Comparison of three neonatal pain scales during minor painful procedures

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

BACKGROUND

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

A randomized double-blind trial comparing the effect on pain of an oral sucrose solution versus placebo in children 1-3 months old needing bladder catheterization

OBJECTIVE

The efficacy of oral sweet solutions to decrease pain in infants during painful procedures remains uncertain. This study aimed to compare the efficacy of an oral sucrose solution versus placebo in reducing pain during bladder catheterization in infants in the Emergency Department (ED).

METHODS

A randomized, double-blind clinical trial was conducted in a pediatric university-affiliated hospital ED. Infants 1-3 months old were recruited and randomly allocated to receive 2 ml of sucrose or placebo, 2 min before bladder catheterization. The primary outcome measure was the difference in pain scores as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale during procedure. Secondary outcome measures were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time, variations in heart rate and adverse events.

RESULTS

Eighty-three participants were recruited and completed the study, 41 and 42 in the sucrose and placebo groups, respectively. The mean difference in FLACC scores compared to baseline was 5.3 in the sucrose group vs. 6.4 in the placebo group during catheterization. There were no differences in FLACC scores or NIPS scores measured at 1, 3 and 5 min post procedure. Mean crying times were similar: 97 vs. 110 s. No significant difference was found in participants' heart rate variations. No adverse events were reported.

CONCLUSIONS

In infants undergoing bladder catheterization in the ED, administration of an oral sweet solution was not associated with lower pain as measured by the FLACC and NIPS scales. Participants' heart rate variations and crying times did not change when sucrose was provided.

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

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

The use and reporting of neonatal pain scales: a systematic review of randomized trials

ABSTRACT

The burden of pain in newborn infants has been investigated in numerous studies, but little is known about the appropriateness of the use of pain scales according to the specific type of pain or infant condition. This systematic review aimed to evaluate the reporting of neonatal pain scales in randomized trials. A systematic search up to March 2019 was performed in Embase, PubMed, PsycINFO, CINAHL, Cochrane Library, Scopus, and Luxid. Randomized and quasirandomized trials reporting neonatal pain scales were included. Screening of the studies for inclusion, data extraction, and quality assessment was performed independently by 2 researchers. Of 3718 trials found, 352 with 29,137 infants and 22 published pain scales were included. Most studies (92%) concerned procedural pain, where the most frequently used pain scales were the Premature Infant Pain Profile or Premature Infant Pain Profile-Revised (48%), followed by the Neonatal Infant Pain Scale (23%). Although the Neonatal Infant Pain Scale is validated only for acute pain, it was also the second most used scale for ongoing and postoperative pain (21%). Only in a third of the trials, blinding for those performing the pain assessment was described. In 55 studies (16%), pain scales that were used lacked validation for the specific neonatal population or type of pain. Six validated pain scales were used in 90% of all trials, although not always in the correct population or type of pain. Depending on the type of pain and population of infants included in a study, appropriate scales should be selected. The inappropriate use raises serious concerns about research ethics and use of resources.

Quantification of neonatal procedural pain severity: a platform for estimating total pain burden in individual infants

There is increasing evidence that long-term outcomes for infants born prematurely are adversely affected by repeated exposure to noxious procedures. These interventions vary widely, for example, in the extent of damage caused and duration. Neonatal intensive care unit (NICU) procedures are therefore likely to each contribute differently to the overall pain burden of individual neonates, ultimately having a different impact on their development. For researchers to quantify the procedural pain burden experienced by infants on NICU, we aimed to estimate the pain severity of common NICU procedures using published pain scores. We extracted pain scores over the first minute (pain reactivity) from the literature, using 59 randomized controlled trials for 15 different procedures. Hierarchical cluster analysis of average pain scores resulted in 5 discrete severity groups; mild (n = 1), mild to moderate (n = 3), moderate (n = 7), severe (n = 3), and very severe (n = 1). The estimate of the severity of individual procedures provided new insight into infant pain reactivity which is not always directly related to the invasiveness and duration of a procedure; thus, both heel lance and skin tape removal are moderately painful procedures. This estimate of procedural pain severity, based on pain reactivity scores, provides a novel platform for retrospective quantification of an individual neonate's pain burden due to NICU procedures. The addition of measures that reflect the recovery from each procedure, such as brain activity and behavioural regulation, would further improve estimates of the pain burden of neonatal intensive care.

A Randomized Controlled Trial Evaluating the Efficacy of Oral Sucrose in Infants 1 to 3 Months Old Needing Intravenous Cannulation

OBJECTIVES

The objective was to compare the efficacy of an oral sucrose versus placebo in reducing pain in infants 1 to 3 months of age during intravenous (IV) cannulation in the emergency department.

METHODS

A randomized, double-blind, placebo clinical trial was conducted. Participants were randomly allocated to receive 2 mL of an oral 88% sucrose solution or 2 mL of a placebo solution orally. The outcome measure were mean difference in pain score at 1 minute post-IV cannulation assessed by the Face, Legs, Activity, Cry, and Consolability Pain Scale (FLACC) and the Neonatal Infant Pain Scale (NIPS), crying time, and variations in heart rate.

RESULTS

Eighty-seven participants completed the study, 45 in the sucrose group and 42 in the placebo group. There was no statistical difference in variations in both the FLACC score (p = 0.49) and the NIPS score (p = 0.36) between the two groups as per the Mann-Whitney U-test. With the same test, median crying times following IV cannulation were statistically significantly different between both groups (17 seconds in the sucrose group vs. 41 seconds in the placebo group, p = 0.04). Mean changes in heart rate 1 minute after IV cannulation were similar in both groups (16 ± 4 beats/min for sucrose vs. 18 ± 4 beats/min for placebo, p = 0.74). Side effects were similar for both groups and no adverse events were reported.

CONCLUSIONS

Administration of an oral sucrose solution in infants 1 to 3 months of age during IV cannulation did not lead to statistically significant changes in pain scores. However, the cry time was significantly reduced.

Randomized placebo-controlled trial of sucrose analgesia on neonatal skin blood flow and pain response during heel lance

OBJECTIVES

To evaluate the effect of oral sucrose on skin blood flow (SBF; perfusion units; PU) measured by Laser Doppler Imager (LDI) in term newborns and pain response (Neonatal Infant Pain Scale score; NIPS score) during heel lance; (2) determine SBF changes during heel lance; and (3) the relationship between SBF and NIPS.

MATERIALS AND METHODS

Term infants ≤7 days old (n=56) undergoing routine heel lance were randomized to pretreatment with 2.0 mL oral 24% sucrose (n=29) or sterile water (n=27) in a double-blinded, placebo-controlled trial. SBF was assessed by LDI scans and NIPS scores at 10 minutes before lance, immediately after lancing, and 5 minutes after blood extraction. Mean SBF and median NIPS scores were compared between groups using General Linear Model or Kruskal-Wallis. Regressions examined the relationship between SBF immediately after heel lance and NIPS score.

RESULTS

Mean SBF and median NIPS scores immediately after heel lance were lower in sucrose-treated infants (167.9±15.5 vs. 205.4±16.0 PU, P=0.09; NIPS 1 [interquartile range 0 to 4] vs. NIPS 3 [interquartile range 0 to 6], P=0.02), although no significant difference in mean SBF. During heel lance NIPS score was predictive of SBF. An increase of 1 in NIPS score was associated with 11 PU increase in SBF (R=0.21; P=0.09) for sucrose, and 16 PU increase for placebo-treated infants (R=0.20; P=0.014).

CONCLUSIONS

Increased SBF assessed by LDI is a pain response among term neonates after routine heel lance, which was not completely attenuated by oral sucrose administration. Increased SBF is associated with NIPS scores. Sucrose analgesic efficacy evidenced by decreased NIPS scores for the sucrose group. Association of SBF with NIPS scores suggests that LDI is potentially useful for assessing newborn procedural pain.