Positioning Effects for Procedural Pain Relief in NICU: Systematic Review

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.

Short-Term Effects of Conventional Chest Physiotherapy and Expiratory Flow Increase Technique on Respiratory Parameters, Heart Rate, and Pain in Mechanically Ventilated Premature Neonates: A Randomized Controlled Trial

Background/Objectives: Prematurity is a leading cause of infant mortality and mechanical ventilation increases respiratory complication risk. The effects of secretion removal techniques in premature infants remain a topic of ongoing debate. The aim of the study is to compare two secretion removal techniques in premature infants on mechanical ventilation; Methods: The participants were randomized into conventional chest physiotherapy (CPT; n = 22) or expiratory flow increase technique (EFIT; n = 21) groups. Each participant completed four sessions on consecutive days with a minimum of one and a maximum of two sessions per day. We assessed peripheral oxygen saturation (SpO2), heart (HR) and respiratory rates (RR), tidal volume (VT), and pain levels at specific time points: before the intervention, immediately after the intervention, 5 min after the intervention, and 10 min after the intervention. The partial Eta squared (ŋp2) was reported to measure the effect size; Results: HR and RR increased post-intervention in both groups (p < 0.001; HR ŋp2 = 0.51; RR ŋp2 = 0.38); post hoc comparisons showed EFIT group decreased RR from the first to last session (p = 0.045). Both groups exhibited increased VT and SpO2 in all sessions (p < 0.001; VT ŋp2 = 0.40; SpO2 ŋp2 = 0.50). The EFIT group had higher SpO2 values (p = 0.013; ŋp2 = 0.15) and lower pain scores (p < 0.001; ŋp2 = 0.46) post-intervention compared to CPT; Conclusions: CPT and EFIT resulted in similar effects on short-term respiratory parameters and heart rate; however, EFIT had advantages, including lower RR, higher SpO2, and reduced pain, suggesting it may be a more effective, comfortable neonatal respiratory treatment.

Characteristics of intervention studies on family-centred care in neonatal intensive care units: a scoping review of randomised controlled trials

BACKGROUND

Different definitions of family-centred care (FCC) exist in the newborn setting, and many FCC interventions have been tested, while a comprehensive review synthesising characteristics of existing intervention studies is still lacking.

OBJECTIVE

This review aims at summarising the characteristics of randomised controlled trials (RCTs) on FCC interventions in neonatal intensive care units.

METHODS

We searched PubMed, Embase, Web of Science and the Cochrane Library up to 31 January 2022, and reference lists of included studies and other reviews. Interventions were grouped into five categories according to a previous Cochrane review: (1) family support, (2) educational, (3) communication, (4) environmental interventions and (5) family-centred policies. Subgroup analyses by time period (RCTs published before vs after 2016) and by country income (based on the World Bank Classification) were conducted.

RESULTS

Out of 6583 retrieved studies, 146 RCTs met the eligibility criteria, with 53 (36.3%) RCTs published after 2016. Overall, 118 (80.8%) RCTs were conducted in high-income countries, 28 (19.1%) in middle-income countries and none in low-income countries. Only two RCTs were multicountry. Although mothers were the most frequent caregiver involved, fathers were included in 41 RCTs (28.1%). Very few studies were conducted in at-term babies (nine RCTs); siblings (two RCTs) and other family members (two RCTs), maternity care units (two RCTs). The role of health professionals was unclear in 65 (44.5%) RCTs. A large variety of intervention combinations was tested, with 52 (35.6%) RCTs testing more than 1 category of interventions, and 24 (16.4%) RCTs including all 5 categories.

CONCLUSION

There is a large and rising number of RCTs on FCC interventions in neonatal intensive care units, with specific research gaps. The large variety of FCC interventions, their high complexity, the need to tailor them to the local context and major gaps in implementation suggest that implementation research is the current priority.

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.

Uni- and multimodal sensory-supported interventions for very preterm and extremely preterm infants in the neonatal intensive care unit: An overview of systematic reviews and interventional studies

BACKGROUND

Very and extremely preterm infants (VEPIs) experience sensory deprivation in the neonatal intensive care unit (NICU). While various sensory-supported interventions might improve immediate physiological response, their impact on long-term development remains unclear. Additionally, these interventions may pose challenges in the NICU environment due to complex treatments and monitoring requirements.

AIMS

This review aimed to understand the current evidence on sensory-supported interventions in the NICU, identify the components of these interventions and determine their effects on the VEPIs.

STUDY DESIGN

A systematic search across nine electronic databases (PubMed, EBSCO, EMBASE, Web of Science, Scopus, Cochrane, Cochrane trial, IEEE Xplore DL and ACM DL) was conducted in December 2020 and updated in September 2022. The search gathers information on sensory-supported interventions for VEPIs in the NICU.

RESULTS

The search yielded 23 systematic reviews and 22 interventional studies, categorized into auditory (19), tactile/kinesthetic (5), positional/movement support (7), visual (1) and multisensory (13) interventions. While unimodal and multimodal interventions showed short-term benefits, their long-term effects on VEPIs are indeterminate. Translating these findings into clinical practice remains a challenge due to identified gaps.

CONCLUSION

Our reviews indicate that sensory-supported interventions have a transient impact, with intervention studies reporting positive effects. Future research should develop and test comprehensive, continuous multisensory interventions tailored for the early NICU stage.

RELEVANCE TO CLINICAL PRACTICE

Multimodal sensory interventions show promise for VEPIs, but long-term effects need further study. Standardizing protocols for NICU integration and parental involvement is crucial. Ongoing research and collaboration are essential for optimizing interventions and personalized care.

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.

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.

Pain responses in preterm infants and parental stress over repeated painful procedures: a randomized pilot trial

OBJECTIVES

In this pilot study, the aims were to determine the feasibility of whether pain behavior in extremely and very preterm infants and perceived parental stress change when parents are involved in pain reducing measures, either actively, performing facilitated tucking or passively, observing the intervention, in comparison to the involvement of nurses only. In addition, the infant's pain reactivity and parental stress over three time points of measurement was of interest.

METHODS

Extremely and very preterm infants in need of subcutaneous erythropoietin were randomly assigned to the two intervention groups. The intervention encompassed that one parent of each infant was involved during the painful procedure: Either parents executed facilitated tucking themselves or stood by, observing the procedure. Usual care involved that nurse executed facilitated tucking. All infants received 0.5 ml of 30% oral glucose solution via cotton swab before the painful procedure. Infant pain was observed with the Bernese Pain Scale for Neonates (BPSN) and measured with the MedStorm skin conductance algesimeter (SCA) before, during, and after the procedure. Parents' stress levels were measured before and after the painful procedure on the infant, using the Current Strain Short Questionnaire (CSSQ). Feasibility of a subsequent trial was determined by assessing recruitment, measurement and active parental involvement. Quantitative data collection methods (i.e. questionnaires, algesimeter) were employed to determine the number of participants for a larger trial and measurement adequacy. Qualitative data (interviews) was employed to determine parents' perspectives of their involvement.

RESULTS

A total of 13 infants (98% participation rate) were included along with their mothers. Median gestational age was 27 weeks (IQR 26-28 weeks), 62% were female. Two infants (12.5%) dropped out of the study as they were transferred to another hospital. Facilitated tucking turned out to be a good method to actively involve parents in pain reducing measures. No significant differences between the two intervention and control groups were found concerning parental stress and infant pain (p = .927). Power analysis indicated that at least N = 741 infants (power of 81%, α = .05) would be needed to obtain statistically significant results in a larger trial, as effect sizes were smaller than expected. Two of the three measurement tools - i.e. the BPSN and CSSQ) - proved easy to implement and were well accepted. owever, the SCA was challenging in this context. Measurements were also found to be time-consuming and resource-intense (i.e. health professionals as assistants).

CONCLUSIONS

Although the intervention was feasible and was readily accepted by parents, the study design was found to be challenging along with the SCA. In preparation of the larger trial, the study design needs to be revisited and adjusted. Thus, issues of time and resources may be resolved. In addition, national and international collaboration with similar neonatal intensive care units (NICU) needs to be considered. Thus, it will be possible to conduct an appropriately powered larger trial, which will yield important results to improve pain management in extremely and preterm infants in NICU.

[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.

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.