Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial

A machine learning artefact detection method for single-channel infant event-related potential studies

Objective. Automated detection of artefact in stimulus-evoked electroencephalographic (EEG) data recorded in neonates will improve the reproducibility and speed of analysis in clinical research compared with manual identification of artefact. Some studies use very short, single-channel epochs of EEG data with little recorded EEG per infant-for example because the clinical vulnerability of the infants limits access for recording. Current artefact-detection methods that perform well on adult data and resting-state and multi-channel data in infants are not suitable for this application. The aim of this study was to create and test an automated method of detecting artefact in single-channel 1500 ms epochs of infant EEG.Approach. A total of 410 epochs of EEG were used, collected from 160 infants of 28-43 weeks postmenstrual age. This dataset-which was balanced to include epochs of background activity and responses to visual, auditory, tactile and noxious stimuli-was presented to seven independent raters, who independently labelled the epochs according to whether or not they were able to visually identify artefacts. The data was split into a training set (340 epochs) and an independent test set (70 epochs). A random forest model was trained to identify epochs as either artefact or not artefact.Main results. This model performs well, achieving a balanced accuracy of 0.81, which is as good as manual review of data. Accuracy was not significantly related to the infant age or type of stimulus.Significance. This method provides an objective tool for automated artefact rejection for short epoch, single-channel EEG in neonates and could increase the utility of EEG in neonates in both the clinical and research setting.

Effects of pain, sedation and analgesia on neonatal brain injury and brain development

Critically ill newborns experience numerous painful procedures as part of lifesaving care in the Neonatal Intensive Care Unit. However, painful exposures in the neonatal period have been associated with alterations in brain maturation and poorer neurodevelopmental outcomes in childhood. The most frequently used medications for pain and sedation in the NICU are opioids, benzodiazepines and sucrose; these have also been associated with abnormalities in brain maturation and neurodevelopment making it challenging to know what the best approach is to treat neonatal pain. This article provides clinicians with an overview of how neonatal exposure to pain as well as analgesic and sedative medications impact brain maturation and neurodevelopmental outcomes in critically ill infants. We also highlight areas in need of future research to develop standardized neonatal pain monitoring and management strategies.

Brain health in preterm infants: importance of early-life pain and analgesia exposure

"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.

Efficacy of sucrose application in minimizing pain perception related to dental injection in children aged 3 to 9 years: a randomized control trial

Background

Dental fear and anxiety are significant challenges in managing behavior in children. Oral administration of sucrose or sweet-tasting solutions has shown effectiveness in reducing procedural pain in infants and neonates. This study aimed to investigate whether pre-application of sucrose solution had an effect on minimizing pain perception during injection and to assess the potential impact of the child's age and sweet preference.

Methods

A randomized control clinical trial was conducted on 60 children aged 3-9 years requiring buccal infiltration injections. Following parental consent, demographic data of the children were recorded. Sweet preferences was assessed using a modified forced-choice test. Children were equally and randomly allocated into study (sucrose) and control groups using a lottery method. Sucrose solution or distilled water, respectively, was applied to the lateral surface of the tongue for 2 min. Topical anesthetic was applied at the site of injection, followed by local anesthesia administration. The children rinsed their mouths thrice with water immediately after anesthetic injection. A video was recorded during injection which was then scored by three blinded examiners on the Sound Eye Motor (SEM) scale. The children also self-evaluated using Wong-Baker Faces Pain Rating Scale (WBFPS).

Results

The mean SEM scores and WBFPS scores were analyzed using the Kruskall-Wallis test. The mean SEM score in the study group was 1.37 ± 0.61, compared to 3.17 ± 0.87 in the control group, showing a statistically significant difference (P < 0.001). Mean pain scores assessed by WBFPS in the study group were 0.60 ± 1.4, while in the control group, they were 6.27 ± 2.33, also showing a statistically significant difference (P < 0.001). Children with a sweet preference demonstrated a subjective reduction in pain perception.

Conclusion

Application of sucrose before dental injections in children helps to minimize pain upon injection across all age groups.

Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates

BACKGROUND

Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations. Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain.

OBJECTIVES

To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention.

SEARCH METHODS

We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals.

DATA COLLECTION AND ANALYSIS

Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates. Facilitated tucking versus standard care (four studies) Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD -2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence). Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD -3.06 beats per minute (bpm), 95% CI -9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI -1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD -1.20, 95% CI -3.47 to 1.07; 1 study, 20 infants; low-certainty evidence). Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence). No studies reported intraventricular haemorrhage (IVH). Familiar odour versus standard care (one study) Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD -0.30, 95% CI -2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD -6.30 bpm, 95% CI -16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD -0.80, 95% CI -4.82 to 3.22; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. White noise (one study) White noise during endotracheal suctioning probably has little or no effect on PIPP (MD -0.65, 95% CI -2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD -1.85 bpm, 95% CI -11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI -2.03 to 6.53; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH.

AUTHORS' CONCLUSIONS

Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning. Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.

Ultrasound-guided spinal anesthesia in infants: a narrative review

BACKGROUND/IMPORTANCE

Infant spinal anesthesia has many potential benefits. However, the delivery of infant spinal anesthesia is technically challenging. The landmark-based technique has not changed for over a century. Advancements in ultrasound technology may provide an opportunity to improve infant spinal procedures.

OBJECTIVE

Our primary objective is to conduct a comprehensive review of the current literature on ultrasonography for spinal anesthesia in infants. Given the narrow scope of this topic, our secondary objective is to review the current literature on ultrasonography for lumbar puncture in infants.

EVIDENCE REVIEW

We reviewed all papers related to the use of ultrasound for infant spinal anesthesia. Two large databases were searched with key terms. Eligibility criteria were full-text articles in English. For our secondary objective, we searched one large database for key terms relating to ultrasonography and infant lumbar puncture. Eligibility criteria were the same.

FINDINGS

Our primary search retrieved six articles. These consisted of four review articles, one case report, and one retrospective observational study. Our secondary search retrieved fourteen articles. These consisted of five randomized control trials, four prospective studies, three retrospective studies, and two review papers.

CONCLUSIONS

Ultrasound yields high-quality images of the infant spine. Most literature regarding ultrasound for infant spinal procedures arises from emergency medicine or interventional radiology specialties. The literature on ultrasound for infant spinal anesthesia is extremely limited, but shows promise. Future studies are needed in order to determine whether ultrasound can improve the success rate for delivery of infant spinal anesthesia.

Sucrose solution for alleviating needle pain during inferior alveolar nerve block in children aged 7-10 years: a randomized clinical trial

Background

Intraoral local anesthesia is essential for delivering dental care; however, injection of this local anesthetic is perceived as the most painful and distressing agent for children, parents, and healthcare providers. Reducing pain as much as possible is essential to ensure smooth subsequent treatment procedures, especially in pediatric dentistry. In clinical practice, oral sucrose administration has been reported to decrease the pain during heel lance and cold pressor tests in neonates and children. This study aimed to determine whether the prior administration of a 30% sucrose solution reduced the pain related to inferior alveolar nerve block in children.

Methods

A total of 42 healthy children aged 7-10 years requiring dental treatment of mandibular molars involving inferior alveolar nerve block were recruited. The participants' demographic details were recorded, height and weight were measured, and the anesthetic injection was delivered after receiving the respective intraoral sucrose solution and distilled water by the intervention (group 1) and control (group 2) group participants for 2 min. The subjective pain perceived during injection was measured using an animated emoji scale. The pain scores between the groups were compared using the Mann-Whitney U test.

Results

The median pain score and range for the intervention and control groups were 4 (2 - 6) and 6 (4 - 8), respectively, and statistically significant differences (P < 0.001) were observed in the intervention group. Age, sex, height, and weight did not influence the analgesic effect of the sucrose solution.

Conclusion

Oral administration of sucrose may relieve pain associated with inferior alveolar nerve block in children.

Effects of fentanyl and sucrose on pain in retinopathy examinations with pain scale, near-infrared spectroscopy, and ultrasonography: a randomized trial

BACKGROUND

This study aimed to compare the efficacy of intravenous, intranasal fentanyl and oral sucrose in reducing the pain response during retinopathy of prematurity examinations using premature infant pain profile (PIPP) scores.

METHOD

The study included 42 infants who underwent retinopathy screening examinations. The infants were divided into three groups: oral sucrose, intranasal fentanyl, and intravenous fentanyl. Vital signs (heart rate, arterial oxygen saturation, and mean arterial pressure) were recorded. The PIPP was used to determine pain severity. Cerebral oxygenation and middle cerebral artery blood flow were evaluated using near-infrared spectroscopy and Doppler ultrasonography, respectively. The data obtained were compared between groups.

RESULTS

There was no significant difference between the three groups regarding postconceptional and postnatal ages or birth weights and weight at the time of examination. All babies had moderate pain during the examination. No correlation was observed between analgesia method and pain scores (P = 0.159). In all three groups, heart rate and mean arterial pressure increased, whereas oxygen saturation decreased during the exam compared with pre-examination values. However, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation (sPO2) values did not differ between groups (HR, P = 0.150; MAP, P = 0.245; sPO2, P = 0.140). The cerebral oxygenation (rSO2) values between the three groups were found to be similar [rSO2: P = 0.545, P = 0.247, P = 0.803; fractional tissue oxygen extraction (FTOE): P = 0.553, P = 0.278]. Regarding cerebral blood flow values, we also did not find any difference between the three groups [mean blood flow velocity (Vmean): P = 0.569, P = 0.975; maximum flow velocity (Vmax): P = 0.820, P = 0.997].

CONCLUSIONS

Intravenous and intranasal fentanyl and oral sucrose were not superior to each other in preventing pain during the examination for retinopathy of prematurity (ROP). Sucrose may be a good alternative for pain control during ROP examination. Our findings suggest that ROP exam may not affect cerebral oxygenation or cerebral blood flow. Larger scale studies are needed to determine the best pharmacological option to reduce pain during ROP exams and evaluate the effects of this procedure on cerebral oxygenation and blood flow.

Sucrose analgesia for heel-lance procedures in neonates

BACKGROUND

Sucrose has been examined for calming and pain-relieving effects in neonates for invasive procedures such as heel lance.

OBJECTIVES

To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long-term outcomes SEARCH METHODS: We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries.

SELECTION CRITERIA

We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non-nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin-to-skin care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. We assessed heterogeneity by the I2 test. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD -1.74 (95% CI -2.11 to -1.37); I2 = 62%; moderate-certainty evidence) and 60 seconds after lancing (MD -2.14, 95% CI -3.34 to -0.94; I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD -1.90, 95% CI -8.58 to 4.78; heterogeneity not applicable (N/A); very low-certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD -2.00, 95% CI -2.42 to -1.58; heterogeneity N/A; moderate-certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI -0.30 to 1.50; heterogeneity not applicable; very low-certainty evidence) and on DAN scores at 30 seconds after lancing (MD -1.20, 95% CI -7.87 to 5.47; heterogeneity N/A; very low-certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD -4.90, 95% CI -5.73 to -4.07; heterogeneity not applicable; very low-certainty evidence) and during recovery after lancing (MD -3.80, 95% CI -4.47 to -3.13; heterogeneity N/A; very low-certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD -0.60, 95% CI -1.47 to 0.27; heterogeneity N/A; very low-certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI -0.70 to 1.22; heterogeneity not applicable; low-certainty evidence) and 60 seconds after lancing (MD -0.02, 95% CI -0.79 to 0.75; heterogeneity N/A; low-certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD -0.70, 95% CI -0.49 to 1.88; I2 = 94%; very low-certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD -2.60, 95% CI -3.06 to -2.14; heterogeneity N/A; very low-certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP-R scores compared to expressed breast milk during (MD 0.3, 95% CI -0.24 to 0.84; heterogeneity not applicable; low-certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI -0.11 to 0.71; heterogeneity N/A; low-certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP-R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low-certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD -1.80, 95% CI -8.47 to 4.87; heterogeneity N/A; very low-certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP-R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD -0.86, 95% CI -1.43 to -0.29; heterogeneity N/A; very low-certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD -2.27, 95% CI -4.66 to 0.12; heterogeneity N/A; very low-certainty evidence) and during recovery after lancing (MD -0.31, 95% CI -1.72 to 1.10; heterogeneity N/A; very low-certainty evidence). Sucrose vs skin-to-skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 30 seconds after 1st (MD 0.13, 95% CI -0.70 to 0.96); 2nd (MD -0.56, 95% CI -1.57 to 0.45); or 3rd lancing (MD-0.15, 95% CI -1.26 to 0.96); heterogeneity N/A, low-certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 60 seconds after 1st (MD -0.61, 95% CI -1.55 to 0.33); 2nd (MD -0.12, 95% CI -0.99 to 0.75); or 3rd lancing (MD-0.40, 95% CI -1.48 to 0.68); heterogeneity N/A, low-certainty evidence for all comparisons. Minor adverse events required no intervention.

AUTHORS' CONCLUSIONS

Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate-certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin-to-skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence.

Evaluation of the effectiveness of sucrose versus xylitol application in minimizing pain related to dental injection in 5-7-year-old children - A randomized controlled pilot study

Background

Oral application of sweet-tasting solutions has found to be effective in minimizing pain on dental injection in children. Xylitol has never been tested in this regard.

Aim

The aim of this study was to compare the effectiveness of prior application of sucrose versus xylitol solution in minimizing pain on dental injection in 5-7-year-old children.

Settings and Design

This study was a randomized controlled clinical trial.

Materials and Methods

Informed consent was taken. A total of 30 children who required maxillary buccal infiltration injection were selected. The children were randomly allocated into the sucrose group, xylitol group, or control group by lottery method. In the sucrose and xylitol groups, 30% sucrose or 30% xylitol solution was applied on the lateral surface of the tongue for 2 min. In the control group, distilled water was applied. In all the groups, the topical anesthetic was applied at the site of injection followed by buccal infiltration. A video was taken during injection, and the sound eye-motor (SEM) scale was recorded by a blinded examiner. Patients were asked to self-evaluate using the Wong-Baker Faces Pain Scale (WBFPS).

Statistical Analysis

Mann-Whitney test was used to analyze the data.

Results

There was a statistically significant difference in the WBFPS and the SEM score between the sucrose and the control group (P < 0.05) and the xylitol and control group (P < 0.05). No statistically significant difference was found between the sucrose and xylitol group.

Conclusion

The application of xylitol solution before dental injection was as effective as sucrose solution in minimizing pain during the injection.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Assessment of Comfort during Less Invasive Surfactant Administration in Very Preterm Infants: A Multicenter Study

INTRODUCTION

This study was set up to investigate if and to what extent non-pharmacological analgesia is able to provide comfort to very preterm infants (VPI) during less invasive surfactant administration (LISA).

METHODS

This was a prospective non-randomized multicenter observational study performed in level IV NICUs. Inborn VPI with a gestational age between 220/7 and 316/7 weeks, signs of respiratory distress syndrome, and the need for surfactant replacement were included. Non-pharmacological analgesia was performed in all infants during LISA. In case of failure of the first LISA attempt, additional analgosedation could be administered. COMFORTneo scores during LISA were assessed.

RESULTS

113 VPI with a mean gestational age of 27 weeks (+/- 2.3 weeks) and mean birth weight of 946 g (+/- 33 g) were included. LISA was successful at the first laryngoscopy attempt in 81%. COMFORTneo scores were highest during laryngoscopy. At this time point, non-pharmacological analgesia provided adequate comfort in 61% of the infants. 74.4% of lower gestational aged infants (i.e., 220-266 weeks) were within the comfort zone during laryngoscopy compared to 51.6% of higher gestational aged infants (i.e., 270-320 weeks) (p = 0.016). The time point of surfactant administration did not influence the COMFORTneo scores during the LISA procedure.

CONCLUSION

Non-pharmacological analgesia provided comfort in as much as 61% of the included VPI during LISA. Further research is needed to both develop strategies to identify infants who, despite receiving non-pharmacological analgesia, are at high risk for experiencing discomfort during LISA and define patient-tailored dosage and choice of analgosedative drugs.

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.

Retroperitoneal localized neuroblastoma in children: a comparison of enhanced recovery after surgery versus traditional care

PURPOSE

To investigate the clinical value of enhanced recovery after surgery (ERAS) protocols for children with neuroblastoma (NB).

METHODS

This retrospective review was conducted by using the electronic medical records of 48 children with retroperitoneal localized NB who underwent tumor resection (surgery for treatment, not diagnosis) between October 2016 and September 2021. The ERAS protocols for NB excision were implemented in 28 children (ERAS group), while 20 children received traditional care (TRAD group). The same group of pediatric surgeons performed all the tumor resections. Intraoperative fluid infusion, the extent of NB resection, time of early ambulation and time of first flatus, time to total enteral nutrition (TEN) after surgery, abdominal drainages, nasogastric tubes and urinary catheters used and duration, the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table on a postoperative day 1 (POD1), 3, 5, length of stay after surgery (LOS), hospitalization expense, postoperative complications, parental satisfaction rate and readmission rate of surgical wards within 30 days after operation were analyzed.

RESULTS

The median postoperative period of early mobilization, first flatus, TEN, LOS and total cost during hospitalization were 1.0 days, 2.0 days, 5.5 days, 9.0 days and 33,397.3 yuan in the ERAS group and 3.0 days, 3.0 days, 7.0 days, 11.0 days and 38,120.3 Yuan in the TRAD group, respectively (all p < 0.05). Median intraoperative fluid volume was 5.0 mL/kg/h compared to 8.0 mL/kg/h and the magnitude of decrease in FLACC scores from POD1 to POD5 was greater in the ERAS group (all p < 0.05). Abdominal drainages, urinary catheters and nasogastric tubes were removed earlier in the ERAS group (p < 0.05). The satisfaction of parents in the ERAS group was slightly higher, but the difference was not statistically significant (P = 0.762). There were no marked differences between the two groups in aspects of the extent of NB resection, operation-related complications and 30-day readmissions (all P = 1.000).

CONCLUSIONS

Application of ERAS protocols in localized retroperitoneal NBs resection in children is feasible and safe. However, applying ERAS protocols in the surgical resection of solid tumors in children still requires much more research, especially randomized prospective research.

Clinical thresholds in pain-related facial activity linked to differences in cortical network activation in neonates

ABSTRACT

In neonates, a noxious stimulus elicits pain-related facial expression changes and distinct brain activity as measured by electroencephalography, but past research has revealed an inconsistent relationship between these responses. Facial activity is the most commonly used index of neonatal pain in clinical settings, with clinical thresholds determining if analgesia should be provided; however, we do not know if these thresholds are associated with differences in how the neonatal brain processes a noxious stimulus. The objective of this study was to examine whether subclinical vs clinically significant levels of pain-related facial activity are related to differences in the pattern of nociceptive brain activity in preterm and term neonates. We recorded whole-head electroencephalography and video in 78 neonates (0-14 days postnatal age) after a clinically required heel lance. Using an optimal constellation of Neonatal Facial Coding System actions (brow bulge, eye squeeze, and nasolabial furrow), we compared the serial network engagement (microstates) between neonates with and without clinically significant pain behaviour. Results revealed a sequence of nociceptive cortical network activation that was independent of pain-related behavior; however, a separate but interleaved sequence of early activity was related to the magnitude of the immediate behavioural response. Importantly, the degree of pain-related behavior is related to how the brain processes a stimulus and not simply the degree of cortical activation. This suggests that neonates who exhibit clinically significant pain behaviours process the stimulus differently and that neonatal pain-related behaviours reflect just a portion of the overall cortical pain response.

A developmental shift in habituation to pain in human neonates

Habituation to recurrent non-threatening or unavoidable noxious stimuli is an important aspect of adaptation to pain. Neonates, especially if preterm, are exposed to repeated noxious procedures during their clinical care. They can mount strong behavioral, autonomic, spinal, and cortical responses to a single noxious stimulus; however, it is not known whether the developing nervous system can adapt to the recurrence of these inputs. Here, we used electroencephalography to investigate changes in cortical microstates (representing the complex sequential processing of noxious inputs) following two consecutive clinically required heel lances in term and preterm infants. We show that stimulus repetition dampens the engagement of initial microstates and associated behavioral and autonomic responses in term infants, while preterm infants do not show signs of habituation. Nevertheless, both groups engage different longer-latency cortical microstates to each lance, which is likely to reflect changes in higher-level stimulus processing with repeated stimulation. These data suggest that while both age groups are capable of encoding contextual differences in pain, the preterm brain does not regulate the initial cortical, behavioral, and autonomic responses to repeated noxious stimuli. Habituation mechanisms to pain are already in place at term age but mature over the equivalent of the last trimester of gestation and are not fully functional in preterm neonates.

Sensorial saturation improves infants' procedure-related pain behaviour in the cardiac intensive care unit: A quasi-experimental study

BACKGROUND

Painful procedures are unavoidable when providing critical care to infants in intensive care units. These adverse experiences during infancy can lead to later hyperalgesia and poor neurodevelopmental outcomes. Thus, appropriate interventions are required to relieve infant pain during these procedures.

OBJECTIVES

This study evaluated the effectiveness of sensorial saturation in reducing pain for infants during jugular central venous catheter removal procedures in intensive care units.

METHODS

This study involved a quasi-experimental, repeated-measures design. Data were collected from participants sequentially recruited from April to June 2019 (control period) and July to September 2019 (experimental period). Participants included 78 infants younger than 1 year with congenital heart disease. The control group (n = 38) received a general nursing intervention using swaddling, a common child-care practice that consists of wrapping infants to restrict movements, whereas the experimental group (n = 40) received sensorial saturation using oral sugar, body massage, and verbal interaction. Infants' physiological reactions to procedural pain were measured by changes in heart rate, oxygen saturation, and respiratory rate. Infants' procedural pain and behavioural indicators were measured using the Modified Behavioural Pain Scale. Data were analysed using descriptive statistics, independent t-tests, χ² tests, and repeated-measures analysis of variance.

RESULTS

Compared with the control group, the experimental group had lower heart rates (F = 53.15, p < .001), respiratory rates (F = 15.19, p < .001), and behavioural pain scores (F = 45.21, p < .001), both during and after the procedure.

CONCLUSIONS

Sensorial saturation can be used as a nursing intervention in infants. Given the many invasive procedures that are part of infant clinical care, sensorial saturation may be a safe analgesic alternative. The findings of this study could lead to the development of evidence-based clinical practice guidelines for the nonpharmacological management of acute pain in infants.

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.

Multicentre, randomised controlled trial to investigate the effects of parental touch on relieving acute procedural pain in neonates (Petal)

INTRODUCTION

Newborn infants routinely undergo minor painful procedures as part of postnatal care, with infants born sick or premature requiring a greater number of procedures. As pain in early life can have long-term neurodevelopmental consequences and lead to parental anxiety and future avoidance of interventions, effective pain management is essential. Non-pharmacological comfort measures such as breastfeeding, swaddling and sweet solutions are inconsistently implemented and are not always practical or effective in reducing the transmission of noxious input to the brain. Stroking of the skin can activate C-tactile fibres and reduce pain, and therefore could provide a simple and safe parent-led intervention for the management of pain. The trial aim is to determine whether parental touch prior to a painful clinical procedure provides effective pain relief in neonates.

METHODS AND ANALYSIS

This is a multicentre randomised controlled trial. A total of 112 neonates born at 35 weeks' gestation or more requiring a blood test in the first week of life will be recruited and randomised to receive parental stroking either preprocedure or postprocedure. We will record brain activity (EEG), cardiac and respiratory dynamics, oxygen saturation and facial expression to provide proxy pain outcome measures. The primary outcome will be the reduction of noxious-evoked brain activity in response to a heel lance. Secondary outcomes will be a reduction in clinical pain scores (Premature Infant Pain Profile-Revised), postprocedural tachycardia and parental anxiety.

ETHICS AND DISSEMINATION

The study has been approved by the London-South East Research Ethics Committee (ref: 21/LO/0523). The results will be widely disseminated through peer-reviewed publications, international conferences and via our partner neonatal charities Bliss and Supporting the Sick Newborn And their Parents (SSNAP). If the parental tactile intervention is effective, recommendations will be submitted via the National Health Service clinical guideline adoption process.

STUDY STATUS

Commenced September 2021.

TRIAL REGISTRATION NUMBER

NCT04901611; 14 135 962.

Breast milk vs 24% sucrose for procedural pain relief in preterm neonates: a non-inferiority randomized controlled trial

OBJECTIVES

To compare the pain scores between the two groups, breast milk (BM) and 24% sucrose, in preterm neonates undergoing automated heel lance for the blood draw.

METHODS

The study is designed as a randomized, single-blinded, non-inferiority trial. Infants born between 30 1/7weeks and 36 6/7 weeks of gestation were randomly assigned to receive either 24% sucrose or expressed BM. The Premature Infant Pain Profile-Revised (PIPP-R) was utilized to provide pain scores.

RESULTS

No differences were noted in the baseline characteristics between the two groups. The quantile regression estimates for PIPP-R scores during the procedure were statistically non-significant at all percentile levels of distribution (50%ile coefficient 0, 95% CI -0.49 to 0.49).

CONCLUSION

We conclude that BM is not inferior to 24% sucrose in providing analgesia during heel lance in moderate and late preterm infants.

TRIAL REGISTRATION

This trial was registered at www.

CLINICALTRIALS

gov (identifier NCT04898881).

The influence of skin-to-skin contact on Cortical Activity during Painful procedures in preterm infants in the neonatal intensive care unit (iCAP mini): study protocol for a randomized control trial

Background

Strong evidence suggests that maternal-infant skin-to-skin contact (SSC) is effective in reducing behavioural responses to pain. Given the multi-sensory benefits of SSC, it is highly likely that SSC provided during pain in early life may reduce pain-induced brain activity. The aim of this study is to examine the effect of SSC compared to 24% sucrose on pain-induced activity in the preterm infant brain during a medically required heel lance. Secondary objectives include determining (a) differences between behavioural pain response and noxious-related brain activity during heel lance and (b) rate of adverse events across groups.

Methods

We will randomly assign 126 babies (32 to 36 completed weeks gestational age) admitted to the neonatal intensive care unit, and their mothers within the first seven days of age to receive (i) SSC plus sterile water and (ii) 24% oral sucrose. Each baby will receive a medically indicated heel lance, following a no treatment baseline period. The primary outcome is noxious-related brain activity measured using an electroencephalogram (EEG) pain-specific event-related potential. Secondary outcomes include pain intensity measured using a bio-behavioural infant pain assessment tool (Premature Infant Pain Profile-Revised) and rate of adverse events.

Discussion

This will be the first clinical trial to compare the effect of SSC and 24% sucrose on pain-induced brain activity in the preterm infant brain during a clinical noxious stimulus, measured using EEG. Given the negative neurodevelopmental outcomes associated with unmanaged pain, it is imperative that preterm babies receive the most effective pain-reducing treatments to improve their health outcomes. Our findings will have important implications in informing optimal pain assessment and management in preterm infants.

Trial registration

ClinicalTrials.gov NCT03745963. Registered on November 19, 2018.

Effects of white noise on procedural pain-related cortical response and pain score in neonates: A randomized controlled trial

Objectives

To evaluate the effects of white noise on pain-related cortical response, pain score, and behavioral and physiological parameters in neonates with procedural pain.

Methods

A double-blind, randomized controlled trial was conducted. Sixty-six neonates from the Neonatal Intensive Care Unit in a university-affiliated general hospital were randomly assigned to listen to white noise at 50 dB (experimental group) or 0 dB (control group) 2 min before radial artery blood sampling and continued until 5 min after needle withdrawal. Pain-related cortical response was measured by regional cerebral oxygen saturation (rScO₂) monitored with near-infrared spectroscopy, and facial expressions and physiological parameters were recorded by two video cameras. Two assessors scored the Premature Infant Pain Profile-Revised (PIPP-R) independently when viewing the videos. Primary outcomes were pain score and rScO₂ during arterial puncture and 5 min after needle withdrawal. Secondary outcomes were pulse oximetric oxygen saturation (SpO₂) and heart rate (HR) during arterial puncture, and duration of painful expressions. The study was registered at the Chinese Clinical Trial Registry (ChiCTR2200055571).

Results

Sixty neonates (experimental group, n = 29; control group, n = 31) were included in the final analysis. The maximum PIPP-R score in the experimental and control groups was 12.00 (9.50, 13.00), 12.50 (10.50, 13.75), respectively (median difference −0.5, 95% CI −2.0 to 0.5), and minimum rScO₂ was (61.22 ± 3.07)%, (61.32 ± 2.79)%, respectively (mean difference −0.325, 95% CI −1.382 to 0.732), without significant differences. During arterial puncture, the mean rScO₂, HR, and SpO₂ did not differ between groups. After needle withdrawal, the trends for rScO₂, PIPP-R score, and facial expression returning to baseline were different between the two groups without statistical significance.

Conclusion

The white noise intervention did not show beneficial effects on pain-related cortical response as well as pain score, behavioral and physiological parameters in neonates with procedural pain.

Empathy at birth: Mother's cortex synchronizes with that of her newborn in pain

Early neonatal relation with the caregiver is vital for newborn survival and for the promotion of an appropriate neural development. The aim of this study was to assess if the empathic cortical response of a mother to her baby's pain is synchronized with the neonatal cortical response to the painful stimulation. We used hyperscanning, a functional neuroimaging approach that allows studying functional synchronization between two brains. Sixteen mother-newborn dyads were recruited. Maternal and neonatal cortical activities were simultaneously monitored, by near-infrared spectroscopy, during a heel prick performed on the baby and observed by the mother. Multiple paired t test was used to identify cortical activation, and wavelet transform coherence method was used to explore possible synchronization between the maternal and neonatal cortical areas. Activations were observed in mother's parietal cortex, bilaterally, and in newborn's superior motor/somatosensory cortex. The main functional synchronization analysis showed that mother's left parietal cortex activity cross-correlated with that of her newborn's superior motor/somatosensory cortex. Such synchronization dynamically changed throughout assessment, becoming positively cross-correlated only after the leading role in synchronizing cortical activities was taken up by the newborn. Thus, maternal empathic cortical response to baby pain was guided by and synchronized to the newborn's cortical response to pain. We conclude that, in case of potential danger for the infant, brain areas involved in mother-newborn relationship appear to be already co-regulated at birth.

Functional near-infrared spectroscopy to assess pain in neonatal circumcisions

INTRODUCTION

Pain assessment is challenging in neonates. Behavioral and physiological pain scales do not assess neocortical nociception, essential to pain encoding and central pain pathway development. Functional near-infrared spectroscopy (fNIRS) can assess neocortical activation to noxious stimuli from changes in oxy-(HbO) and total-hemoglobin concentrations (HbT). This study aims to assess fNIRS nociceptive functional activation in the prefrontal cortex of neonates undergoing circumcision through changes in HbO and HbT, and the correlation between changes in fNIRS and Neonatal Infant Pain Scale (NIPS), a behavioral pain assessment scale.

METHODS

In healthy term neonates, HbO, HbT, and NIPS were recorded during sequential circumcision events 1-Prep before local anesthetic injection; 2-Local anesthetic injection; 3-Prep before incision; 4-Oral sucrose; 5-Incision; 6-Gomco (hemostatic device) attached; 7-Gomco twisted on; and 8-Gomco removed. fNIRS and NIPS changes after each event were assessed with Wilcoxon signed-rank test and summarized as median and interquartile range (IQR). Changes in fNIRS vs. NIPS were correlated with Spearman coefficient.

RESULTS

In 31 neonates fNIRS increased (median [IQR] µmol/L) with noxious events: Local injection (HbO: 1.1 [0.5, 3.1], p < .001; HbT: 2.3 [0.2, 7.6], p < .001), Gomco attached (HbO: 0.7 [0.1, 1.7], p = .002; HbT: 0.7 [-0.2, 2.9], p = .02), and Gomco twisted on (HbO: 0.5 [-0.2, 1.7], p = .03; HbT: 0.8 [-0.1, 3.3], p = .02). fNIRS decreased with non-noxious event: Prep before incision (HbO: -0.6 [-1.2, -0.2] p < .001; HbT: -1 [-1.8, -0.4], p < .001). Local anesthetic attenuated fNIRS increases to subsequent sharp stimuli. NIPS increased with subsequent sharp stimuli despite local anesthetic. Although fNIRS and NIPS changed in the same direction, there was not a strong correlation between them.

CONCLUSIONS

During neonatal circumcision, changes in fNIRS differed between different types of painful stimuli, which was not the case for NIPS, suggesting that fNIRS may complement NIPS to assess the quality of pain.

Event-related potentials evoked by skin puncture reflect activation of Aβ fibers: comparison with intraepidermal and transcutaneous electrical stimulations

Background

Recently, event-related potentials (ERPs) evoked by skin puncture, commonly used for blood sampling, have received attention as a pain assessment tool in neonates. However, their latency appears to be far shorter than the latency of ERPs evoked by intraepidermal electrical stimulation (IES), which selectively activates nociceptive Aδ and C fibers. To clarify this important issue, we examined whether ERPs evoked by skin puncture appropriately reflect central nociceptive processing, as is the case with IES.

Methods

In Experiment 1, we recorded evoked potentials to the click sound produced by a lance device (click-only), lance stimulation with the click sound (click+lance), or lance stimulation with white noise (WN+lance) in eight healthy adults to investigate the effect of the click sound on the ERP evoked by skin puncture. In Experiment 2, we tested 18 heathy adults and recorded evoked potentials to shallow lance stimulation (SL) with a blade that did not reach the dermis (0.1 mm insertion depth); normal lance stimulation (CL) (1 mm depth); transcutaneous electrical stimulation (ES), which mainly activates Aβ fibers; and IES, which selectively activates Aδ fibers when low stimulation current intensities are applied. White noise was continuously presented during the experiments. The stimulations were applied to the hand dorsum. In the SL, the lance device did not touch the skin and the blade was inserted to a depth of 0.1 mm into the epidermis, where the free nerve endings of Aδ fibers are located, which minimized the tactile sensation caused by the device touching the skin and the activation of Aβ fibers by the blade reaching the dermis. In the CL, as in clinical use, the lance device touched the skin and the blade reached a depth of 1 mm from the skin surface, i.e., the depth of the dermis at which the Aβ fibers are located.

Results

The ERP N2 latencies for click-only (122 ± 2.9 ms) and click+lance (121 ± 6.5 ms) were significantly shorter than that for WN+lance (154 ± 7.1 ms). The ERP P2 latency for click-only (191 ± 11.3 ms) was significantly shorter than those for click+lance (249 ± 18.6 ms) and WN+lance (253 ± 11.2 ms). This suggests that the click sound shortens the N2 latency of the ERP evoked by skin puncture. The ERP N2 latencies for SL, CL, ES, and IES were 146 ± 8.3, 149 ± 9.9, 148 ± 13.1, and 197 ± 21.2 ms, respectively. The ERP P2 latencies were 250 ± 18.2, 251 ± 14.1, 237 ± 26.3, and 294 ± 30.0 ms, respectively. The ERP latency for SL was significantly shorter than that for IES and was similar to that for ES. This suggests that the penetration force generated by the blade of the lance device activates the Aβ fibers, consequently shortening the ERP latency.

Conclusions

Lance ERP may reflect the activation of Aβ fibers rather than Aδ fibers. A pain index that correctly and reliably reflects nociceptive processing must be developed to improve pain assessment and management in neonates.

Prediction of Nociception in Children Using the Nociceptive Flexion Reflex Threshold and the Bispectral Index-A Prospective Exploratory Observational Study

OBJECTIVES

The prediction of patient responses to potentially painful stimuli remains a challenge in PICUs. We investigated the ability of the paintracker analgesia monitor (Dolosys GmbH, Berlin, Germany) measuring the nociceptive flexion reflex threshold, the cerebral sedation monitor bispectral index (Medtronic, Dublin, Ireland), the COMFORT Behavior, and the modified Face, Legs, Activity, Cry, Consolability Scale scores to predict patient responses following a noxious stimulus.

DESIGN

Single-center prospective exploratory observational study.

SETTING

Fourteen-bed multidisciplinary PICU at the University Children's Hospital, University Medical Center Hamburg Eppendorf, Germany.

PATIENTS

Children on mechanical ventilation receiving analgesic and sedative medications.

INTERVENTIONS

Noxious stimulation by way of endotracheal suctioning.

MEASUREMENTS AND MAIN RESULTS

Two independent observers assessed modified Face, Legs, Activity, Cry, Consolability and COMFORT Behavior Scales scores during noxious stimulation (n = 59) in 26 patients. Vital signs were recorded immediately before and during noxious stimulation; bispectral index and nociceptive flexion reflex threshold were recorded continuously. Mean prestimulation bispectral index (55.5; CI, 44.2-66.9 vs 39.9; CI, 33.1-46.8; p = 0.007), and COMFORT Behavior values (9.5; CI, 9.2-13.2 vs 7.5; CI, 6.7-8.5; p = 0.023) were significantly higher in observations with a response than in those without a response. Prediction probability (Pk) values for patient responses were high when the bispectral index was used (Pk = 0.85) but only fair when the nociceptive flexion reflex threshold (Pk = 0.69) or COMFORT Behavior Scale score (Pk = 0.73) was used. A logistic mixed-effects model confirmed the bispectral index as a significant potential predictor of patient response (p = 0.007).

CONCLUSIONS

In our sample of ventilated children in the PICU, bispectral index and nociceptive flexion reflex threshold provided good and fair prediction accuracy for patient responses to endotracheal suctioning.

Effects of Temperature and Position Change on Neonatal Brain Regional Oxygen Saturation in Tub Bathing: A Prospective Study

INTRODUCTION

A major goal in neonatal medicine is to reduce stress as much as possible in routine care. Bathing is one of the important routine cares for neonates, but it makes a big environmental change for them. We aimed to examine whether water temperature, room temperature, and position changes in tub bathing serve as noxious stimuli to neonates.

METHODS

This prospective trial was performed in full-term and non-low-birth-weight neonates admitted to the hospital between July 2020 and March 2021. Those with underlying diseases, fetal distress, infection, and other medical conditions were excluded. Measurements were taken during the neonates' first tub bath since birth, which was performed by a trained nurse. Changes in regional oxygen saturation (rSO₂), determined using near-infrared spectroscopy, and water and room temperature, were examined at five different time points: upon entering the bath, head washing, position change, exiting the bath, and during the 3 min after bathing.

RESULTS

In total, 17 neonates were analyzed. No changes in rSO₂ due to head washing or position change were observed; however, rSO₂ significantly decreased upon entering (78.5 ± 4.1% vs. 75.7 ± 4.1%, p < 0.001) and exiting the bath (75.8 ± 5.7% vs. 74.4 ± 5.4%, p < 0.04). The rate change in rSO₂ upon entering the bath showed a significant inverse correlation with water temperature (r =  - 0.53, p < 0.03), and there were no significant correlations between rSO₂ and water or room temperature upon exiting the bath. There was no change in body skin temperature before and after bathing, but rSO₂ gradually decreased during the 3 min after bathing.

CONCLUSIONS

Neonates may perceive certain temperatures during bathing as noxious stimuli. Therefore, methods to minimize stress associated with bathing should be implemented to reduce the difference between water temperature and room temperature during bathing.

TRIAL REGISTRATION

This trial has been registered at UMIN repository with the trial number UMIN000041045 ( https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046500 ). The date of the final dataset was April 01, 2021.

Collaboration to Improve Neuroprotection and Neuropromotion in the NICU: Team Education and Family Engagement

The number of babies born extremely low birth weight surviving to be discharged home after experiencing the NICU continues to improve. Unfortunately, early sensory development for these babies occurs in an environment vastly different from the intended in-utero environment and places them at high risk of long-term neurodevelopmental and neurocognitive challenges. Our goal in the NICU must transition from simply discharge home to supporting the neurosensory development necessary for a thriving lifetime. To accomplish a goal of thriving families and thriving babies, it is clear the NICU interprofessional team must share an understanding of neurosensory development, the neuroprotective strategies safeguarding development, the neuropromotive strategies supporting intended maturational development, and the essential nature of family integration in these processes. We share the educational endeavors of 11 center collaboratives in establishing the foundational knowledge necessary to support preterm babies and their families.

An examination of the reciprocal and concurrent relations between behavioral and cardiac indicators of acute pain in toddlerhood

The aim of this study was to examine the concurrent and predictive relations between healthy toddlers' pain behavior and cardiac indicators (ie, heart rate [HR] and respiratory sinus arrhythmia [RSA]) during routine vaccinations. Caregiver-infant dyads were part of a longitudinal cohort observed during their 12- and 18-month vaccinations. Behavioral and cardiac data were simultaneously collected for 1-minute preneedle and 3-minutes postneedle. Videotapes were coded for pain behaviors (FLACC; Merkel et al., 1997), and cardiac data were analyzed (HR, RSA) during sequential 30-second epochs. Four separate cross-lagged path models were estimated using data from the 12- (n = 147) and 18-month (n = 122) vaccinations. Across 12- and 18-month vaccinations, predictive within-measure relations were consistent for FLACC, HR, and RSA, reflecting good stability of these pain indicators. Behavioral indicators predicted subsequent HR and RSA within the immediate postneedle period. Both baseline behavior and HR/RSA predicted future pain scores. Concurrent residual relations between behavioral and cardiac indicators were inconsistent across time and indicators. Results suggest that behavioral and cardiac indicators reflect unique aspects of the nociceptive response. As such, multimodal assessment tools should be used and contextualized by child age, cardiac indicator, baseline behavior/physiology, and pain phase.

Massage therapy as a non-pharmacological analgesia for procedural pain in neonates: A scoping review

INTRODUCTION

Neonates who undergo painful medical procedures should be given analgesics to reduce future adverse risks. The evidence for massage therapy (MT) as an analgesic method still varies, both in its terminology and implementation. Only a few studies on this topic have been conducted using a standardised trial approach. This review can thus become the basis for better future research.

OBJECTIVE

This review aims to identify literature on MT practices as a method to manage or control pain in neonates undergoing painful procedures.

METHODS

The methodology for this review followed the JBI scoping review methodology guidelines. Searches were performed in several databases: MEDLINE (PubMed), CINAHL (EBSCO), Scopus (Elsevier) and EMBASE. Data collected were then extracted by two independent reviewers, synthesised and presented in the form of tables and narratives.

RESULTS

Fifteen studies involving a total of 1,058 neonates in nine countries were identified in the search as meeting the criteria set for this review. One study was a comparative study, five were quasi-experiment studies and nine were randomised control trials (RCT).

CONCLUSION

The implementation of massage as a non-pharmacological analgesic method for neonates undergoing painful procedures varied among the reviewed studies. Differences were identified in terms of the body part massaged, the duration and intensity of the massage, the level of pressure and the combination of massage with other methods. All studies presented positive results for reducing pain intensity in neonates undergoing procedural pain. Therefore, it is crucial that the method used for giving massage should be practical, accurate and safe.

The influence of breastfeeding on cortical and bio-behavioural indicators of procedural pain in newborns: Findings of a randomized controlled trial

AIMS

The objective of this study was to compare the influence of breastfeeding and 24% oral sucrose on pain-related electrophysiologic activity, bio-behavioural pain scores, physiologic recovery, and adverse events during heel lance.

STUDY DESIGN

Single-blind randomized controlled trial.

SUBJECTS

39 full-term infants were randomized to receive breastfeeding or 0.24 mL of 24% oral sucrose plus offered non-nutritive sucking 2 min prior to heel lance.

OUTCOME MEASURES

The primary outcome of pain-related potential was recorded on electroencephalogram. Secondary outcomes included Premature Infant Pain Profile - Revised (PIPP-R) score, physiologic recovery, and adverse events. Data were analyzed per protocol (ClinicalTrials.gov: NCT03272594).

RESULTS

Between November 2017 and January 2019, 20 infants were randomized to breastfeeding and 19 infants to receive oral sucrose. Infants who were breastfeeding had an appreciably smaller, yet not statistically different (F[1,15.9] = 0.58, p = 0.64, SE = 11.79), amplitude pain-related potential (peak amplitude 0.29 μV) following heel lance compared to infants who received oral sucrose (peak amplitude 8.97 μV). Mean PIPP-R scores were not statistically significantly different between groups following heel lance, however, they were indicative of low pain across groups. Mean time in seconds to physiologic recovery was faster in breastfeeding infants (M = 17.5, SD = 31.1) compared to oral sucrose (M = 70.8, SD = 144.3). There were no safety concerns.

DISCUSSION

Breastfeeding and oral sucrose both reduce bio-behavioural responses to pain, however, may differentially modulate pain response in the infant brain. Further research to understand the neurophysiologic effects of these interventions during acute painful procedures is needed.

The efficacy of administrating a sweet-tasting solution for reducing the pain related to dental injections in children: A randomized controlled trial

BACKGROUND

Anaesthetic injections are an unpleasant experience for children in the dental office. Oral intake of sweet substances by newborns has been shown to be effective in reducing pain.

AIM

The purpose of this study was to determine whether a prior administration of a sweet-tasting solution has an effect on dental injection pain.

DESIGN

A total of 56 healthy children needing bilateral maxillary primary canine extraction were included in this split-mouth randomized clinical trial. In the test side, dental injection (local infiltration) was applied after the patient received a sweet-tasting solution, while in the control side sterile water was administered. The patients' demographic characteristics, body mass index (BMI), and sweet taste preference were recorded. Pain perception during injection was measured using visual analogue scale (VAS) and sound, eye, body movement (SEM).

RESULTS

Mean VAS (28.30 ± 6.43) and SEM (2.14 ± 0.78) in the test side were lower than the control side (45.80 ± 7.17 and 2.95 ± 1.00). It was shown that higher BMI was associated with reduction in the analgesic effect, while the individual's tendency to sweetness increased pain reduction.

CONCLUSIONS

Sweet taste administration before dental injections in children helps to control the associated pain. This effect is influenced by the individual's sweet taste tendency and BMI.

Can Event-Related Potentials Evoked by Heel Lance Assess Pain Processing in Neonates? A Systematic Review

To clarify the possibility of event-related potential (ERP) evoked by heel lance in neonates as an index of pain assessment, knowledge acquired by and problems of the methods used in studies on ERP evoked by heel lance in neonates were systematically reviewed, including knowledge about Aδ and C fibers responding to noxious stimuli and Aβ fibers responding to non-noxious stimuli. Of the 863 reports searched, 19 were selected for the final analysis. The following points were identified as problems for ERP evoked by heel lance in neonates to serve as a pain assessment index: (1) It is possible that the ERP evoked by heel lance reflected the activation of Aβ fibers responding to non-noxious stimuli and not the activation of Aδ or C fibers responding to noxious stimulation; (2) Sample size calculation was presented in few studies, and the number of stimulation trials to obtain an averaged ERP was small. Accordingly, to establish ERP evoked by heel lance as a pain assessment in neonates, it is necessary to perform a study to clarify ERP evoked by Aδ- and C-fiber stimulations accompanied by heel lance in neonates.

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.

Oculocardiac Reflex During ROP Exams

Purpose

Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery.

Patients and Methods

Electrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls.

Results

From 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72–98%), kurtosis 1.60 and skewness −1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA) – 11, r(279)=0.33, p<0.01) and with birthweight (%OCR = 0.02 (BW) + 38, r(279) =0.35, p<0.01). The duration of bradycardia induced by ROP exam averaged 92 ± 34 seconds (range 34–240 seconds).

Conclusion

Bradycardia is common during eye exams in the smallest premature infants with greater degree, more rapid onset and longer duration than OCR during strabismus surgery.

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A survey of procedural pain assessment and non-pharmacologic analgesic interventions in neonates in Spanish public maternity units

OBJECTIVE

To qualify and quantify clinical practices related to pain assessment and non-pharmacologic analgesia (NPA) in newborns in Spanish public maternity hospitals STUDY DESIGN: We surveyed providers online regarding their use of pain assessment scales, NPA interventions in neonates undergoing procedures, as well parents' presence or absence during interventions.

RESULTS

The number of painful procedures and the subjective grading of pain from the responding physicians were similar in all hospitals. Only 12.5% of hospitals used pain scales. No NPA was employed in 37.7% of procedures, with less NPA used in the lower complexity hospitals for venous extraction (p < 0.001) and gastric lavage (p = 0.001). Respondents reported parents' absence during 56.1% of procedures.

CONCLUSIONS

Available pain assessment scales and NPA interventions to mitigate pain are being underused. The presence of the parents during painful interventions is low despite the evidence that this may help to reduce newborns' perception of pain.

Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis

Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings.

METHODS

We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620.

FINDINGS

Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible.

INTERPRETATION

We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings.

FUNDING

Wellcome Trust Research Programme, and the Africa-Oxford Initiative.

The impact of parental contact upon cortical noxious-related activity in human neonates

BACKGROUND

Neonates display strong behavioural, physiological and cortical responses to tissue-damaging procedures. Parental contact can successfully regulate general behavioural and physiological reactivity of the infant, but it is not known whether it can influence noxious-related activity in the brain. Brain activity is highly dependent upon maternal presence in animal models, and therefore this could be an important contextual factor in human infant pain-related brain activity.

METHODS

Global topographic analysis was used to identify the presence and inter-group differences in noxious-related activity in three separate parental contexts. EEG was recorded during a clinically required heel lance in three age and sex-matched groups of neonates (a) while held by a parent in skin-to-skin (n = 9), (b) while held by a parent with clothing (n = 9) or (c) not held at all, but in individualized care (n = 9).

RESULTS

The lance elicited a sequence of 4-5 event-related potentials (ERPs), including the noxious ERP (nERP), which was smallest for infants held skin-to-skin and largest for infants held with clothing (p=0.016). The nERP was then followed by additional and divergent long-latency ERPs (> 750 ms post-lance), not previously described, in each of the groups, suggesting the engagement of different higher level cortical processes depending on parental contact.

CONCLUSIONS

These results show the importance of considering contextual factors in determining infant brain activity and reveal the powerful influence of parental contact upon noxious-related activity across the developing human brain.

SIGNIFICANCE

This observational study found that the way in which the neonatal brain processes a noxious stimulus is altered by the type of contact the infant has with their mother. Specifically, being held in skin-to-skin reduces the magnitude of noxious-related cortical activity. This work has also shown that different neural mechanisms are engaged depending on the mother/infant context, suggesting maternal contact can change how a baby's brain processes a noxious stimulus.

Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive care unit hospitalization: a single-blind randomized controlled trial

Preterm neonates hospitalized in the neonatal intensive care unit undergo frequent painful procedures daily, often without pain treatment, with associated long-term adverse effects. Maternal-infant skin-to-skin contact, or kangaroo care (KC), and sweet-tasting solutions such as sucrose are effective strategies to reduce pain during a single procedure; however, evidence of sustained efficacy over repeated procedures is limited. We aimed to determine the relative sustained efficacy of maternal KC, administered alone or in combination with 24% sucrose, to reduce behavioral pain intensity associated with routine neonatal procedures, compared with 24% sucrose alone. Stable preterm infants (n = 242) were randomized to receive KC and water, KC and 24% sucrose, or 24% sucrose before all routine painful procedures throughout their neonatal intensive care unit stay. Pain intensity, determined using the Premature Infant Pain Profile, was measured during 3 medically indicated heel lances distributed across hospitalization. Maternal and neonatal baseline characteristics, Premature Infant Pain Profile scores at 30, 60, or 90 seconds after heel lance, the distribution of infants with pain scores suggesting mild, moderate, or severe pain, Neurobehavioral Assessment of the Preterm Infant scores, and incidence of adverse outcomes were not statistically significantly different between groups. Maternal KC, as a pain-relieving intervention, remained efficacious over time and repeated painful procedures without evidence of any harm or neurological impact. It seemed to be equally effective as 24% oral sucrose, and the combination of maternal KC and sucrose did not seem to provide additional benefit, challenging the existing recommendation of using sucrose as the primary standard of care.

A perinatal stress calculator for the neonatal intensive care unit: an unobtrusive approach

OBJECTIVE

Early experience of pain and stress in the neonatal intensive care unit is known to have an effect on the neurodevelopment of the infant. However, an automated method to quantify the procedural pain or perinatal stress in premature patients does not exist.

APPROACH

In the current study, EEG and ECG data were collected for more than 3 hours from 136 patients in order to quantify stress exposure. Specifically, features extracted from the EEG and heart-rate variability in both quiet and non-quiet sleep segments were used to develop a subspace linear-discriminant analysis stress classifier.

MAIN RESULTS

The main novelty of the study lies in the absence of intrusive methods or pain elicitation protocols to develop the stress classifier. Three main findings can be reported. First, we developed different stress classifiers for the different age groups and stress intensities, obtaining an area under the curve in the range [0.78-0.93] for non-quiet sleep and [0.77-0.96] for quiet sleep. Second, a dysmature EEG was found in patients under stress. Third, an enhanced cortical connectivity and increased brain-heart communication was correlated with a higher stress load, while the autonomic activity did not seem to be associated to stress exposure.

SIGNIFICANCE

The results shed a light on the pain and stress processing in preterm neonates, suggesting that software tools to investigate dysmature EEG might be helpful to assess stress load in premature patients. These results could be the foundation to assess the impact of stress on infants' development and to tune preventive care.

Modified Sensory Stimulation Using Breastmilk for Reducing Pain Intensity in Neonates in Indonesia: A Randomized Controlled Trial

PURPOSE

Several studies have shown that oral sucrose reduces pain in newborns. However, sucrose has no efficacy in eliminating pain and long-term effects remain unclear. Breast milk may be useful as an alternative, safe sweet solution. Sensorial saturation (SS) is a multisensory analgesic non-pharmacological treatment, which includes touch and sounds as distractors. This study aimed to compare the analgesic effects of SS with sucrose (SSS), SS with breast milk (SSB), and oral sucrose alone (S24%) in neonates undergoing venipuncture.

DESIGN AND METHODS

This was a randomized controlled trial conducted on 108 neonates who underwent venipuncture at neonatology wards. All babies were randomly assigned to one of three groups: two intervention groups and one control group. Pain response was assessed using the premature infant pain profile-revised (PIPP-R). Data analysis was conducted using the Kruskal-Wallis test and Mann-Whitney U test.

RESULTS

SSB and SSS were more effective than S24% (p = 0.001). No difference was observed between SSB and SSS (p = 0.669).

CONCLUSION

Multisensory stimulation is more effective in reducing pain than unimodal (oral sucrose) analgesia. Breast milk can be used as a sensory gustatory stimulus in multisensory stimulation to reduce pain intensity in neonates, and demonstrates a similar analgesic effect to sucrose.

PRACTICE IMPLICATIONS

The study findings suggest that neonatal nurses could use SSB for management of pain. This intervention could serve as an effective, inexpensive, and safe non-pharmacological analgesic. Additional testing of this intervention is warranted to support its use as an evidence-based pain reduction approach.

Blinded randomized crossover trial: Skin-to-skin care vs. sucrose for preterm neonatal pain

OBJECTIVE

To compare skin-to-skin care (SSC) and oral sucrose for preterm neonatal pain control.

METHODS

Preterm neonates (28-36 weeks gestation) requiring heel-stick were eligible. In group-A, SSC was given 15-min before first heel-stick, and sucrose was given 2-min before second heel-stick. In group-B, the sequence was reversed. Blinded premature infant pain profile (PIPP) score assessment was done at 0, 1, and 5-min of heel-stick by two assessors.

RESULTS

A hundred neonates were enrolled. The inter-rater agreement for the PIPP score was good. The behavior state component was significantly lower in the sucrose group at all assessment points. The mean (SD) difference between 1-min and 0 min was similar [SSC 3.58(3.16) vs. sucrose 4.09(3.82), p = 0.24] between groups. The PIPP score attained baseline values at 5-min in both groups.

CONCLUSION

Albeit sucrose indicated instantaneous action, SSC and sucrose have comparable clinical efficacy for preterm neonatal pain control. Multisensory stimulation with SSC may result in a higher behavioral state component of the PIPP score.

Optimizing Analgesic Use During Infant Lumbar Puncture in the Emergency Department

Introduction:

Lumbar puncture (LP) for the collection of cerebrospinal fluid is an important diagnostic tool for the evaluation of febrile or ill-appearing infants. This invasive procedure is painful for patients; inadequate analgesia may have lasting effects. The American Academy of Pediatrics recommends analgesia during all LP procedures, and oral sucrose alone does not offer sufficient analgesia. Our objective was to identify analgesic use trends during infant LP in our emergency department and create a system of analgesic administration. We aimed for complete compliance with one method of analgesia and an increase in our use of 2 or more methods to 85% over 12 months.

Methods:

We utilized Plan-Do-Study-Act cycle methodology and retrospective chart review. Five interventions focused on staff communication, collaboration, and education. Inclusion criteria: infants <60 days who underwent LP procedure due to fever >38°C, hypothermia <36.5°C of unknown origin, or ill-appearance.

Results:

One hundred infant LPs analyzed: 52 preintervention and 48 intervention. The use of one analgesic increased from 98% preintervention to 100%. The use of 2 or more analgesics increased from 58% preintervention to 87%. Topical lidocaine use increased from 56% preintervention to 73%. LP success rates were high in both groups, with no statistically significant change in the success rate.

Conclusion:

We created a streamlined process to ensure all infants undergoing lumbar puncture received at least 1 analgesic and increased the proportion of infants treated with 2 or more analgesics. This work could be expanded to improve analgesia during other invasive procedures in the emergency department.

The Operant Plantar Thermal Assay: A Novel Device for Assessing Thermal Pain Tolerance in Mice

Pain is a multidimensional experience of sensory-discriminative, cognitive, and affective processes; however, current basic research methods rely heavily on response to threshold stimuli, bypassing the supraspinal processing that ultimately gives rise to the pain experience. We developed the operant plantar thermal assay (OPTA), which utilizes a novel, conflict-based operant task requiring evaluation and active decision-making to obtain reward under thermally aversive conditions to quantify thermal pain tolerance. In baseline measures, male and female mice exhibited similar temperature preferences, however in the OPTA, female mice exhibited greater temperature-dependent tolerance, as defined by choice time spent in an adverse thermal condition to obtain reward. Increasing reward salience (4% vs 10% sucrose solution) led to increased thermal tolerance for males but not females. To determine whether neuropathic and inflammatory pain models alter thermal tolerance, animals with chronic constriction injury (CCI) or complete Freund's adjuvant (CFA), respectively, were tested in the OPTA. Surprisingly, neuropathic animals exhibited increased thermal tolerance, as shown by greater time spent in the reward zone in an adverse thermal condition, compared with sham animals. There was no effect of inflammation on thermal tolerance. Administration of clonidine in the CCI model led to increased thermal tolerance in both injured and sham animals. In contrast, the non-steroidal anti-inflammatory meloxicam was anti-hyperalgesic in the CFA model, but reduced thermal pain tolerance. These data support the feasibility of using the OPTA to assess thermal pain tolerance to gain new insights into complex pain behaviors and to investigate novel aspects of analgesic efficacy.

Low dose fentanyl infusion versus 24% oral sucrose for pain management during laser treatment for retinopathy of prematurity-an open label randomized clinical trial

To compare the efficacy of low dose fentanyl infusion and 24% oral sucrose in providing optimal pain relief during laser for retinopathy of prematurity (ROP), we enrolled fifty-eight spontaneously breathing preterm infants undergoing laser. The preterm infants were randomized to either fentanyl infusion (1 mcg/kg/hr) or 24% oral sucrose (2 ml). We evaluated and compared the proportion of time spent crying during the procedure, salivary cortisol before and after the procedure, premature infant pain profile- revised (PIPP-R) scores during the procedure, apnoea during and after the procedure, need for mechanical ventilation, and feed intolerance and urinary retention 24 h after the procedure between the two groups. We found that the proportion of time spent crying during the procedure was significantly less in the fentanyl group [62.5% (50.7-74.2) vs 73.8% (55.6-83.4); P = 0.02]. Average PIPP-R score during the procedure was significantly less in the fentanyl group [7.2 vs 9.0; (mean difference of - 1.8; P = 0.01)]. There was no difference in other outcomes between the two groups.Conclusion: During laser for ROP, low dose fentanyl infusion was found to be efficacious in reducing pain as compared with 24% sucrose.What is Known:• Preterm infants undergoing laser photocoagulation for ROP suffer significant amount of pain.• Standard of care for pain relief in infants undergoing laser therapy in developed countries is general anesthesia (GA) or combination of sedation, analgesia, and paralysis (SAP).What is New:• During laser photocoagulation for ROP, fentanyl infusion at low dose (1 mcg/kg/hr) is efficacious in reducing pain as compared to 24% oral sucrose.

Prophylactic low-dose paracetamol administration associated with lowered rate of patent ductus arteriosus in preterm infants - Impact on outcome and pain perception

BACKGROUND

To determine the rate of patent ductus arteriosus after prophylactic low-dose paracetamol administration, the impact on outcome parameters, possible treatment side-effects and the influence on pain perception.

METHODS

We report retrospective single-centre outcome data of premature infants ≤ 32 weeks of gestation (n = 476). The intervention group received intravenous paracetamol, the control group obtained no preventive therapy. Ductal closure rate and outcome parameters were compared between the two groups. Adverse effects were determined by laboratory parameters. For the assessment of pain the Bernese Pain Scale for Neonates was used.

RESULTS

The rate of patent ductus arteriosus was significantly lower in the paracetamol-treated group compared to the control group (13.6% vs. 38.2%, p < 0.001). With regard to secondary outcome parameters, severe and moderate bronchopulmonary dysplasia (2.7% vs. 7.4%, p = 0.023), severe retinopathy of prematurity (0% vs. 4.4%, p = 0.002) and late onset sepsis (2.7% vs. 8.3%, p = 0.009) were significantly less frequent in the paracetamol group. Except for a 1.5-fold increased risk for hyperbilirubinemia (86.0% vs. 77.6%, p = 0.035) in the paracetamol group following treatment, no significant differences in laboratory parameters were found. Relating to pain, the administration of Glucose 33% was significantly more often necessary in the control group compared to the paracetamol-treated group (mean 13.48 vs. 8.71, p < 0.001), just as the need for additional treatment with systemic analgesics, which was more frequent in the control group (mean 0.72 vs. 0.57, p = 0.361).

CONCLUSION

In our study we were able to show a significantly lower rate of patent ductus arteriosus after prophylactic paracetamol administration without serious adverse effect, but a beneficial influence of this regime on the patient's pain perception.