Considerations for neonatal and pediatric pain management

Long-term effects of neonatal pain and sucrose treatment

Purpose

In neonatal intensive care units, applying sucrose solution for analgesia is now a routine treatment for mild procedural pain. Studies of animal and human infants provide clear evidence of benefits in the short term, but few studies have investigated the long term benefits. Thus, we determined whether sucrose could ameliorate painful stimulation during infancy in Sprague-Dawley rats and also explored the long-term effects of repeated sucrose administration during infancy. Female and male rats were included to investigate sex-related differences.

Methods

Rat pups were stimulated either with painful or tactile stimuli for the first 14 days of their lives. Pups were pretreated either with sucrose or not treated before stimulation. Behavioral tests were conducted during adolescence and adulthood. Hotplate, rotarod, open field, elevated plus maze, and radial arm water maze tests were employed to assess the behavioral consequences of early life manipulations and treatments.

Results

Painful stimulation during infancy increased the sensitivity to pain later in life, and sucrose did not remedy this effect. Motility, coordination, anxiety, and cognition tests in adulthood obtained mixed results. Pain during infancy appeared to increase anxiety during adulthood. Learning and memory in adulthood were affected by pain during infancy, and sucrose had a negative effect even in the absence of pain. No sex-related differences were observed in any of the behavioral tests by employing this model of neonatal pain.

Conclusion

Painful stimulation during infancy resulted in deficiencies in some behavioral tests later in life. Sucrose pretreatment did not mitigate these shortcomings and it actually resulted in negative outcomes.

A Literature Review: The Mechanisms and Treatment of Neuropathic Pain-A Brief Discussion

Classically, neuropathic pain is described as a pain caused by a lesion or disease of the somatosensory system. However, one must note that the presence of somatosensory pathology alone does not guarantee a progression to neuropathic pain. This is due, in part, to the fact that neuropathic pain is a notoriously complex disease process, involving sensitization of both the central and peripheral nervous systems. Its causes are also numerous and varied, including trauma, the compression of a nerve, autoimmune disorders, diabetes, and infections. Due to the various manifestations, causes, and symptoms of neuropathic pain, the treatment of this disease process has proved challenging for generations of physicians. This section aims to elaborate on newly proposed mechanisms for pharmacological and targeted therapies, such as neurostimulation, which aim to reduce the negative somatosensory effects of neuropathic pain.

Regional Anesthesia for Neonates

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Pediatric pain knowledge and attitudes among health care professionals-A National Danish Survey

Aim

To explore and compare Danish health-care professionals' attitudes and knowledge towards pain management of children.

Methods

The cross-sectional study was carried out using the Pediatric Pain Knowledge and Attitudes Questionnaire. The questionnaire was distributed to all health care professionals caring for children in three hospital settings, including nurses and physicians in departments of pediatric, emergency, and anesthesia and medical laboratory technologists.

Results

The study was conducted in 2020 and 765 health care professionals participated. Within the six main categories included in the questionnaire, there were significant differences between nurses and physicians in three subcategories: view on the care of children in pain, using drugs to relieve pain, and the four mandatories. Comparing nurses with medical laboratory technicians, there were significant differences in the subcategory "view on the care of children in pain." Comparing types of clinical departments, there were significant differences in the subcategories' view on the care of children in pain, using drugs to relieve pain, and the four mandatories. Overall, we found that the participating health professionals did not have a uniform understanding of pain management and therefore might treat children differently.

Conclusion

The present study highlights the need to align health care professionals' knowledge regarding pain assessment and management of children, as well as the need to develop and test interventions that support the use of knowledge in practice.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Posterior transversus abdominis plane block versus lateral quadratus lumborum block in children undergoing open orchiopexy: a randomized clinical trial☆

BACKGROUND

Due to the complex innervation of the testicle and spermatic cord, analgesic management can be challenging in orchiopexy. We aimed to compare the effects of posterior Transversus Abdominis Plane (TAP) and lateral Quadratus Lumborum Block (QLB) on analgesic use, pain, and parent satisfaction in unilateral orchiopexy.

METHODS

ASA I-III, aged 6 months - 12 years children undergoing unilateral orchiopexy were included to this double-blinded randomized trial. Patients were randomized into two groups with the closed envelope method before the surgery. Lateral QLB or posterior TAP block was applied under ultrasonography with 0.4 mL.kg^-1 0.25% bupivacaine for both groups. The primary outcome was the assessment of additional analgesic usage in the peri-postoperative period. Evaluation of postoperative pain until 24 hours after surgery and parental satisfaction were also assessed as secondary outcomes.

RESULTS

A total of 90 patients were included in the analysis (45 patients in each group). The number of patients needing remifentanil was significantly higher in the TAP group (p < 0.001). The average FLACC (TAP: 2.74 ± 1.8, QLB: 0.7 ± 0.84) and Wong-Baker scores (TAP: 3.13 ± 2.42, QLB: 0.53 ± 1.12) were significantly higher for TAP (p < 0.001). Additional analgesic consumption at the 10^th, 20^th minutes, 6^th, 16^th, and 24^th hours, especially after the 6^th hour, were significantly higher for TAP. Parent satisfaction was significantly higher in the QLB group (p < 0.001).

CONCLUSION

Lateral QLB provided more effective analgesia than posterior TAP block in children undergoing elective open unilateral orchiopexy.

CLINICAL TRIALS REGISTRY

NCT03969316.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

Development and Implementation of a Neonatal Pain Management Guideline for Minor Surgeries

BACKGROUND

Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use.

PURPOSE

To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time.

METHODS

An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months.

RESULTS

The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time.

IMPLICATIONS FOR PRACTICE

A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse.

IMPLICATIONS FOR RESEARCH

Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.

Evaluation of Methods to Minimize Pain in Newborns during Capillary Blood Sampling for Screening: A Randomized Clinical Trial

Aim: The aim of the study was to assess the severity of pain experienced by a newborn during a heel puncture for screening using the Newborn Pain Scale (NIPS), measure the heart rate and compare the effectiveness of non-pharmacological methods of pain control. Design: Randomized clinical trial. No experimental factors. The test was performed during routine screening. Surroundings: Provincial Specialist Hospital in Olsztyn. Patients/Participants: Pain was assessed in 90 full-term newborns. The newborns were rooming in with their mothers in the hospital. Interventions: Newborns were divided into three groups. Three different methods of pain relief were used: breastfeeding, 20% glucose administered orally and non-nutritional sucking. Main Outcome Measures: The primary pain outcome was measured using the NIPS and the secondary pain outcome measures (heart rate, oxygen saturation) were measured using a pulse oximeter. Results: During capillary blood sampling from the heel, most newborns, n = 56 (62.2%), experienced no pain or mild discomfort, severe pain occurred in n = 23 (25.6%) and moderate pain occurred in n = 11 (12.2%). No significant statistical differences were found between the degree of pain intensity and the intervention used to minimize the pain p = 0.24. Statistically significant relationships were demonstrated between heart rate variability and the degree of pain intensity (p = 0.01). There were no statistically significant differences between the newborn’s pain intensity and the mother’s opinion on the effectiveness of breastfeeding in minimizing pain. Conclusions: This study did not answer the question of which pain management method used during the heel prick was statistically more effective in reducing pain. However, the results indicate that each of the non-pharmacological interventions (breastfeeding, oral glucose dosing and non-nutritive sucking) applied during heel puncture resulted in effective pain management in most of the newborns enrolled in the study. The relationship between heart rate variability and the severity of pain was confirmed. Mothers of newborns in the breastfeeding group were satisfied with the pain relief methods used in the child and the opportunity to console their newborn during painful procedures in a technologically invasive environment.

Effectiveness of clown intervention for pain relief in children: A systematic review and meta-analysis

BACKGROUND

Pain is common in children receiving medical procedures, and there is a lack of adequate awareness and management. In addition, children who undergo medical procedures involving pain may also experience stress, crying and prolonged hospitalisation. Clown intervention is a promising nonpharmacological intervention. However, studies on the effectiveness of clown intervention in pain management have reported conflicting findings.

OBJECTIVE

To evaluate the effectiveness of clown intervention in relieving pain in children, as well as its effects on cortisol levels, crying duration and length of hospital stay.

DESIGN

Systematic review and meta-analysis of randomised controlled studies.

DATA SOURCES

PubMed, Web of Science (SCI), Embase, PsycINFO, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Weipu (VIP), Wanfang Data and SinoMed were systematically searched from inception date to December 31, 2020.

REVIEW METHODS

Two reviewers independently used the Cochrane risk of bias tool to assess the risk of bias of the included studies. Meta-analysis was conducted when data were available, otherwise, a narrative description was provided. Data were analysed using Review Manager 5.3. The review process is reported according to PRISMA.

RESULTS

Nine studies including 852 children met the inclusion criteria. The results showed that compared with standard care, clown intervention was beneficial for relieving pain. Further subgroup analysis showed that it was more effective with children aged 2-7 years. The duration of crying after the procedure and the length of stay were shortened, but there was no significant difference in cortisol levels.

CONCLUSION

Clown intervention may be a promising way to relieve acute pain in children, especially those aged 2-7 years. It also seems to shorten the duration of crying and the length of hospital stays, but the effect on cortisol levels is still uncertain. More high-quality randomised controlled trials are needed to confirm these results and take into account different age groups, cultural backgrounds and specific populations.

Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study

The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.

Pain prevalence in infants and preschool children in a Colombian hospital

Introduction: The pain prevalence in hospitalized infants and preschool children has not been accurately identified in high-income countries, and in low and medium-income countries it has not been extensively studied. The assessment instruments are limited. Objective: To describe the prevalence and management of pain in infants and preschool children during the first 24 hours of hospitalization in a third level institution in Colombia, using the CRIES scale. Methods: An observational study was conducted during the first 24 hours of hospitalization. Demographic information was recorded, pain was assessed at admission, after 4, and 24 hours using the CRIES scale. Pharmacological therapy was also documented. Results: 250 children between one month and 5 years old were studied. The pain prevalence at admission was 12 %. The pain prevalence per subgroups was higher among the surgical patients, as compared to the clinical patients (35.9 % vs. 7.6 %). The pharmacological analysis revealed that 70.8 % of patients received treatment; the most widely used medications were oral acetaminophen and intravenous dipyrone. Conclusions: Pain prevalence was lower than the levels described for the general pediatric population. This result may be due to the sensitivity of the CRIES instrument, or to a particular pain behavior. Further studies are needed to identify the sensitivity of the assessment instruments in early life and to accurately investigate any associated phenomena.

Complementarity of pain assessment instruments in children with central nervous system impairment

ABSTRACT Objective: To evaluate the complementarity of the revised Face, Legs, Activity, Cry, Consolability scale and of the Inventory of Pain Behavior in Neurological Disability for the assessment of pain in children with severe neurological impairment. Method: Cross-sectional study conducted in pediatric units of a university hospital in the southern region of Brazil. The sample consisted of 26 children with severe neurological impairment, hospitalized from January to August 2019, and their caregivers. The data were analyzed by descriptive statistics; Kappa Coefficient, Fisher’s Exact Test and Spearman’s Coefficient were used (p≤0,05). Results: Most children primary diagnosis was cerebral palsy (80.8%). Pain was present in 50.0% of children with the application of the scale and in 34.6% with that of the inventory. Considering the two instruments, there was good agreement (84.6%) between respondents (k=0.692; 95% CI 0.437-0.967; p=0.000). Conclusion: The instruments can be used complementarily to assess pain in children with this profile.

Creative Music Therapy with Premature Infants and Their Parents: A Mixed-Method Pilot Study on Parents' Anxiety, Stress and Depressive Symptoms and Parent-Infant Attachment

Premature birth is stressful for infants and parents and can adversely affect the parent–infant dyad. This mixed-methods pilot study evaluates whether creative music therapy (CMT) can alleviate anxiety, stress, and depressive symptoms in parents and support the bonding process with their infant. Sixteen parent couples were included. Ten couples were randomly allocated to the music therapy group (MTG) and six to the control group (CG). All couples completed psychological questionnaires measuring anxiety and depressive symptoms as well as an implicit measure of parent–infant attachment at two weeks postpartum (T1), at approximate neonatal intensive care unit (NICU) hospitalization halftime (T2), and two weeks after the infant had been discharged (T3). At T1 and T2, the parents additionally completed a questionnaire assessing the degree of stress they experienced at the NICU. Qualitative data were collected through a semi-structured, problem-centered interview with MTG parents at T3. The results of the quantitative analyses revealed reductions in anxiety levels from T1 to T2 (p = 0.002) as well as decreases in depressive symptoms from T2 to T3 (p = 0.022). No such changes were apparent in the CG. In fact, parental stress increased from T1 to T2 (p = 0.016). Significant increases in attachment across time were also observed within the MTG, but not in the CG. The qualitative inquiry confirmed that CMT can support the parent–infant relationship. Being in musical interaction evoked feelings of joy and relaxation in the parents and encouraged them to interact more profoundly with their infant. The results call for a more extensive powered follow-up study to further investigate CMT’s potential for parental well-being and parent–infant bonding.

Study protocol: parents as pain management in Swedish neonatal care - SWEpap, a multi-center randomized controlled trial

BACKGROUND

During the first period of life, critically ill as well as healthy newborn infants experience recurrent painful procedures. Parents are a valuable but often overlooked resource in procedural pain management in newborns. Interventions to improve parents' knowledge and involvement in infants' pain management are essential to implement in the care of the newborn infant. Neonatal pain research has studied a range of non-pharmacological pain alleviating strategies during painful procedures, yet, regarding combined multisensorial parent-driven non-pharmacological pain management, research is still lacking.

METHODS/DESIGN

A multi-center randomized controlled trial (RCT) with three parallel groups with the allocation ratio 1:1:1 is planned. The RCT "Parents as pain management in Swedish neonatal care - SWEpap", will investigate the efficacy of combined pain management with skin-to-skin contact, breastfeeding and live parental lullaby singing compared with standard pain care initiated by health care professionals, during routine metabolic screening of newborn infants (PKU-test).

DISCUSSION

Parental involvement in neonatal pain management enables a range of comforting parental interventions such as skin-to-skin contact, breastfeeding, rocking and soothing vocalizations. To date, few studies have been published examining the efficacy of combined multisensorial parent-driven interventions. So far, research shows that the use of combined parent-driven pain management such as skin-to-skin contact and breastfeeding, is more effective in reducing behavioral responses to pain in infants, than using the pain-relieving interventions alone. Combined parental soothing behaviors that provide rhythmic (holding/rocking/vocalizing) or orogustatory/orotactile (feeding/pacifying) stimulation that keep the parent close to the infant, are more effective in a painful context. In the SWEpap study we also include parental live lullaby singing, which is an unexplored but promising biopsychosocial, multimodal and multisensory pain alleviating adjuvant, especially in combination with skin-to-skin contact and breastfeeding.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04341194 ) 10 April 2020.