Psychometric Testing of the Turkish Version of the Premature Infant Pain Profile Revised-PIPP-R

The Effect of Swaddling and Oropharyngeal Colostrum During Endotracheal Suctioning on Procedural Pain and Comfort in Premature Neonates: A Randomized Controlled Trial

BACKGROUND

Endotracheal suctioning (ES) is a painful procedure frequently performed in the neonatal intensive care unit. This procedure negatively affects the comfort level of premature neonates.

PURPOSE

To determine the effect of 2 nonpharmacologic methods, swaddling and the administration of oropharyngeal colostrum, on the pain and comfort levels of preterm neonates during ES.

METHODS

This randomized controlled experimental study comprised 48 intubated premature neonates (swaddling group n = 16; oropharyngeal colostrum group n = 16; and control group n = 16) at 26 to 37 weeks of gestation. The neonates were swaddled with a white soft cotton cloth or administered 0.4 mL of oropharyngeal colostrum 2 minutes before ES, according to the group in which they were included. Two observers evaluated the pain levels (Premature Infant Pain Profile-Revize [PIPP-R]) and comfort (Newborn Comfort Behavior Scale [COMFORTneo]) of the infants by observing video recordings of before, during, and after the procedure.

FINDINGS/RESULTS

A significantly lower mean PIPP-R score was found in the swaddling group during ES compared with the control group ( P = .002). The mean COMFORTneo scores of the swaddling and oropharyngeal colostrum groups during ES ( P < .01, P = .002) and the mean PIPP-R and COMFORTneo scores immediately after ES and 5, 10, and 15 minutes later were significantly lower than the control group ( P < .005).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Swaddling was effective both during and after the procedure, while oropharyngeal colostrum was effective only after the procedure in reducing ES-related pain in premature neonates. Swaddling and oropharyngeal colostrum were effective in increasing comfort both during and after the procedure.

The effect of music on pain, comfort, and physiological parameters during premature retinopathy examination

AIM

To determine the effect of music applied during the ROP examination on pain, comfort, and physiological parameters in preterm infants.

METHODS

The sample of this prospective randomized controlled double-blind experimental study consisted of 28 preterm infants who were examined for ROP of a tertiary hospital in the Neonatal Unit. Data were collected with a Questionnaire, Physiological Parameters Observation Form (PPOF), Revised-Premature Infant Pain Profile (PIPP-R), and Premature Infant Comfort Scale (PICS).

RESULTS

The results revealed that the crying times of the infants in the experimental group were shorter than the infants in the control group. The preterm infants in the experimental group had statistically lower PIPP-R scores during and after the procedure than the PIPP-R scores of the infants in the control group (p < 0.001) and the music applied to the preterm infants resulted in a mean decrease of 3.857 in the post-procedure and pre-procedure PIPP-R scores (p < 0.05). While there was no statistical difference between the pre-procedure and pre-procedural PICS scores of the preterm infants in the experimental and control groups (p = 0.599; p = 117), the post-procedure PICS values of the preterm infants in the experimental group were found to be lower than those of the control group (p < 0.001). It was found that the music applied to preterm infants during the ROP examination resulted in a mean decrease of 1.286 in PICS scores after the procedure and before the procedure (p < 0.05).

CONCLUSION

It was determined that the music listened to during the ROP examination decreased the PIPP-R pain scores of preterm infants, had a positive effect on the PICS scores after the procedure, but did not affect the physiological parameters positively.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05263973.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

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.

Effectiveness of a Virtual Program on Nurses' Pain-Related Knowledge and Pain-Measurement Skills

BACKGROUND

Aim: To test whether a comprehensive virtual program for using pain scales to manage neonatal pain improved nurses' knowledge and skill acquisition.

METHODS

This non-blind randomized controlled trial included 64 participants who were randomly divided into intervention and control groups; changes in scores between pre- and posttests were compared. Certified neonatal intensive care nurses were recruited from across Japan. The learning intervention group received online training in pain measurement using structured scales, such as the Face Scale for Pain Assessment of Preterm Infants and the Japanese version of the Premature Infant Pain Profile. The control group received no training. Independent t tests and χ² tests were used to compare the baseline scores. The outcome measure was score change on a 40-point test (20 for knowledge and 20 for skill) before and after the e-learning program.

RESULTS

No differences in baseline data were found between the groups. Generalized linear regression models yielded a significant difference in the least squared means (95% confidence interval [CI]) for the amount of change in the total, knowledge, and skill scores between groups: 6.22 (4.18, 8.26; p < .001) for total score, 4.66 (3.37, 5.95; p < .001) for knowledge score, and 1.53 (0.06, 3.00; p = .041) for skill score.

CONCLUSIONS

The results showed that the e-learning program improved nurses' neonatal pain knowledge and pain-measurement skills compared with no training.

Cultural Adaptation and Validation of the Premature Infant Pain Profile-Revised (PIPP-R) Pain Measurement Scale: Research Protocol

INTRODUCTION

The main objective of this study is to validate the PIPP-R scale (Premature Infant Pain Profile-Revised) for measuring neonatal pain in the Spanish hospital setting.

MATERIALS AND METHODS

The original scale will be translated from English into Spanish and a consensus translation will be prepared by the research team, which will be back-translated from Spanish into English. The content validity of the Spanish version of the scale will be measured using the Delphi method. Subsequently, a multicenter observational study will be conducted to assess construct validity, internal consistency, and intra-observer and inter-observer agreement. Pain will be assessed by comparing scores for a specific non-painful procedure with those for a specific painful procedure. The sample will include 300 subjects in intensive care and intermediate care units, who will be equally distributed among the participating hospitals. The subjects will be stratified into three groups by gestational age.

DISCUSSION

The original version of the PIPP-R scale is useful for objectively assessing neonatal acute and procedural pain from a gestational age of 25 weeks and over. It is important to culturally adapt the original validated scale and to test its validity and reliability in the Spanish healthcare context. The results of this study may represent significant progress in pain management.

Neonatal pain assessment: Do we have the right tools?

BACKGROUND

The assessment and management of neonatal pain is crucial for the development and wellbeing of vulnerable infants. Specifically, neonatal pain is associated with adverse health outcomes but is often under-identified and therefore under-treated. Neonatal stress may be misinterpreted as pain and may therefore be treated inappropriately. The assessment of neonatal pain is complicated by the non-verbal status of patients, age-dependent variation in pain responses, limited education on identifying pain in premature infants, and the clinical utility of existing tools.

OBJECTIVE

We review research surrounding neonatal pain assessment scales currently in use to assess neonatal pain in the neonatal intensive care unit.

METHODS

We performed a systematic review of original research using PRISMA guidelines for literature published between 2016 and 2021 using the key words "neonatal pain assessment" in the databases Web of Science, PubMed, and CINAHL. Fifteen articles remained after review, duplicate, irrelevant, or low-quality articles were eliminated.

RESULTS

We found research evaluating 13 neonatal pain scales. Important measurement categories include behavioral parameters, physiological parameters, continuous pain, acute pain, chronic pain, and the ability to distinguish between pain and stress. Provider education, inter-rater reliability and ease of use are important factors that contribute to an assessment tool's success. Each scale studied had strengths and limitations that aided or hindered its use for measuring neonatal pain in the neonatal intensive care unit, but no scale excelled in all areas identified as important for reliably identifying and measuring pain in this vulnerable population.

CONCLUSION

A more comprehensive neonatal pain assessment tool and more provider education on differences in pain signals in premature neonates may be needed to increase the clinical utility of pain scales that address the different aspects of neonatal pain.

Implementation and Evaluation of the Premature Infant Pain Profile-revised (PIPP-R) e-Learning Module for Assessing Pain in Infants

OBJECTIVES

The Premature Infant Pain Profile-revised (PIPP-R) is a well-established measure for infant pain assessment. The aim of this study was to evaluate the implementation and clinical utility of the PIPP-R electronic learning (e-Learning) module to promote standardized health care training for nurses.

MATERIALS AND METHODS

A descriptive mixed-methods study was conducted in 2 tertiary Neonatal Intensive Care Units in Canada. Nurses were recruited and asked to complete the PIPP-R e-Learning Module and evaluate it. A 26-item questionnaire was used to describe nurse demographics and clinical experience and to evaluate implementation success (ie, acceptability, feasibility, usability) and clinical utility.

RESULTS

In all, 98 nurses from 2 settings in Central and Eastern Canada participated; most were registered nurses highly experienced in neonatal nursing care. The majority had received previous training on the PIPP-R (61.2%) and routinely used it in practice (67.4%). They considered the e-Learning module as acceptable and feasible as it was easy to access (94.9%) and to navigate (94.8%). Content was considered clear (98.9%) and met users' learning needs (99.0%). Nurses agreed that completing the module improved their understanding of neonatal pain (96.0%) and was clinically useful in improving their ability to assess pain in neonates (97.9%). The module was accessed primarily from work settings (77.8%) using desktop computers (49.0%) or tablets (28.0%) and was usually completed in a single session (75.7%).

DISCUSSION

Nurses' evaluation of the PIPP-R e-Learning module was overwhelmingly positive. The module was perceived as easy to implement, clinically useful, and was considered as a promising online educational tool. Further testing in clinical practice is needed to build on the results of this study and support the importance of dissemination of this module for standardized training purposes.

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.

Pain Control with Lavender Oil in Premature Infants: A Double-Blind Randomized Controlled Study

Objectives: Aromatherapy has become popular in pain control in recent years compared with other complementary methods. Lavender (Lavandula angustifolia Miller) is a fragrant essential oil used in aromatherapy for its antibacterial, antifungal, muscle-relaxing, and analgesic effects. The smell of lavender oil, known for its soothing effect on adults, has not been adequately investigated in regards to pain control in premature infants. The purpose of our study was to assign the effect of the scent of lavender oil on pain in preterm infants during heel lancing. Design: A double-blind randomized controlled clinical study. Settings/Location: The study was conducted in a third-level neonatal intensive care unit of Bezmialem Vakif University Hospital from March 2019 to November 2019. It consisted of two groups. Subjects: Sixty-one premature babies (24-37 weeks of gestation) were enrolled in the study. Interventions: Heel stick sampling for metabolic screening was used for both study groups. The interventions were performed by two experienced nurses. Heart rate, oxygen saturation, and the baby's facial expression were recorded by a camera 3 min before the intervention, during the sampling, and 3 min after the procedure. After collecting the data, the head researcher and the assistant researcher separately watched the videos and scored them by using the Premature Infant Pain Profile-Revised (PIPP-R). Outcome measures: The difference of pain scores (PIIP-R) between two groups. Results: There was a statistically significant difference between the two groups in terms of PIPP-R scores during and after the sampling (p = 0.008 and p = 0.03 respectively). The PIPP-R scores at the beginning of the procedure were not found to be significantly different between the groups (p > 0.05). Conclusions: Inhalation of lavender scent is effective in pain control in premature infants. It is safe and low cost; it does not interfere with medical care.