmacological interventions for neonatal pain: an overview of systematic reviews

OBJECTIVES

To synthesise current evidence from systematic reviews (SRs) regarding the efficacy and safety of non-pharmacological interventions to prevent and treat pain in newborn infants.

DESIGN

Overview of SRs.

DATA SOURCES

We searched PubMed, Embase, Cochrane Library, Web of Science, CINAHL, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, Chinese Science and Technology Periodical Database (VIP) and Google Scholar to identify all relevant SRs published in the last 5 years.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included SRs that evaluated the efficacy and safety of non-pharmacological interventions for neonatal pain.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data, assessed the methodological quality using a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 and graded the evidence quality with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 29 SRs were included in this overview, of which 28 focused on procedural pain and only 1 focused on postoperative pain. Based on AMSTAR 2, seven reviews were found to be of 'high quality', eight of 'moderate quality', five of 'low quality' and nine of 'critically low quality'. The GRADE results suggested that facilitated tucking, kangaroo care, sweet solutions, familiar odour or combined non-pharmacological interventions, such as a combination of sucrose and non-nutritive sucking, were effective and safe in reducing pain from medical procedures in neonates. However, sucrose alone was less effective than local anaesthesia or a combination of the two during circumcision.

CONCLUSIONS

Facilitated tucking, small volumes of sweet solutions, kangaroo care and familiar odour were recommended. Scientific implementation strategies should be developed to promote the clinical use of these effective non-pharmacological interventions. Meanwhile, further rigorous trials and SRs are needed to identify the best non-pharmacological approaches for pain from common surgery and illnesses in neonates.

PROSPERO REGISTRATION NUMBER

CRD42021292583.

The effect of gentle human touch on pain, comfort and physiological parameters in preterm infants during heel lancing

OBJECTIVE

This research was conducted to evaluate the effects of gentle human touch (GHT) on pain, comfort, and physiologic parameters in preterm infants during heel lancing.

METHOD

This prospective, assessor-blind, randomized controlled study was performed between August 10, 2021 and September 10, 2021 in the Neonatal Intensive Care Units (NICU) of a tertiary hospital in the Central Anatolia Region of Turkey. Fifty preterm infants were randomly appointed to GHT and control groups. The researcher applied GHT to the infants in the GHT group by placing one hand on the infant's head and the other hand on the lower abdomen covering the waist and hips for 15 min. Data were collected with a Questionnaire, Physiological Parameters Observation Form, Newborn Infant Pain Scale (NIPS), The Comfort Scale (COMFORT), and Pulse Oximeter.

RESULTS

The NIPS and COMFORT mean scores of preterm infants in the GHT group were lower during (p < 0.001, p < 0.05, respectively) and after heel lancing (p < 0.05, p < 0.001, respectively). There was no difference between the preterm infants' peak heart rate, respiratory rate, and SPO₂ values in the GHT and control groups during and after heel lancing (p > 0.05). The study found that preterm infants in the GHT group had less crying time during the heel lancing (p < 0.001).

CONCLUSION

It could recommend using in painful procedures because GHT may positively affect preterm infants' pain, comfort, and physiologic parameters. The results of this study will contribute to NICU nurses should include non-pharmacological methods such as GHT to decrease pain of preterm infants in procedural pain.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05001191).

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.

Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments

BACKGROUND

Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale.

PURPOSE

The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit.

METHODS

Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management.

RESULTS

There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores (P< .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.

Pharmacologic Analgesia and Sedation in Neonates

Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.

The Effect of Endotracheal Suctioning Using the Four-handed Care on Physiological Criteria and Behavioral Responses of the Preterm Infants: Randomized Crossover Clinical Trial

Introduction: Endotracheal suctioning is one of the procedures that can cause pain and stress for infants admitted to neonatal intensive care units (NICUs). Pain and stress can be manifested with physiological and behavioral responses. This study is a crossover randomized clinical trial design that aimed to investigate the effect of endotracheal suctioning, using four-handed care on the physiological criteria and behavioral responses of preterm infants. Methods: In this study, 40 infants were randomly divided into two groups of 20, one group was first suctioned by the routine method (two hands) and then with the four-handed method. The other group was first suctioned by the four-handed method and then with the routine one. The ALPS-Neo (Astrid Lindgren Children’s Hospital Pain Scale Neonates) was used to evaluate pain and stress in infants. One camera recorded facial expressions and body movements, and physiological data were recorded from the monitor simultaneously. Results: Repeated measures analysis of variance (ANOVA) showed no statistically significant difference in changes in arterial saturation, heart rate and behavioral response scores between the two methods, but there was a significant difference in the mean heart rate of infants during and two minutes after suctioning in four-handed method using independent t test. Data were analyzed using SPSS version 13. Conclusion: Four-handed suctioning method can prevent an increase in the heart rate during and two minutes after suctioning, but it does not seem to affect behavioral responses and oxygen saturation of the infants. Since one of the symptoms of pain and stress in infants is the change of vital signs, especially the heart rate, we recommend four-handed method for suctioning of endotracheal tube.

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.

Painful procedures and pain management in newborns admitted to an intensive care unit

OBJECTIVE

To characterize painful procedures, analgesic strategies, vital signs, and pain scores in hospitalized newborns.

METHOD

This is a primary, observational, prospective clinical study, developed in a Brazilian public hospital. Demographic data, painful procedures, pain relief measures, vital signs, and pain scores were collected from the clinical records of 90 newborns admitted to the intensive care unit and evaluated between admission and the third day of admission. For statistical analysis, the software Statistic Package for the Social Sciences and the R Software were used.

RESULTS

Newborns underwent 2,732 painful procedures, 540 non-pharmacological and 216 pharmacological strategies. The most frequently performed procedure was the heel prick (20.96%). The most commonly recorded non-pharmacological strategy was dim lighting (28.33%) and continuous fentanyl (48.83%) was the main pharmacological measure adopted. Pain score and vital signs show variability in the period evaluated.

CONCLUSION

Despite the high number of painful procedures, pain assessment records do not reflect procedural pain and the use of analgesic strategies was insufficient.

Gabapentin in Infants: Critical Evaluation of a Novel Sedative/Analgesic Medication

Chronic pain and agitation can complicate the clinical course of critically ill infants. Randomized controlled trials of analgesia and sedation in neonatal intensive care have focused on relatively short durations of exposure. To date, clinicians have few options to treat chronic visceral pain and hyperalgesia. Gabapentin has emerged as a common therapy for a diverse group of pain syndromes and neurologic conditions in adults. In neonates, case reports and series describe the successful treatment of visceral hyperalgesia arising from gastrointestinal insults with or without concomitant neurologic morbidities. Additionally, a case report and series describe the utility of gabapentin for neonatal abstinence syndrome refractory to standard pharmacotherapy. The adverse effect profile of gabapentin, most notably bradycardia and sedation, compares favorably to alternative analgesics and sedatives. However, the long-term impacts of prolonged gabapentin therapy have not been studied. Therefore, candidates for therapy must be selected carefully, and response must be assessed objectively. Future studies must assess the short-term and long-term benefits and risks of gabapentin compared to standard therapies for chronic pain and agitation in infants and refractory neonatal abstinence syndrome.

The impact of Nonpharmacological Interventions on Cortisol During Heel Lance Procedures on Preterm Infants: A Meta-Analysis Of RCTs

BACKGROUND

Current research suggests a need to implement environmental, behavioral, and even nutritional interventions, with the objective of improving the comfort and stability of preterm newborn infants, as well as reducing their stress and pain levels. Several studies have used the salivary reactivity of cortisol to assess stress or pain in preterm infants. The aim of this study was to analyze the results of published randomized controlled trials that tested the effects of nonpharmacological interventions on cortisol as a treatment for heel lance pain/stress in preterm infants.

METHODS

Published randomized controlled trials (RCTs) were searched in PubMed, Embase, CINHAL, Web of Science Cochrane Library, and Cochrane Database of Systematic Reviews, and six studies met the eligibility criteria. The quality of the included studies was appraised using Cochrane's Collaboration tool.

RESULTS

The meta-analysis showed that non-pharmacological interventions were associated with a reduction in levels of salivary cortisol in comparison with other interventions and controls, with fixed effect mean differences of -0.11, and with a 95% C.I. of -0.28 to -0.05. Prone-nest position, breast milk odor, kangaroo care, and twins co-bedding led to a decrease in cortisol levels in saliva.

CONCLUSION

Future studies should be performed on nonpainful interventions in order to gain more knowledge about the regulation of cortisol in saliva in preterm infants with involving control group and larger sample sizes.

A protocol to develop a standard guideline for neonatal pain management

BACKGROUND

Hospitalized newborns experience a high frequency of painful procedures. Undertreated pain has a series of adverse physical and psychosocial effects on newborns. Guidelines successfully applied in clinical practice can effectively improve pain management in NICUs and reduce the incidence of pain. Neonatal care providers in China are in urgent need of a high-quality, evidence-based guideline for the treatment and management of neonatal pain. The National Clinical Research Center for Child Health and Disorders is leading the development of a standard guideline for neonatal pain management suitable for the medical environment in China providing empirical support and safety guarantees for clinical practice. The WHO Collaborating Centre for Guideline Implementation and Knowledge Translation will provide technical support and guidance. The purpose of this paper is to outline the detailed methodology and technical route of guideline development.

METHODS

We will follow the WHO principles and methods for the formulation of standard guidelines. The critical steps for developing the guideline are as follows: (I) definition of the guideline Scope; (II) establishment of guideline working groups; (III) selection of the clinical questions; (IV) performance of systematic reviews; (V) grading the quality of the body of evidence; and (VI) formulating recommendations and reaching consensus.

DISCUSSION

This protocol would ensure that the process of guideline development is normative, scientific, and transparent. The standard guideline for neonatal pain management based on the available high-quality evidence and tailored to the Chinese health care system will help neonatal caregivers in NICUs effectively manage neonatal pain.

GUIDELINE REGISTRATION

The guideline was registered at the International Practice Guidelines Registry Platform. The registration No. is IPGRP-2021CN044.

Procedural Pain in Hospitalized Neonates in Kenya

PURPOSE

The study was conducted to understand the nature and frequency of painful procedures and use of analgesia in neonatal units in Kenya.

DESIGN AND METHODS

Descriptive prospective study was conducted in a regional Level I and a university-affiliated Level II neonatal unit in Western Kenya. Two hundred term and preterm neonates who were hospitalized during the first day of life were recruited. A validated checklist was used to audit medical charts of hospitalized neonates. Painful procedures and pain treatment interventions accompanying all procedures performed during the first seven days of hospitalization were documented. Descriptive statistics, t-tests and χ² were usedto determine frequency and factors influencing the frequency of procedures.

RESULTS

A total of 1693 painful procedures (mean = 1.6 ± 1.1) were performed with most of them being tissue-damaging (n = 1291) including intravenous cannulation and intramuscular injection. Neonates were less likely to undergo procedures if there were born at term (RR 0.85; 95% CI, 0.76-0.95, p = .003) but more likely to experience procedures if admitted in a higher level of care (RR 1.57, 95% CI, 1.43-1.74, p < .001). Only one procedure was accompanied by analgesia.

CONCLUSIONS

Neonates underwent few but highly invasive procedures without analgesia. Prematurity and a high level of care predisposed neonates to a higher burden of pain.

IMPLICATIONS

Our findings underscore the urgent need for development of context-specific clinical practice guidelines on procedural pain treatment in sub-Saharan Africa.

Pain intensity of sedated paediatric intensive care unit patients during treatment and care procedures

BACKGROUND

Although various pharmacological and non-pharmacological methods are used in the management of pain in the Paediatric Intensive Care Unit, patients experience more pain than those being treated in other units.

AIM AND OBJECTIVES

This study was conducted to determine the intensity of pain during invasive patient care and dressing change procedures in sedated paediatric intensive care unit (PICU) patients and to assess the impact of analgesics and demographic factors. The study also sought to evaluate any correlation between the face, legs, activity, cry, consolability (FLACC) and COMFORT scales.

DESIGN

The research was conducted as a descriptive cross-sectional study.

METHODS

The total sample size consisted of 30 mild-to-moderately sedated patients under the age of 18 in the PICU of a university hospital in Turkey between September the 1st, 2016, and December the 31st, 2016. The procedures were classified in to three groups: Invasive, Patient Care and Dressing Change. The FLACC and COMFORT scales were utilized to assess pain.

RESULTS

The intensity of pain did not differ according to the demographic characteristics (median [IQR]) by gender-COMFORT female: (16.05 [15.10-17.0]); male: (15.15 [14.7-16.5]) (P = .284)-age: (COMFORT: P = .165); intensive care admission indications: (COMFORT: P = .647); or administration of analgesics-COMFORT Yes: (15.90 [14.80-16.65]), No: (15.50 [14.70-16.45]) (P = .634). The invasive procedures produced the most intense pain (median [IQR]): FLACC: (5 [4-6])/COMFORT: (16 [15-20]). Patient care procedures were second in intensity of pain FLACC: (4 [3-5])/COMFORT: (15 [14-17]), while dressing changes produced significantly less pain FLACC: (3 [2-4])/COMFORT: (14 [12-17]) (P < .001). A positive correlation was noted between the pain scores observed on the FLACC and COMFORT scales (rs: Invasive procedures:0.992/Care procedure:0.991/Dressing procedures: 0.996) (P < .001).

CONCLUSIONS

Besides invasive procedures, patient care and dressing changes also cause sedated PICU patients' pain. The pain management was insufficient to prevent pain for most of the procedures in the PICU.

RELEVANCE TO CLINICAL PRACTICE

Besides making use of evidence-based pharmacological and non-pharmacological methods in invasive procedures, care must also be focused on preventing pain during patient care and dressing procedures so that the most effective treatment can be achieved.

The Effect of 3 Positions Given to Preterm Infants During Heelstick Procedure on Pain and Durations of Crying and Procedure

The purpose of this randomized controlled study was to determine the effect of 3 positions given to preterm infant during heelstick procedure on the pain and durations of crying and procedure. The sample of the study consisted of 90 preterm infants (30 in each group). The heelstick procedure was video recorded. Data from the pain scores, durations of crying, and procedure were collected watching the video recordings. It was determined that the pain mean score of the infants in the control group (supine on the crib) (5.50 ± 2.13) was statistically significantly higher than that of the infants in the positions of upright (3.00 ± 2.17) and supine on the lap (3.20 ± 2.46) (P < .01), and there was no difference between the positions of upright and supine on the lap (P > .05). Giving the positions of upright or supine on the lap during heelstick is effective in reducing pain, shortening the duration of crying, and calming down the infant. Heelstick in the position of upright on the lap shortened the procedure duration and allowed the infants to be subjected to less painful procedure. It is recommended for nurses to take the preterm infants on their laps during heel lancing and give them the upright position, in particular.

Pain, Smell, and Taste in Adults: A Narrative Review of Multisensory Perception and Interaction

Every day our sensory systems perceive and integrate a variety of stimuli containing information vital for our survival. Pain acts as a protective warning system, eliciting a response to remove harmful stimuli; it may also be a symptom of an illness or present as a disease itself. There is a growing need for additional pain-relieving therapies involving the multisensory integration of smell and taste in pain modulation, an approach that may provide new strategies for the treatment and management of pain. While pain, smell, and taste share common features and are strongly linked to emotion and cognition, their interaction has been poorly explored. In this review, we provide an overview of the literature on pain modulation by olfactory and gustatory substances. It includes adult human studies investigating measures of pain threshold, tolerance, intensity, and/or unpleasantness. Due to the limited number of studies currently available, we have structured this review as a narrative in which we comment on experimentally induced and clinical pain separately on pain–smell and pain–taste interaction. Inconsistent study findings notwithstanding, pain, smell, and taste seem to interact at both the behavioral and the neural levels. Pain intensity and unpleasantness seem to be affected more by olfactory substances, whereas pain threshold and tolerance are influenced by gustatory substances. Few pilot studies to date have investigated these effects in clinical populations. While the current results are promising for the future, more evidence is needed to elucidate the link between the chemical senses and pain. Doing so has the potential to improve and develop novel options for pain treatment.

Oral Sucrose for Neonatal Pain: Perception of Jordanian Nurses

BACKGROUND

Neonatal pain management using sucrose has been an established practice in Western countries. However, in the developing world, the practice is still not widely accepted. Neonatal nurses' perceptions about the neonatal pain experience and efficacy of oral sucrose may influence that decision.

PURPOSE

To investigate Jordanian neonatal nurses' perceptions about the use of oral sucrose for neonatal pain.

DESIGN AND SAMPLE

A cross-sectional descriptive design was used to collect data from 191 neonatal nurses working in 3 different hospital settings in northern and middle central Jordan.

MAIN OUTCOME VARIABLES

Knowledge and perception of Jordanian nurses about neonatal pain and oral sucrose and their relationship to demographic variables.

RESULTS

More than half of nurses had knowledge deficit about pain management. Fifty-five percent of the nurses had a positive perception toward pain assessment tools, and the majority indicated positive opinion toward oral sucrose usage. Demographic factors can impact their perceptions.

Comparison the Effect of Breast Milk Smell, White Noise and Facilitated Tucking Applied to Turkish Preterm Infants During Endotracheal Suctioning on Pain and Physiological Parameters

PURPOSE

This study aimed to determine the effect of the breast milk smell, white noise and facilitated tucking during endotracheal suctioning (ES) on pain and physiological findings.

DESIGN AND METHODS

The present study was conducted as a randomized, controlled experimental trial study. The sample of the study was composed of a total of 80 preterm infants. Pain was measured with PIPP-R pain scale. rMANOVA and bonferroni tests were used in the comparison of the pain scores of the groups.

RESULTS

It was determined that white noise and facilitated tucking were more effective in relieving infants before ES procedure (p < .05). No statistically significant difference was found between the groups in reducing the pain during ES procedure (p > .05). After the procedure, facilitated tucking was determined more effective in the recovery of preterm infants (p < .05).

PRACTICE IMPLICATIONS

It is recommended to use facilitated tucking and white noise for decreasing pain of ventilated preterm infants during the ES procedure.

CONCLUSIONS

White noise and facilitated tucking were effective in relieving pain before procedure and facilitated tucking recovery in preterm infants after the ES procedure.

Practical approaches to sedation and analgesia in the newborn

The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.

[Prematurity and music therapy: harmonic encounters?]

Premature birth can cause complications of varying nature and intensity in the child's development. The developmental care given to babies born prematurely is of major importance to their physical and psychological development. After clinical assessment, music therapy can be integrated into this care. It is a source of observed benefits.

The effect of Yakson and Gentle Human Touch methods on pain and physiological parameters in preterm infants during heel lancing

BACKGROUND

Various non-pharmacologic methods are used to alleviate pain in preterm infants who spend their first days in neonatal intensive care units (NICU) because they are exposed to numerous painful interventions.

OBJECTIVE

To determine the effects of Yakson and Gentle Human Touch (GHT) methods on pain and physiologic parameters during heel lancing procedures in preterm infants.

DESIGN AND METHODS

This was a randomised controlled trial. The study was conducted in a NICU between June 2018 and June 2019. A total of 90 preterm infants were divided into three groups: 30 infants in the Yakson group, 30 infants in the GHT group, and 30 infants in the control group. All preterm infants were randomly divided into groups. Pain responses were evaluated using the Neonatal Infant Pain Scale.

RESULTS

It was found that pain scores and heart rates were significantly lower during and after heel lancing in preterm infants in the Yakson and GHT groups than in the control group, the difference was statistically significant (p < .001).

PRACTICAL IMPLICATIONS

Yakson and GHT applied to preterm infants during heel lancing has positive effects on pain and physiologic parameters.

Vitamin K Deficiency Bleeding: An Ounce of Prevention

Vitamin K is a fat-soluble vitamin essential for the formation of factors in the clotting cascade. Newborns are born with insufficient levels of vitamin K, resulting in high risk for vitamin K deficiency bleeding (VKDB). Vitamin K deficiency bleeding can occur in the first week of life ("classic" VKDB) and also between 2 weeks and 3 months of age ("late" VKDB). Vitamin K deficiency bleeding can present as bleeding in the skin or gastrointestinal tract, with as many as half of affected neonates experiencing intracranial bleeding. A single intramuscular injection of vitamin K effectively prevents both classic and late VKDB. Although intramuscular vitamin K is safe and effective, VKDB has reemerged because of decreased utilization. Parents refuse intramuscular vitamin K for a variety of reasons, including a disproven association with childhood cancer, the desire to avoid exposure to additives, and valid concerns about early neonatal pain. Many parents request oral vitamin K, an inferior alternative strategy that requires multiple doses utilizing products not designed for neonatal oral administration. In this setting, health care professionals must understand the epidemiology of VKDB and compassionately counsel parents to assuage concerns. Delivery of intramuscular vitamin K to all newborns remains a public health imperative, benefitting thousands of infants annually.

Peaceful End of Life in an Unviable Newborn: A Case Report

The limit of viability is a period of uncertainty regarding the prognosis and treatment, where palliative care (PC) is important to dignify death, although, in several countries, they are not implemented as in Colombia. The peculiarities of newborns make PC differ from care at other stages of life and which are rarely accepted by professionals who consider them overwhelming. The case of a newborn of 23 weeks of gestation is exposed where nursing care is revealed to the newborn and his family according to the theory of the peaceful end of life (PEL). The theory of the PEL is useful in the development of neonatal PC, which must be differentiated, improving well-being, and family support. Furthermore, health systems must recognize emotional risks for professionals.

Historical roots of pain management in infants: A bibliometric analysis using reference publication year spectroscopy

Retrospective evaluations of the historical role of previously published research are often fraught with subjective bias and misrepresentation, which leads to contested scientific claims. This paper investigates the historical roots of infant pain management using novel quantitative methods to identify the published literature and evaluate its relative importance. A bibliometric analysis named “reference publication year spectroscopy” (RPYS), was performed using the program CitedReferencesExplorer (CRExplorer) to avoid the subjectivity associated with comparative evaluations of individual research studies. Web of Science (WoS) search queries on infant‐related synonyms, pain‐related synonyms, and analgesia or anesthesia‐related synonyms were combined using the Boolean operator “AND,” to identify all publications related to pain management in infants. The RPYS analyses were based on 8697 papers in our publication set containing the citations for 86268 references. Selected cited publications were associated with peak citation years in 1951, 1954, 1957, 1965, 1987, 1990, 1997, 1999, and 2000. Subsequent analyses suggested that research on infant pain management made rapid progress during 1982‐1992. Landmark publications were defined as those belonging to the top 10% of the most frequently referenced publications for longer than 25 years. Through this analysis, we identified and ranked 24 landmark publications to illustrate the historical background and early research on infant pain management. From the first‐ever application of RPYS (an objective, reproducible approach to study the early history of any scholarly activity) to pain research, infant pain management appears rooted in the scientific rationale for neonatal pain perception, randomized trials of opioid anesthesia/analgesia, and studies describing the facial expressions and crying activity following heel‐lance procedures in newborns.

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.

The effect of gentle human touch during endotracheal suctioning on procedural pain response in preterm infant admitted to neonatal intensive care units: a randomized controlled crossover study

Background: Neonates in the neonatal intensive care unit are frequently subjected to painful procedures. Non-pharmacological pain control techniques are useful for reducing procedural pain. Touch as one of the aspects of developmental care used to reduce neonatal pain. The purpose of this study was to determine the effect of gentle human touch during endotracheal suctioning on procedural pain response in preterm neonates.Methods: This was a clinical trial study with a crossover design. The study was conducted in a level III NICU in a hospital, affiliated to Iran University of Medical Sciences. Thirty-four neonates were enrolled in this study based on inclusion criteria. The samples were randomly received a sequence of suctioning with/without or suctioning without/with gentle human touch. Preterm Infant Pain Profile (PIPP) was used to collect the data. SPSS version 22 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.Results: 85.3% of neonates experienced moderate and 8.8% severe pain during suctioning without intervention, and only 64.7% of them experienced moderate and 2.9% severe pain during suctioning with intervention. The results of the paired t-test show that there is a statistically significant difference between the mean scores of pain in nonintervention and intervention cases (p < .002), and the mean pain score substantially reduced in cases with intervention.Conclusions: Results from this study showed that the pain due to suctioning procedure is considerably reduced by applying Gentle Human Touch. And nurses can use this method as one of the non-pharmacological methods of pain management.