Effect of music (Brahms lullaby) and non-nutritive sucking on heel lance in preterm infants: A randomized controlled crossover trial

Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants

BACKGROUND

Preterm birth interferes with brain maturation, and subsequent clinical events and interventions may have additional deleterious effects. Music as therapy is offered increasingly in neonatal intensive care units aiming to improve health outcomes and quality of life for both preterm infants and the well-being of their parents. Systematic reviews of mixed methodological quality have demonstrated ambiguous results for the efficacy of various types of auditory stimulation of preterm infants. A more comprehensive and rigorous systematic review is needed to address controversies arising from apparently conflicting studies and reviews.

OBJECTIVES

We assessed the overall efficacy of music and vocal interventions for physiological and neurodevelopmental outcomes in preterm infants (< 37 weeks' gestation) compared to standard care. In addition, we aimed to determine specific effects of various interventions for physiological, anthropometric, social-emotional, neurodevelopmental short- and long-term outcomes in the infants, parental well-being, and bonding.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, RILM Abstracts, and ERIC in November 2021; and Proquest Dissertations in February 2019. We searched the reference lists of related systematic reviews, and of studies selected for inclusion and clinical trial registries.

SELECTION CRITERIA

We included parallel, and cluster-randomised controlled trials with preterm infants < 37 weeks` gestation during hospitalisation, and parents when they were involved in the intervention. Interventions were any music or vocal stimulation provided live or via a recording by a music therapist, a parent, or a healthcare professional compared to standard care. The intervention duration was greater than five minutes and needed to occur more than three times.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We analysed the treatment effects of the individual trials using RevMan Web using a fixed-effects model to combine the data. Where possible, we presented results in meta-analyses using mean differences with 95% CI. We performed heterogeneity tests. When the I2 statistic was higher than 50%, we assessed the source of the heterogeneity by sensitivity and subgroup analyses. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 trials recruiting 1532 infants and 691 parents (21 parallel-group RCTs, four cross-over RCTs). The infants gestational age at birth varied from 23 to 36 weeks, taking place in NICUs (level 1 to 3) around the world. Within the trials, the intervention varied widely in type, delivery, frequency, and duration. Music and voice were mainly characterised by calm, soft, musical parameters in lullaby style, often integrating the sung mother's voice live or recorded, defined as music therapy or music medicine. The general risk of bias in the included studies varied from low to high risk of bias. Music and vocal interventions compared to standard care Music/vocal interventions do not increase oxygen saturation in the infants during the intervention (mean difference (MD) 0.13, 95% CI -0.33 to 0.59; P = 0.59; 958 infants, 10 studies; high-certainty evidence). Music and voice probably do not increase oxygen saturation post-intervention either (MD 0.63, 95% CI -0.01 to 1.26; P = 0.05; 800 infants, 7 studies; moderate-certainty evidence). The intervention may not increase infant development (Bayley Scales of Infant and Toddler Development (BSID)) with the cognitive composition score (MD 0.35, 95% CI -4.85 to 5.55; P = 0.90; 69 infants, 2 studies; low-certainty evidence); the motor composition score (MD -0.17, 95% CI -5.45 to 5.11; P = 0.95; 69 infants, 2 studies; low-certainty evidence); and the language composition score (MD 0.38, 95% CI -5.45 to 6.21; P = 0.90; 69 infants, 2 studies; low-certainty evidence). Music therapy may not reduce parental state-trait anxiety (MD -1.12, 95% CI -3.20 to 0.96; P = 0.29; 97 parents, 4 studies; low-certainty evidence). The intervention probably does not reduce respiratory rate during the intervention (MD 0.42, 95% CI -1.05 to 1.90; P = 0.57; 750 infants; 7 studies; moderate-certainty evidence) and post-intervention (MD 0.51, 95% CI -1.57 to 2.58; P = 0.63; 636 infants, 5 studies; moderate-certainty evidence). However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention (MD -1.38, 95% CI -2.63 to -0.12; P = 0.03; 1014 infants; 11 studies; moderate-certainty evidence). This beneficial effect was even stronger after the intervention. Music/vocal interventions reduce heart rate post-intervention (MD -3.80, 95% CI -5.05 to -2.55; P < 0.00001; 903 infants, 9 studies; high-certainty evidence) with wide CIs ranging from medium to large beneficial effects. Music therapy may not reduce postnatal depression (MD 0.50, 95% CI -1.80 to 2.81; P = 0.67; 67 participants; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of music therapy on parental state anxiety (MD -0.15, 95% CI -2.72 to 2.41; P = 0.91; 87 parents, 3 studies; very low-certainty evidence). We are uncertain about any further effects regarding all other secondary short- and long-term outcomes on the infants, parental well-being, and bonding/attachment. Two studies evaluated adverse effects as an explicit outcome of interest and reported no adverse effects from music and voice.

AUTHORS' CONCLUSIONS

Music/vocal interventions do not increase oxygen saturation during and probably not after the intervention compared to standard care. The evidence suggests that music and voice do not increase infant development (BSID) or reduce parental state-trait anxiety. The intervention probably does not reduce respiratory rate in preterm infants. However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention, and this beneficial effect is even stronger after the intervention, demonstrating that music/vocal interventions reduce heart rates in preterm infants post-intervention. We found no reports of adverse effects from music and voice. Due to low-certainty evidence for all other outcomes, we could not draw any further conclusions regarding overall efficacy nor the possible impact of different intervention types, frequencies, or durations. Further research with more power, fewer risks of bias, and more sensitive and clinically relevant outcomes are needed.

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.

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.

Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis

Background

Pain management is currently important in neonatal intensive care unit (NICU). The superiority in pain relief of the combined oral sucrose (OS) and nonnutritive sucking (NNS) to other single intervention has not been well established. The administration of sucrose has been considered to potentially induce adverse events, which has been controversial. This study aims to investigate the combined effects and safety in comparison with other single intervention methods, including NNS, OS alone, breast milk and oral glucose.

Methods

We searched databases including Medline (via Pubmed), Embase (via Ovid), web of science, and Cochrane Library for randomized controlled trials from Jan 1, 2000 to Mar 31, 2021. The data were analyzed in the meta-analysis using Review manager Version 5.3. Pain score was the primary outcome in this meta-analysis. The adverse events were assessed qualitatively.

Results

A total of 16 studies were eligible in the meta-analysis. The results demonstrated a significant reduction in pain score in the NNS+OS group compared with NNS alone (SMD = -1.69, 95%CI, -1.69,-0.65) or sucrose alone (SMD = -1.39, 95% CI, -2.21,-0.57) during the painful procedures. When compared NNS+OS with breast milk, no significant difference was detected (SMD = -0.19, 95% CI: -0.5, 0.11).

Conclusion

The combined effects of NNS and OS might be superior to other single intervention method. However, the effects might be mild for moderate-to-severe pain.

Clinical benefits of music-based interventions on preterm infants' health: A systematic review of randomised trials

AIM

This systematic review aimed to differentiate and isolate the results of different music-based interventions used with preterm infants in the neonatal intensive care unit and explore their clinical benefits.

METHODS

The last search was performed on 5 July 2021 on Web of Science, Scopus, EMBASE, PsycINFO, CINAHL, LILACS and CENTRAL. Only randomised clinical trials that explored the health benefits of music-based interventions were considered.

RESULTS

A total of 39 studies were included. All music-based interventions were divided into music medicine and music therapy. The overall results suggested that music medicine interventions were associated with a significant improvement in pain relief; in turn, improvements in cardiac and respiratory function, weight gain, eating behaviour, and quiet alert and sleep states were more consistent in studies that followed a music therapy approach with the presence of a music therapist.

CONCLUSION

This review supports the beneficial effects of music-based interventions on the health of preterm infants in a neonatal intensive care unit; however, it also offers suggestions for future studies in order to increase the number of interventions with music therapists, since the results of music therapy approaches were more consistent for physiological and behavioural outcomes.

Music Intervention for Pain Control in the Pediatric Population: A Systematic Review and Meta-Analysis

Music intervention (MI) has been applied as an effective adjunctive treatment for pain control in various clinical settings. However, no meta-analysis has yet been published on the analgesic effects of MI in infants and children. We performed a systematic review of PubMed, EMBASE, Web of Science, and Cochrane Library databases to identify randomized controlled trials (RCTs) with the keywords "pain" AND "music therapy" from inception to January 2022. Primary outcomes were pain intensity and vital signs. Standardized mean difference (SMD) values and the corresponding 95% confidence intervals (CIs) were computed using a random effect model. Subgroup analyses with age groups, types of pain, and music styles were conducted. A total of 38 RCTs involving 5601 participants met the selection criteria. MI significantly decreased the pain levels (SMD = -0.57, p < 0.001), both in the newborn group (p = 0.007) and in the infant/children group (p < 0.001). MI significantly reduced heart rate (SMD = -0.50, p < 0.001) and respiratory rate (SMD = -0.60, p = 0.002) and increased peripheral capillary oxygen saturation (SMD = 0.44, p < 0.001). In subgroup analyses of types of pain, MI had significant effects on prick pain (p = 0.003), chronic and procedural pain (p < 0.001), and postoperative pain (p = 0.018). As for music styles, significant analgesic effects were observed for classical music (p < 0.001), kids' music (p < 0.001), and pop music (p = 0.001), but not for world music (p = 0.196), special composition (p = 0.092), and multiple music combinations (p = 0.420). In conclusion, our analysis provides supportive evidence about the efficacy of MI, especially classical, kids', and pop music, in controlling prick, procedural, and postoperative pain in the pediatric population.

Effect of Non-nutritive Sucking during Heel-stick Procedure in Pain Management of Term Infants in the Neonatal Intensive Care Unit: A Systematic Review and Meta-analysis

BACKGROUND

This study aimed to evaluate the efficacy of non-nutritive sucking for analgesia in term infants undergoing heel-stick procedures.

METHODS

Randomized controlled trials and non-randomized studies based on the PICO framework were included in the study. Review articles, commentary, pilot, and non-English articles were excluded. Databases, such as PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane, were searched until January 31st, 2021, using the keywords "Pain management", 'Non-nutritive sucking", and "Heel stick". All studies were reviewed and retrieved by two authors independently using a standardized form according to the inclusion criteria, and any disagreements were examined by a third scholar. Quality assessment was evaluated by using the ROB-2 tool. Data were analyzed using Stata version 12.0 software, and a random-effects model was used for analysis.

RESULTS

A total of 5,629 articles were retrieved from all databases, and after the screening, finally, 6 relevant articles were included in the analysis. The tools used to control pain in infants in the articles included PIPP, NFCS, NIPS, and NPASS. The results showed that the pain scores were significantly lower in the NNS group compared to the control group (MD, -1.05; 95% CI, -1.53 to -0.57) and NNS had a significant effect on oxygen saturation (O2 Sat) increasing in newborns compared to the control group, but no significant reduction in the heart rate (HR) between two groups was observed.

CONCLUSION

NNS effectively provides analgesia in full-term neonates undergoing heel-stick procedures; however, its effects on the long-term outcomes of infants are unclear. The results showed that NNS was effective in improving heel-stick pain in infants.

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.

Effect of music combined with swaddling on pain in full-term newborns: randomized clinical trial

OBJECTIVES

to evaluate the effect of music applied within ten and 15 minutes, combined with swaddling, on behavioral (facial action) and physiological (heart rate) responses to pain in full-term newborns, before and during venipuncture for blood sampling.

METHODS

a randomized, triple-blind, clinical trial with 52 rooming in infants randomly assigned to four groups of 13: Experimental 1 (music [ten minutes] plus swaddling), Experimental 2 (music [15 minutes] plus swaddling), Control 1 (no music [ten minutes] plus swaddling), and Control 2 (no music [15 minutes] plus swaddling). Pain was measured using the Neonatal Facial Coding System in the basal and procedural moments.

RESULTS

experimental 2 group showed high pain absence (p < 0.05); low heart rate mean (p < 0.0001) in the basal and procedural (antisepsis, puncture, blood squeezing/aspiration, compression) moments.

CONCLUSIONS

neonates who listened to 15 minutes of music plus swaddling showed a greater absence of facial pain actions.

Psychosocial and Neurobiological Vulnerabilities of the Hospitalized Preterm Infant and Relevant Non-pharmacological Pain Mitigation Strategies

Background: Preterm pain is common in the Neonatal Intensive Care Unit (NICU), with multiple invasive procedures occurring daily. Objective: To review the psychosocial and neurobiological vulnerabilities of preterm infants and to provide an updated overview of non-pharmacological strategies for acute procedural pain in hospitalized preterm infants. Methods: We utilized a narrative review methodology, which also included a synthesis of key pieces of published systematic reviews that are relevant to the current work. Results and Conclusions: Preterm infants are uniquely susceptible to the impact of painful procedures and prolonged separation from caregivers that are often inherent in a NICU stay. Non-pharmacological interventions can be efficacious for mitigating procedural pain for preterm infants. Interventions should continue to be evaluated with high quality randomized controlled trials, and should endeavor to take into account the neurobiological and psychosocial aspects of preterm vulnerability for pain prevention and management strategies.

The impact of Nonpharmacological Interventions on Cortisol During Heel Lance Procedures on Preterm Infants: A Meta-Analysis Of RCTs

BACKGROUND

Current research suggests a need to implement environmental, behavioral, and even nutritional interventions, with the objective of improving the comfort and stability of preterm newborn infants, as well as reducing their stress and pain levels. Several studies have used the salivary reactivity of cortisol to assess stress or pain in preterm infants. The aim of this study was to analyze the results of published randomized controlled trials that tested the effects of nonpharmacological interventions on cortisol as a treatment for heel lance pain/stress in preterm infants.

METHODS

Published randomized controlled trials (RCTs) were searched in PubMed, Embase, CINHAL, Web of Science Cochrane Library, and Cochrane Database of Systematic Reviews, and six studies met the eligibility criteria. The quality of the included studies was appraised using Cochrane's Collaboration tool.

RESULTS

The meta-analysis showed that non-pharmacological interventions were associated with a reduction in levels of salivary cortisol in comparison with other interventions and controls, with fixed effect mean differences of -0.11, and with a 95% C.I. of -0.28 to -0.05. Prone-nest position, breast milk odor, kangaroo care, and twins co-bedding led to a decrease in cortisol levels in saliva.

CONCLUSION

Future studies should be performed on nonpainful interventions in order to gain more knowledge about the regulation of cortisol in saliva in preterm infants with involving control group and larger sample sizes.

Effect of a multicomponent nutritional supplement on functional outcomes for Duchenne muscular dystrophy: A randomized controlled trial

BACKGROUND & AIMS

Duchenne muscular dystrophy (DMD) is an X-linked neuromuscular condition causing progressive muscle weakness and premature death. Whilst effective treatments such as gene therapy are developed, families often seek complementary therapies such as nutrition supplements to help their son maintain function; however, there is limited evidence supporting the use of nutritional supplements in DMD. This study aimed to compare the effect of a Standard nutritional supplement with an Enhanced nutritional supplement combining three nutriceuticals on functional outcomes in ambulatory boys with Duchenne muscular dystrophy (DMD).

DESIGN

A 50-week double blinded, randomized, controlled crossover trial was conducted in four Australian neuromuscular centres. Primary outcome measures were 6-min walk distance (6MWD) and community ambulation (StepWatch™ Activity Monitoring). Secondary outcome measures included body composition and quality of life. Serum 25-hydroxyvitamin D was measured.

RESULTS

Twenty-seven boys completed the intervention. Traditional crossover analysis demonstrated the Enhanced supplement compared to the Standard supplement was associated with a difference of +12 (95% CI: -16, 40) metres in 6MWD, +0.5 (95% CI: -53, 54) inactive minutes per day and -95 (95% CI: -887, 696) steps per day. A mixed effect model indicated a potentially clinically important effect of the Enhanced supplement on the 6MWD of +31 (95% CI: -19, 81) metres. Mean serum 25 hydroxyvitamin D levels at week 50 was 94 (95% CI: 84, 104) nmol/L. There was no observable effect of either supplement regime on body composition or quality of life.

CONCLUSIONS

Whilst a positive effect of the Enhanced supplement on functional outcomes was observed, this finding was inconclusive due to the small sample size. The results do not support the use of combined nutritional supplements to improve body composition or quality of life in DMD. A dose of 2000 IU vitamin D was an adequate dose to raise serum 25-hydroxyvitamin D over 50 weeks.

CLINICAL TRIAL REGISTRY

Registry #: ACTRN12610000462088, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12610000462088.

Effect of combined pharmacological, behavioral, and physical interventions for procedural pain on salivary cortisol and neurobehavioral development in preterm infants: a randomized controlled trial

Repeated procedural pain may lead to increased secretion of cortisol and future neurobehavioral development disorders in preterm infants. Changes in the cortisol level may mediate the effect of neonatal repetitive procedural pain on altered childhood neurobehavioral development in preterm infants. However, few studies have investigated the effect of combined pharmacological, behavioral, and physical interventions over repeated painful procedures on pain response, cortisol level, and neurobehavioral development. This study examined (1) the efficacy and safety of sucrose combined with massage, music, non-nutritive sucking, and gentle human touch to treat preterm infants with repeated procedural pain; (2) the cortisol level at discharge from the neonatal intensive care unit (NICU); (3) neurobehavioral development at 40 weeks' corrected gestational age; and (4) the potential mediating effect of the cortisol level in the combined interventions on neurobehavioral development. Stable preterm infants (n = 76) were randomized to receive routine care or combined interventions across repeated painful procedures throughout their NICU stay. The Premature Infant Pain Profile scores in the early, middle, and late periods of the NICU stay were measured, as were the basal salivary cortisol level at admission and discharge, the Neonatal Behavioral Neurological Assessment score at 40 weeks' corrected gestational age, and the incidence of adverse effects during the study period. Our findings indicated that the combined interventions remained efficacious and safe for reducing repeated procedural pain, decreased the cortisol level at discharge, and promoted early neurobehavioral development in preterm infants. This effect may have been mediated through decreased cortisol levels and reduced repeated procedural pain.

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.

Non-pharmaceutical intervention and pain management situation for neonatal analgesia

Neonatal pain management is an important issue which should have great attention. More and more researches have proved that neonates can feel pain when undergoes painful procedures such as vaccination, heel stick, and so on, and it will result in short-term and long-term outcomes. So it is very important to manage neonatal pain. This article summarized some non-pharmaceutical interventions, including sucrose or glucose, non-nutritional sucking (NNS), breastfeeding, facilitated tucking (FT), kangaroo mother care (KMC), swaddling, heel warming, sensorial saturation (SS), and music therapy, which showed obvious effects for neonatal pain. In addition, this article summarized the progress of neonatal pain intervention in various countries and showed that many countries have not paid enough attention to this problem, while some countries have carried out promotion programs for neonatal pain management which give some clinical enlightenment to our country that we need to pay more attention to this problem.