The effect of nesting positions on pain, stress and comfort during heel lance in premature infants

Nest positioning on motor development, sleep patterns, weight gain in preterm infants: systematic review

The aim was to evaluate the effects of Nest Positioning (NP) on motor development, sleep patterns, and weight gain in preterm newborns (PTNB) hospitalized in a neonatal intensive care unit (NICU). This study was constructed based on PRISMA guideline criteria. Systematic research was carried out in electronic databases: MEDLINE via PubMed, Web of Science, Scopus, and VHL-BIREME following the PICOS strategy. Studies with PTNB populations who were hospitalized in the NICU and received therapeutic NP as an intervention strategy in this population were included in this study. We sought outcomes related to sleep patterns, weight gain, and motor development. After selection, 12 studies were included in this systematic review, of which 5 (41.7%) evaluated motor development as their primary outcome, 6 (50%) sleep-wake cycle patterns, and 1 (8.3%), weight gain and, subsequently, hospital discharge. Qualitative results indicate that prolonged exposure to decubitus variations may favor PTNB hospitalized in NICUs acquiring flexor postures, stimulate their midline, and increase their total sleep time. Studies reported no adverse effects regarding the use of NP. Evidence suggests that NP benefits motor development and sleep pattern in PTNB hospitalized in NICUs. IMPACT: Nest positioning improves sleep quality in preterm newborns hospitalized in neonatal intensive care unit. Nest positioning improves motor development in preterm newborns hospitalized in neonatal intensive care unit. No evidence of nest positioning on weight gain was observed. Half of the included clinical studies showed good methodological quality. Nesting positioning is a secure and cost-effective method.

[Clinical study of prone positioning in invasive respiratory support for neonatal respiratory distress syndrome]

OBJECTIVES

To assess the effectiveness and safety of prone positioning in the treatment of neonatal respiratory distress syndrome (NRDS) using invasive respiratory support.

METHODS

A prospective study was conducted from June 2020 to September 2023 at Suining County People's Hospital, involving 77 preterm infants with gestational ages less than 35 weeks requiring invasive respiratory support for NRDS. The infants were randomly divided into a supine group (37 infants) and a prone group (40 infants). Infants in the prone group were ventilated in the prone position for 6 hours followed by 2 hours in the supine position, continuing in this cycle until weaning from the ventilator. The effectiveness and safety of the two approaches were compared.

RESULTS

At 6 hours after enrollment, the prone group showed lower arterial blood carbon dioxide levels, inspired oxygen concentration, oxygenation index, rates of tracheal intubation bacterial colonization, and Neonatal Pain, Agitation and Sedation Scale scores compared to the supine group (P<0.05). There were no significant differences between the groups in terms of pH, arterial oxygen pressure, positive end-expiratory pressure, duration of mechanical ventilation, accidental extubation, ventilator-associated pneumonia, air leak syndrome, skin pressure sores, feeding intolerance, and grades II-IV intraventricular hemorrhage (P>0.05).

CONCLUSIONS

Compared to supine positioning, prone ventilation effectively improves oxygenation, increases comfort, and reduces tracheal intubation bacterial colonization in neonates requiring mechanical ventilation for NRDS, without significantly increasing adverse reactions.

The Impact of Using Nesting Care on Heart Rate, Oxygen Saturation, and Pain Among Premature Neonates in Neonatal Intensive Care Units in Saudi Arabia: A Quasi-Experimental Study

BACKGROUND

Supportive positioning may mimic the intrauterine environment and enhance neonates' physiological and developmental outcomes. Limited research in Saudi Arabia examined the effect of supportive positioning aids (nesting) on infant outcomes in neonatal intensive care units (NICUs).

OBJECTIVE

This study compared nesting care to non-nesting care in the short-term outcomes of premature neonates (heart rate, oxygen saturation, and pain) in Saudi NICUs.

METHODS

A quasi-experimental design compared two groups of premature neonates from two NICUs regarding their heart rate, oxygen saturation, and pain level. Nesting was used in the first group, and not in the second group. Seventy premature neonates (35 per group) were recruited. An independent t-test was used to compare the two groups.

RESULTS

Heart rate was significantly lower in the nesting group than the non-nesting group at baseline and after procedures (136bpm and 139bpm vs 144bpm and 148bpm, P ≤ 0.05). The pain level was significantly lower in the nesting group than the non-nesting group at baseline and after procedures (3.7 and 3.8 vs 4.7 and 4.6, P ≤ 0.05). There was no significant difference between the two groups in oxygen saturation.

CONCLUSION

Nesting care supported premature neonates in the NICU. It helped stabilize the heart rate and pain. NICUs in Saudi Arabia would benefit from educating NICU nurses and informing NICU managers and policymakers of nesting care.

Effects of the use of a cocoon on the autonomic, motor, and regulatory systems in preterm newborns: Randomized clinical trial

INTRODUCTION

The wrapping of the newborn in an orthopedic tubular mesh, simulating a cocoon, can allow the infant to regain the feeling of security and stability experienced in the uterus given that the movement of one of the parts of the body exerts tactile and pressure variation in others.

OBJECTIVE

We aimed to evaluate the influence of an orthopedic tubular mesh, simulating a cocoon, in therapeutic positioning, on the variables of the autonomous, motor, and regulatory systems of preterm newborns.

METHODS

A controlled and randomized clinical trial was conducted with preterm newborns positioned in dorsal decubitus and divided into two groups: (a) cocoon - newborns covered with an orthopedic tubular mesh, and (b) control - newborns positioned according to the sector's routine and without the use of an orthopedic mesh. During the follow-up, each newborn was placed in the position for 30 min and was recorded for a total of 2 min, once at the beginning and again at the end of the observation period. Variables related to the autonomous system (heart rate, respiratory rate, and peripheral oxygen saturation), motor system (general movements), and regulatory system (Neonatal Infant Pain Scale) were evaluated before and after the intervention. The videos were evaluated by a researcher blind to the purpose of the study, and the resulting data were analyzed using SPSS.

RESULTS

Of the 40 preterm newborns evaluated (32.5 ± 1.83 weeks), 21 were female, and 20 were allocated to the cocoon group. The variables related to the autonomous, motor, and regulatory systems remained unchanged following the positioning in the cocoon, as compared to the typical positioning employed in the neonatal unit.

CONCLUSION

The simulation of a cocoon, utilizing an orthopedic tubular mesh, when applied to preterm newborns admitted to a neonatal intensive care unit can contribute to maintaining low levels of stress, without altering variables of the autonomous, motor, and regulatory systems.

The Effect of Lullabies and Classical Music on Preterm Neonates' Cerebral Oxygenation, Vital Signs, and Comfort During Orogastric Tube Feeding: A Randomized Controlled Trial

OBJECTIVE

This study investigated the effect of lullabies and classical music on preterm neonates' cerebral oxygenation, vital signs, and comfort during orogastric (OG) tube feeding.

METHODS

This was a parallel-group pretest-posttest randomized controlled study. The research was conducted between December 2020 and May 2022. The sample consisted of 51 preterm neonates hospitalized in the neonatal intensive care unit (NICU) of Selçuk University Faculty of Medicine Hospital in Konya, Türkiye. Participants were randomized into three groups (17 preterm infants in each group). The first group listened to lullabies sung by their mothers and the second group listened to classical music during OG tube feeding. The control group received routine care with no music. Data were collected using a Neonatal Identification Information Form, Physiological Parameters and rSO2 Monitoring Form, and the Newborn Comfort Behavior Scale (Comfort-Neo). The study was registered on the ClinicalTrials database (NCT05333575).

RESULTS

The lullaby group had stable peak heart rates and oxygen saturation levels (p = .002). Both lullaby and classical music groups had significantly higher cerebral oxygenation levels than the control group. The classical music group had the highest cerebral oxygenation level (p = .001). Both lullaby and classical music groups had significantly higher mean Comfort-Neo scores than the control group. The classical music group had the highest mean Comfort-Neo score (p = .040).

CONCLUSION

Preterm neonates who listen to lullabies and classical music are likely to have higher cerebral oxygen and comfort levels. Listening to lullabies helps stabilize vital signs. These results suggest that healthcare professionals should encourage parents to get their preterm neonates to listen to lullabies and classical music.

Positioning for lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.

OBJECTIVES

To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.99, 95% CI 0.88 to 1.12; RD 0.00, 95% CI -0.06 to 0.05; I2 = 47% and 46% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts as specified in this review. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position (I2 = not applicable; 2 studies; 1102 infants; high-certainty evidence; in one of the study median and IQR to report time to perform the lumbar puncture were 8 (5-13) and 8 (5-12) in the lateral and sitting position, respectively, I2 = not applicable; 1 study, 1082 infants; in the other study: mean difference 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.

AUTHORS' CONCLUSIONS

When compared to sitting position, lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts as specified in this review. Furthermore, infants in a sitting position likely experience less episodes of bradycardia and oxygen desaturation than in the lateral decubitus, and there may be little to no difference in episodes of apnea. Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.

Positioning for lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.

OBJECTIVES

To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.93, 95% CI 0.85 to 1.02; RD -0.04, 95% CI -0.09 to 0.01; I2 = 70% and 72% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). The evidence is very uncertain regarding the effect of lateral decubitus position on time to perform the lumbar puncture (MD 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants, very low-certainty evidence). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.

AUTHORS' CONCLUSIONS

When compared to sitting position, lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts. Furthermore, infants in a lateral decubitus position likely experience more episodes of bradycardia and oxygen desaturation, and there may be little to no difference in episodes of apnea. The evidence is very uncertain regarding time to perform lumbar puncture. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.

Effect of Acupoint Stimulation on Controlling Pain from Heel Lance in Neonates: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To evaluate the effect of acupoint stimulation compared to other interventions on pain control in neonates who underwent heel lance, we searched for randomized controlled trials across six databases (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, and Web of Science) published up to January 2023. Studies comparing acupoint stimulation and other interventions for controlling heel lance pain in neonates were included. These reports measured at least one of the following variables: pain score, crying time, oxygenation saturation, heart rate, respiration rate, and duration of the procedure. The data were independently extracted by two authors, and the PRISMA guidelines for study selection were followed. A total of 79 articles were screened, and 10 studies, with results on 813 neonates, were included in the final selection. The pain scores recorded during the heel lance procedure were not significantly different between the acupoint stimulation cohort and the control cohort (SMD of -0.26, 95% confidence interval (CI) from -0.52 to 0.01; p = 0.06; I² = 68%). After processing the subgroup analyses, significant differences were found in the comparisons of acupuncture vs. usual care (SMD of -1.25, 95% CI from -2.23 to 0.27) and acupressure vs. usual care (SMD of -0.62, 95% CI from -0.96 to -0.28); nonsignificant differences were found in other comparisons. Our results demonstrate that acupoint stimulation may improve pain score during the heel lance procedure.

Vitamin D supplementation improved physical growth and neurologic development of Preterm Infants receiving Nesting Care in the neonatal Intensive Care Unit

OBJECTIVE

To study the effects of vitamin D supplementation on physical growth and neurologic development of very preterm infants receiving nesting intervention in the neonatal intensive care unit (NICU).

METHODS

A total of 196 preterm infants had been hospitalized in NICU with the gestational age (GA) between 28 and 32 weeks. Among them, 98 preterm infants received nesting intervention, and the other 98 cases received both nesting and vitamin D supplementation (400 IU). The interventions were continued until 36 weeks postmenstrual age (PMA). The 25(OH)D serum levels, anthropometric parameters, and Premie-Neuro (PN) scores were compared at 36 weeks PMA.

RESULTS

Higher median serum level of 25(OH)D was found in the nesting + vitamin D [38.40 ng/mL (IQR: 17.20 ~ 70.88) ng/mL] as compared to the nesting group [15.95 ng/mL (IQR: 10.80 ~ 24.30) ng/mL] at 36 weeks PMA. Besides, infants receiving combined nesting intervention and vitamin D supplementation had less proportion of vitamin D deficiency [VDD, 25(OH)D levels < 20 ng/mL] than those receiving nesting intervention alone. After intervention, the anthropometric parameters of infants, including weight, length, BMI and head circumference were improved in the nesting + vitamin D group as compared to the nesting group at 36 weeks PMA, with higher scores of neurological, movement and responsiveness.

CONCLUSIONS

Vitamin D supplementation effectively decreased the prevalence of VDD and led to higher concentrations of 25(OH)D at 36 weeks PMA. This was one more study that supported the necessity of vitamin D supplementation to improve physical growth and neurologic development of preterm-born newborns who received nesting intervention in the NICU.

COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates?

OBJECTIVE

We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain.

STUDY DESIGN

This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity.

RESULT

Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively.

CONCLUSION

The COMFORTneo can be used to reliably and validly assess pain in NICU patients.

Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants

OBJECTIVE

To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU.

DATA SOURCES

We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles.

STUDY SELECTION

We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria.

DATA EXTRACTION

Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies.

DATA SYNTHESIS

From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain.

CONCLUSION

There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.

Manual and alternative therapies as non-pharmacological interventions for pain and stress control in newborns: a systematic review

BACKGROUND

Supporting therapies that provide stress and pain control of preterm and term newborns infants contribute positively to the neuropsychomotor development. Non-pharmacological interventions that involve manual techniques are described, considering protocols that can be reproduced by physical therapists, with positive and negative outcomes reports.

DATA SOURCES

Systematic review follows PRISMA 2020 statements guidelines. Primary and specific health sciences databases (Science Direct, Pubmed, Scielo, Embase and Scopus) were consulted between October 2021 and May 2022. Articles considered were clinical trials, randomized or not, that included descriptions of the type of intervention as non-pharmacological and that studied the following outcomes: "pain" and "stress".

RESULTS

Fifteen articles were selected for analysis, reaching a methodological quality of at least 3 on the Jadad Scale for the Quality of Researched Sources. The non-pharmacological therapies most applied in isolation were massage, swaddling or wrapping, gentle touch and kinesthetic stimulation, and the combined therapies were non-nutritive sucking and swaddling, oral sucrose and swaddling, sensory stimulation and familiar odors, and sensory saturation. The outcomes found were relaxation, pain, and stress reduction after the application of painful procedures. The behavioral changes included crying, grimacing, yawning, sneezing, jerky arm or leg movements, startles, and finger flaring. The vital signs included heart rate, blood oxygen saturation level, and pulse respiration.

CONCLUSIONS

Combined techniques lead to better results in controlling neonatal pain when compared to isolated techniques. They can be applied both in preterm and term infants in a safe way and are reproducible in any health unit in a simple and economical way.

Assessment of salivary cortisol concentrations for procedural pain monitoring in newborns

OBJECTIVES

The study aimed to evaluate the usefulness of salivary cortisol (SC) for the assessment of procedural pain intensity in preterm and term newborns.

METHODS

Three groups of neonates (term, 37⁰-41⁶ weeks; moderate to late preterm, 32⁰-36⁶; and very preterm, <32⁰) hospitalized in neonatal intensive care unit were assessed for the study. Response to nappy change, lung ultrasound (LUS), and blood sampling was analyzed. The intensity of pain was evaluated using continuous heart rate and blood oxygen saturation (SpO₂) monitoring, Neonatal Infant Pain Scale (NIPS), and SC concentrations. Saliva samples were collected before and 20 min after the procedure's end.

RESULTS

Seventy-one infants were examined: 30 term, 21 moderate to late preterm, and 20 very preterm. SC has increased significantly in response to nappy change only in very preterm newborns (2.13 ng/mL [1.55-3.68] vs. 2.84 ng/mL [1.93-9.06], p = 0.01). LUS did not affect concentrations of SC in any group. Significant increase in SC was observed after blood sampling in term and very preterm infants (2.2 ng/mL [1.45-2.92] vs. 4.29 ng/mL [3.88-5.73], p = 0.002, and 1.88 ng/mL [1.47-4.13] vs. 5.3 ng/mL [3.42-8.02], p = 0.002, respectively). A significant correlation between values of SC increase and NIPS scores was found (Spearman's rank correlation coefficient [r_s] = 0.31, p = 0.001).

CONCLUSIONS

We observed the increase in SC concentrations in response to painful stimulus. The presence of a correlation between NIPS scores and SC increase suggests that SC can be used as an objective parameter to assess pain in neonates.

Assessing Neonatal Pain with NIPS and COMFORT-B: Evaluation of NICU’s Staff Competences

Background

Pain is considered “the 5th vital sign” that should be regularly assessed in the neonatal intensive care setting. Although over 40 pain assessment tools have been developed for neonates, their implementation in everyday practice is challenging. Epidemiological studies demonstrate that pain is still underassessed and undertreated in European NICUs.

Purpose

To evaluate the interrater and intrarater reliability of the NIPS and COMFORT-B scales among the tertiary NICU's staff members 4 years after their implementation in local pain guidelines with no prior dedicated training.

Methods

Physicians and nurses were invited to evaluate 5 video recordings of infants hospitalized in the intensive care settings, using the NIPS and COMFORT-B scales. The assessment took part twice at a 3-month interval. Interrater reliability was calculated for both scales using Kendall's W coefficient of concordance and Krippendorff's alpha coefficient. Cohen's kappa was used to assess intrarater reliability.

Results

17 physicians and 19 nurses took part in the study. Interrater agreement for the COMFORT-B scale was above 0.8 for Kendall's W coefficient (p < .01) and above 0.667 for Krippendorff's alpha coefficient. Kendall's W coefficient for the NIPS scores ranged between 0.7 and 0.8 (p < .01). Krippendorff's alpha was above 0.667. Intrarater agreement for both the COMFORT-B and NIPS scales was 0.693 and 0.724, respectively.

Conclusions

Overall, the agreement between our staff members was moderately good for both scales. This is not enough to avoid inadequate pain assessment. More training is needed to improve NICU's staff competences in using pain scales.

Lumbar Puncture in the prone position for Low Birth Weight Neonates

Background

Lumbar puncture in the lateral decubitus position will make the neonates uncomfortable and is likely to cause position change and unstable vital signs, and the application of sedative drugs will cause adverse effects. This study explored a novel method for lumbar puncture in the prone position for low weight neonates.

Methods

The neonates were randomly assigned into the standard position group receiving lumbar puncture in the lateral decubitus position; and the improved position group receiving lumbar puncture in the prone position. The success rate of first time attempts and the overall success rate of lumbar puncture, incidence of adverse effects, NIAPAS scores were collected and compared between these two groups. The difference in success rate and adverse effects incidence rate was analysed through Chi-square. Student’s t-test was used for the test of NIAPAS rating.

Results

The improved position group had a higher success rate of first attempt and overall success rate, significantly lower incidence of adverse effect and lower NIAPAS scores than those of the standard position group (P<0.05).

Conclusion

This lumbar puncture in the prone position is safer, more effective, and more comfortable for preterm neonates and those with low birth weight. Thus, this method is worth of further promotion.

Trial registration

Registration number, ChiCTR2100049923; Date of Registration, August 11, 2021; Retrospectively registered.

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.

The effect on pain level and comfort of foot massages given by mothers to newborns before heel lancing: Double-blind randomized controlled study

INTRODUCTION

In addition to pharmacological methods, non-pharmacological methods can also be used for reducing pain and increasing comfort during invasive procedures in newborn babies. This study was conducted to determine the effect on pain level and comfort of foot massages given by mothers to newborns before heel lancing.

METHODS

This is a double-blind randomized controlled experimental study. The sample consisted of 128 newborns including 64 in the intervention group and 64 in the control group. The Newborn Infant Pain Scale (NIPS) and Newborn Comfort Behavior Scale (NCBS) were used to collect the data, along with questionnaires for information on the newborn and mother. The researcher explained to each mother in theory how to do a foot massage at least 2 h before the heel lancing procedure. Mothers then drew random assignments to either an intervention group that would give a foot massage for 3 min with baby oil, or a control group that simply waited 3 min, immediately prior to the lancing.

RESULTS

It was determined that the foot massage performed by the mother reduced the pain level of babies, increased their comfort levels, and decreased their distress levels.

CONCLUSION

Nurses play an active role in defining and evaluating the newborn's responses to pain. It is thought that this study will guide nurses working in the clinic in reducing the acute pain that develops with invasive interventions performed on newborns and in preventing the negative effects of pain on the newborn.

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.

Effect of Body Position on Cardiorespiratory Stabilization and Comfort in Preterm Infants on Continuous Positive Airway Pressure

PURPOSE

The purpose of the study is to investigate the effect of four body positions (supine, prone, left lateral, right lateral) on cardiorespiratory stabilization and comfort in preterm infants receiving Nasal Continuous Positive Airway Pressure (NCPAP).

DESIGN AND METHODS

In the study conducted as a randomized crossover design, the sample was composed of 20 preterm infants receiving NCPAP therapy. At each change of position, the baby was allowed to stabilize for 15 min, and heart rate and oxygen saturation values were recorded every 10 min for the next 60 min. The comfort levels of the infants in each position were evaluated at 30th and 60th minutes using the Premature Infant Comfort Scale.

RESULTS

At the end of the study, it was determined that there was no statistically significant difference between heart rate (p = .83), respiratory rate (p = .90) and oxygen saturation (p = .15) of the infants in terms of their positions. When the mean comfort scores of the preterm infants were compared in terms of position, it was found that there was a difference between the positions (p < .01). According to the scale evaluation, the highest comfort level of the infants was in the prone position, which was followed by right lateral, supine and left lateral positions.

PRACTICE IMPLICATIONS

Prone position was the most comfortable for preterm infants. However, comfort levels of preterm infants were also high enough in other positions so that no intervention is needed. In order to ensure comfort and cardiorespiratory stabilization, any of the four body positions can be chosen.

Positioning Effects for Procedural Pain Relief in NICU: Systematic Review

OBJECTIVES

To systematically review the literature regarding the effectiveness of different positioning methods for procedural pain relief in neonates admitted to the Neonatal Intensive Care Unit (NICU).

DESIGN

A systemized search of the literature was carried out by means of two independent evaluators through the systematic search of electronic index databases.

DATA SOURCES

A search for relevant studies was performed in four databases (Medline, Web of Science, Scopus, and BVS-BIREME).

REVIEW/ANALYSIS METHODS

Manual searches were conducted on suitable references from the included articles, and 1,941 publications were eligible for the analysis. The flowchart for the articles' selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, and in relation to bias risks according to the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Based on the inclusion criteria, only 20 publications remained. According to the PEDro scale, 75% of the studies presented good methodological quality, with scores between 6 and 8, and 5% scored ≤4 points. None of them were blinded in relation to the therapies, but all of them performed intergroup statistical comparisons. According to the results of this review, we recommend facilitated tucking by parents (FTP) in NICU of at least 30 minutes duration, starting 15 minutes before, during the painful procedure, and 15 minutes after to relieve pain and to stabilize the physiological, hormonal, and behavioral responses of the newborns.

CONCLUSIONS

Positioning should be used as a nonpharmacological strategy for procedural pain relief in newborns. This review showed that facilitated tucking by parents for 30 minutes was the best position for pain relief in premature newborns during procedures in the NICU. Positioning is recommended as a nonpharmacological method for pain relief; FTP of at least 30 minutes duration should be the first positioning choice during procedures in the NICU.

The effects of auditory interventions on pain and comfort in premature newborns in the neonatal intensive care unit; a randomised controlled trial

OBJECTIVE

This study investigated the effects of three auditory interventions; white noise, recorded mother's voice, and MiniMuffs, applied during a heel lance on pain and comfort in premature infants in the neonatal intensive care units.

DESIGN AND METHODS

This experimental, parallel, randomised controlled research was conducted in a state hospital tertiary-level neonatal intensive care unit. The sample comprised sixty-four premature infants with gestational ages of 31-36 weeks. The infants were randomly assigned to four groups: i) white noise, ii) recorded mother's voice, iii) MiniMuffs, and iv) control. Pain and comfort of newborns were evaluated according to the Neonatal Infant Pain Scale (NIPS) and the COMFORTneo scale. Oxygen saturation, heart rate, and crying time were also measured.

RESULTS

The mean of oxygen saturation levels in the white noise, recorded mother's voice, and MiniMuffs group were higher than the control group. The heart rate, crying time, mean NIPS score, COMFORTneo score of the premature neonates in the white noise, recorded mother's voice, and MiniMuffs groups were significantly lower than the control group (p < .001).

CONCLUSION

Auditory interventions used during heel lance reduce the pain and increase the comfort of the premature infants. White noise is extremely effective in preventing infants's pain.

The Effectiveness of Prone and Supine Nesting Positions on Changes of Oxygen Saturation and Weight in Premature Babies

Introduction: Stress experienced by the baby will affect the body’s function by increasing the body’s metabolism. Nesting is used to reduce stress in premature babies. Nesting can be done in a supine or prone position. Few studies have examined the effects of body position on body weight and oxygen saturation. The objective of the study was to determine the difference in oxygen saturation and weight change on the use of nesting in the prone and supine positions in premature babies.Methods: The research used a quasi-experimental design. The sample consisted of 30 premature babies, which was obtained using a consecutive sample technique. The independent variables were nesting positioning (supine and prone), and the dependent variables were oxygen saturation and body weight. The data of oxygen saturation and the baby’s weight were collected using pulse oximetry; the baby’s weight scale used observation sheets. The data was analysed using the t-test, Wilcoxon Sign Ranks Test, and Mann Whitney U Test.Results: The results showed that there was a difference in oxygen saturation before and after the use of nesting in the supine (p=0.001) and prone position (p=0.000). There was a weight difference before and after the use of nesting in both supine (p=0.000) and prone position (p=0.000). There was no difference in oxygen saturation value and infant weight, before or after, between the supine position and the prone position (p=0.18; p=0.9).Conclusion: The use of nesting in both positions (supine or prone) can increase oxygen saturation and infant weight. Researchers recommend the use of nesting with supine or prone positions routinely in premature babies.

Cohort profile: the Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) cohort, a prospective preterm birth cohort in New York City

PURPOSE

The Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) longitudinal preterm birth cohort studies the impact of the NICU exposome on early-life development. NICU-HEALTH collects multiple biospecimens, complex observational and survey data and comprehensive multisystem outcome assessments to allow measurement of the impact of modifiable environmental exposures during the preterm period on neurodevelopmental, pulmonary and growth outcomes.

PARTICIPANTS

Moderately preterm infants without genetic or congenital anomalies and their mothers are recruited from an urban academic medical centre level IV NICU in New York City, New York, USA. Recruitment began in 2011 and continues through multiple enrolment phases to the present with goal enrolment of 400 infants. Follow-up includes daily data collection throughout the NICU stay and six follow-up visits in the first 2 years. Study retention is 77% to date, with the oldest patients turning age 8 in 2019.

FINDINGS TO DATE

NICU-HEALTH has already contributed significantly to our understanding of phthalate exposure in the NICU. Phase I produced the first evidence of the clinical impact of phthalate exposure in the NICU population. Further study identified specific sources of exposure to clinically relevant phthalate mixtures in the NICU.

FUTURE PLANS

Follow-up from age 3 to 12 is co-ordinated through integration with the Environmental Influences on Child Health Outcomes (ECHO) programme. The NICU-HEALTH cohort will generate a wealth of biomarker, clinical and outcome data from which future studies of the impact of early-life chemical and non-chemical environmental exposures can benefit. Findings from study of this cohort and other collaborating environmental health cohorts will likely translate into improvements in the hospital environment for infant development.

TRIAL REGISTRATION NUMBERS

This observational cohort is registered with ClinicalTrials.gov (NCT01420029 and NCT01963065).