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Bueno M, Ballantyne M, Campbell-Yeo M, Estabrooks C, Gibbins S, Harrison D, McNair C, Riahi S, Squires J, Synnes AR, Taddio A, Victor C, Yamada J, Stevens B. Cumulative sucrose exposure for repeated procedural pain in preterm neonates and neurodevelopment at 18 months of corrected age: a prospective observational longitudinal study. BMJ Paediatr Open 2024; 8:e002604. [PMID: 38986541 PMCID: PMC11284924 DOI: 10.1136/bmjpo-2024-002604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/27/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Oral sucrose is repeatedly administered to neonates in the neonatal intensive care unit (NICU) to treat pain from commonly performed procedures; however, there is limited evidence on its long-term cumulative effect on neurodevelopment. We examined the association between total sucrose volumes administered to preterm neonates for pain mitigation in the NICU and their neurodevelopment at 18 months of corrected age (CA). METHODS A prospective longitudinal single-arm observational study that enrolled hospitalised preterm neonates <32 weeks of gestational age at birth and <10 days of life was conducted in four level III NICUs in Canada. Neonates received 0.1 mL of 24% sucrose 2 min prior to all commonly performed painful procedures during their NICU stay. Neurodevelopment was assessed at 18 months of CA using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Multiple neonatal and maternal factors known to affect development were adjusted for in the generalised linear model analysis. RESULTS 172 preterm neonates were enrolled and 118 were included in the analysis at 18 months of CA. The total mean sucrose volume administered/neonate/NICU stay was 5.96 (±5.6) mL, and the mean Bayley-III composite scores were: cognitive 91 (±17), language 86 (±18) and motor 88 (±18). There was no association between Bayley-III scores and the total sucrose volume: cognitive (p=0.57), language (p=0.42) and motor (p=0.70). CONCLUSION Cumulative sucrose exposure for repeated procedural pain in preterm neonates was neither associated with a delay in neurodevelopment nor neuroprotective effects at 18 months of CA. If sucrose is used, we suggest the minimally effective dose combined with other non-pharmacological interventions with demonstrated effectiveness such as skin-to-skin contact, non-nutritive sucking, facilitated tucking and swaddling. TRIAL REGISTRATION NUMBER NCT02725814.
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Affiliation(s)
- Mariana Bueno
- University of Toronto Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada
| | - Marilyn Ballantyne
- University of Toronto Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Marsha Campbell-Yeo
- School of Nursing, Faculty of Health and Departments of Pediatrics, Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Carole Estabrooks
- Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
| | - Sharyn Gibbins
- Neonatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Denise Harrison
- Nursing, University of Melbourne School of Health Sciences, Melbourne, Victoria, Australia
- School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
| | - Carol McNair
- Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shirine Riahi
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janet Squires
- School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anne R Synnes
- Neonatology, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
- Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna Taddio
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto Leslie Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Charles Victor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Janet Yamada
- Toronto Metropolitan University Daphne Cockwell School of Nursing, Toronto, Ontario, Canada
| | - Bonnie Stevens
- University of Toronto Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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Agakidou E, Kontou A, Stathopoulou T, Farini M, Thomaidou A, Tsoni K, Chotas W, Sarafidis K. Intertemporal Improvement in Physicians' Perceptions of the Short-Term Adverse Outcomes of Neonatal Pain: Results of a Two-Time-Point National Survey. CHILDREN (BASEL, SWITZERLAND) 2024; 11:471. [PMID: 38671688 PMCID: PMC11049171 DOI: 10.3390/children11040471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
Pain in early life may seriously impact neonatal outcomes. This study aimed to evaluate whether the perceptions of physicians working in neonatal intensive care units (NICUs) of the short-term adverse outcomes associated with neonatal pain have changed over a 20-year period. Self-administered questionnaires were distributed to 117 and 145 neonatologists, pediatricians, and fellows working in level III NICUs in 2000 (T1) and 2019 (T2), respectively. The questionnaire consisted of four domains, including the central nervous, cardiovascular, and respiratory systems, as well as "other systems" (metabolic/endocrine system, growth, and general condition), with 21 total items overall. Although the proportion of positive (correct) responses to the total and system-specific domain scores was significantly higher at T2 than T1, the knowledge of certain short-term adverse outcomes was suboptimal even at T2. Adjustment for cofactors confirmed the independent association of the survey time-point with the total and system-specific domain scores. Moreover, NICU type was an independent significant factor associated with the adjusted total and central nervous system scores, while young doctors had a better knowledge of adverse cardiovascular effects. Conclusions: The perceptions of NICU physicians concerning the short-term outcomes associated with neonatal pain have significantly improved over the past 20 years, although remaining knowledge gaps mandate ongoing efforts to achieve an improvement in neonatal care.
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Affiliation(s)
- Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Angeliki Kontou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Theodora Stathopoulou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Maria Farini
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Agathi Thomaidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - Konstantina Tsoni
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Hippokrateion General Hospital, 54642 Thessaloniki, Greece; (A.K.); (M.F.); (K.S.)
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Bueno M, Ballantyne M, Campbell‐Yeo M, Estabrooks C, Gibbins S, Harrison D, McNair C, Riahi S, Squires J, Synnes A, Taddio A, Victor C, Yamada J, Stevens B. A longitudinal observational study on the epidemiology of painful procedures and sucrose administration in hospitalized preterm neonates. PAEDIATRIC & NEONATAL PAIN 2024; 6:10-18. [PMID: 38504869 PMCID: PMC10946675 DOI: 10.1002/pne2.12114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 03/21/2024]
Abstract
Although sucrose is widely administered to hospitalized infants for single painful procedures, total sucrose volume during the entire neonatal intensive care unit (NICU) stay and associated adverse events are unknown. In a longitudinal observation study, we aimed to quantify and contextualize sucrose administration during the NICU stay. Specifically, we investigated the frequency, nature, and severity of painful procedures; proportion of procedures where neonates received sucrose; total volume of sucrose administered for painful procedures; and incidence and type of adverse events. Neonates <32 weeks gestational age at birth and <10 days of life were recruited from four Canadian tertiary NICUs. Daily chart reviews of documented painful procedures, sucrose administration, and any associated adverse events were undertaken. One hundred sixty-eight neonates underwent a total of 9093 skin-breaking procedures (mean 54.1 [±65.2] procedures/neonate or 1.1 [±0.9] procedures/day/neonate) during an average NICU stay of 45.9 (±31.4) days. Pain severity was recorded for 5399/9093 (59.4%) of the painful procedures; the majority (5051 [93.5%]) were heel lances of moderate pain intensity. Sucrose was administered for 7839/9093 (86.2%) of painful procedures. The total average sucrose volume was 5.5 (±5.4) mL/neonate or 0.11 (±0.08) mL/neonate/day. Infants experienced an average of 7.9 (±12.7) minor adverse events associated with pain and/or sucrose administration that resolved without intervention. The total number of painful procedures, sucrose volume, and incidence of adverse events throughout the NICU stay were described addressing an important knowledge gap in neonatal pain. These data provide a baseline for examining the association between total sucrose volume during NICU stay and research on longer-term behavioral and neurodevelopmental outcomes.
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Affiliation(s)
| | - Marilyn Ballantyne
- University of TorontoTorontoOntarioCanada
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada
| | - Marsha Campbell‐Yeo
- Dalhousie UniversityHalifaxNova ScotiaCanada
- IWK Health CentreHalifaxNova ScotiaCanada
| | | | | | - Denise Harrison
- University of MelbourneMelbourneVictoriaAustralia
- Murdoch Children's Research InstituteMelbourneVictoriaAustralia
- University of OttawaOttawaOntarioCanada
| | - Carol McNair
- The Hospital for Sick ChildrenTorontoOntarioCanada
| | | | | | - Anne Synnes
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Anna Taddio
- The Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - Charles Victor
- University of TorontoTorontoOntarioCanada
- The Institute of Health PolicyManagement and EvaluationTorontoOntarioCanada
| | - Janet Yamada
- Toronto Metropolitan UniversityTorontoOntarioCanada
| | - Bonnie Stevens
- The Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
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Faqihi S, Ismail A, Hasan AAH. Neonatal Intensive Care Unit Nurses' Knowledge and Use of Sucrose for Neonatal Pain Management in Saudi Arabia. SAGE Open Nurs 2024; 10:23779608241234401. [PMID: 38410813 PMCID: PMC10896065 DOI: 10.1177/23779608241234401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/27/2024] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Sucrose is an evidence-based intervention used for short-term pain management and distress from minor procedures. Limited research exists on nurses' knowledge and use of sucrose in Neonatal Intensive Care Units in Saudi Arabia. Objective To assess nurses' knowledge and use of sucrose in Neonatal Intensive Care Units in Saudi Arabia. Methods A cross-sectional online survey was used to collect data from a convenience sample of 68 neonatal intensive care nurses in Saudi Arabia. A modified tool assessed the knowledge and use of sucrose. Logistic regression analysis was used to find the predictors for sucrose use. Results Most respondents never used sucrose for neonatal pain management and did not receive any training on sucrose. The mean knowledge of nurses regarding sucrose and its use was very low (38%): 16% had a high level of knowledge regarding sucrose, 13% moderate, 19% low, and 52% very low. Nurses who received training on sucrose use and nurses who read or heard about sucrose predicted the use of sucrose. Conclusion Nurses' knowledge and use of sucrose were inadequate. Interventional programs are needed to enhance the nurses' knowledge regarding sucrose and its use and to enhance the utilization of sucrose as a pain management intervention in the Neonatal Intensive Care Units in Saudi Arabia.
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Affiliation(s)
- Sumayah Faqihi
- Neonatal Intensive Care Nursing, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | - Ahmad Ismail
- Director of the Master Program in Neonatal Intensive Care Nursing, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | - Abd Al-Hadi Hasan
- Nursing Department, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
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Yamada J, Bueno M, Santos L, Haliburton S, Campbell-Yeo M, Stevens B. Sucrose analgesia for heel-lance procedures in neonates. Cochrane Database Syst Rev 2023; 8:CD014806. [PMID: 37655530 PMCID: PMC10466459 DOI: 10.1002/14651858.cd014806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- Janet Yamada
- Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, Canada
| | | | | | | | - Marsha Campbell-Yeo
- School of Nursing, Faculty of Health and Departments of Pediatrics, Psychology and Neuroscience, Dalhousie University and IWK Health, Halifax, Canada
| | - Bonnie Stevens
- Nursing Research, The Hospital for Sick Children, Toronto, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Lawrence S Bloomberg Faculty of Nursing Faculties of Medicine and Dentistry, University of Toronto, Toronto, Canada
- Centre for the Study of Pain, University of Toronto, Toronto, Canada
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Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S, DiLorenzo-Klas M, Racine NM, Ahola Kohut S, Lisi D, Turcotte K, Stevens B, Uman LS. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 2023; 6:CD006275. [PMID: 37314064 PMCID: PMC10265939 DOI: 10.1002/14651858.cd006275.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
| | - Oana Bucsea
- Department of Psychology, York University, Toronto, Canada
| | - Ilana Shiff
- Department of Psychology, York University, Toronto, Canada
| | - Cheryl Chow
- Department of Psychology, York University, Toronto, Canada
| | | | | | | | - Nicole M Racine
- Department of Psychology, University of Calgary, Calgary, Canada
| | - Sara Ahola Kohut
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Diana Lisi
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Kara Turcotte
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Bonnie Stevens
- Nursing Research, The Hospital for Sick Children, Toronto, Canada
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Zhao T, Griffith T, Zhang Y, Li H, Hussain N, Lester B, Cong X. Early-life factors associated with neurobehavioral outcomes in preterm infants during NICU hospitalization. Pediatr Res 2022; 92:1695-1704. [PMID: 35338349 PMCID: PMC9509490 DOI: 10.1038/s41390-022-02021-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study was to investigate the influence of early-life pain/stress and medical characteristics on neurobehavioral outcomes in preterm infants. METHODS A prospective cohort study was conducted with 92 preterm infants (28-32 weeks gestational age [GA]). Early-life pain/stress was measured via the Neonatal Infant Stressor Scale (NISS) during the first 28 days of NICU hospitalization. Neurobehavioral outcomes were evaluated using the NICU Network Neurobehavioral Scale at 36-38 weeks post-menstrual age. Functional regression and machine learning models were performed to investigate the predictors of neurobehavioral outcomes. RESULTS Infants experienced daily acute pain/stress (24.99 ± 7.13 frequencies) and chronic events (41.13 ± 17.81 h). Up to 12 days after birth, both higher acute and chronic NISS scores were associated with higher stress scores; and higher chronic NISS scores were also related to lower self-regulation and quality of movement. Younger GA predicted worse neurobehavioral outcomes; GA < 31.57 weeks predicted worse stress/abstinence, self-regulation, and excitability; GA < 30.57 weeks predicted poor quality of movement. A higher proportion of maternal breastmilk intake predicted better self-regulation, excitability, and quality of movement in older GA infants. CONCLUSIONS Preterm infants are vulnerable to the impact of early-life pain/stress. Neurobehavioral outcomes are positively associated with increased GA and higher maternal breastmilk intake. IMPACT During the first 12 days of life, preterm infant neurobehavioral outcomes were vulnerable to the negative impact of acute and chronic pain/stress. Future research is warranted to investigate the long-term effects of early-life pain/stress on neurobehavioral outcomes. Gestational age remains one of the critical factors to predict neurobehavioral outcomes in preterm infants; older gestational age significantly predicted better neurobehavioral outcomes. Feeding with a higher proportion of maternal breastmilk predicted better neurobehavioral outcomes. Future research is warranted to investigate how maternal breastmilk may buffer the negative effects of early-life pain/stress on neurobehavioral outcomes.
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Affiliation(s)
- Tingting Zhao
- School of Nursing, University of Connecticut, Storrs, CT, USA
| | - Thao Griffith
- Department of Family and Community Health Nursing, Marcella Niehoff School of Nursing, Loyola University Chicago, Maywood, IL, USA
| | - Yiming Zhang
- Department of Statistics, University of Connecticut, Storrs, CT, USA
| | - Hongfei Li
- Department of Statistics, University of Connecticut, Storrs, CT, USA
| | - Naveed Hussain
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
- Division of Neonatology, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Barry Lester
- Brown Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Xiaomei Cong
- School of Nursing, University of Connecticut, Storrs, CT, USA.
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.
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Velumula PK, Elbakoush F, Tabb C, Farooqi A, Lulic-Botica M, Jani S, Natarajan G, Bajaj M. Breast milk vs 24% sucrose for procedural pain relief in preterm neonates: a non-inferiority randomized controlled trial. J Perinatol 2022; 42:914-919. [PMID: 35197549 DOI: 10.1038/s41372-022-01352-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
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).
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Affiliation(s)
| | - Faesal Elbakoush
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA
| | - Carl Tabb
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA
| | | | - Mirjana Lulic-Botica
- Hutzel Women's Hospital, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - Sanket Jani
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Girija Natarajan
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Monika Bajaj
- Hutzel Women's Hospital, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
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Maya-Enero S, Fàbregas-Mitjans M, Llufriu-Marquès RM, Candel-Pau J, Garcia-Garcia J, López-Vílchez MÁ. Comparison of the analgesic effect of inhaled lavender vs vanilla essential oil for neonatal frenotomy: a randomized clinical trial (NCT04867824). Eur J Pediatr 2022; 181:3923-3929. [PMID: 36076107 PMCID: PMC9458311 DOI: 10.1007/s00431-022-04608-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 11/25/2022]
Abstract
UNLABELLED It is necessary to treat neonatal pain because it may have short- and long-term adverse effects. Frenotomy is a painful procedure where sucking, a common strategy to relieve pain, cannot be used because the technique is performed on the tongue. In a previous randomized clinical trial, we demonstrated that inhaled lavender essential oil (LEO) reduced the signs of pain during neonatal frenotomy. We aimed to find out whether inhaled vanilla essential oil (VEO) is more effective in reducing pain during frenotomy than LEO. Randomized clinical trial with neonates who underwent a frenotomy for type 3 tongue-ties between May and October 2021. Pain was assessed using pre and post-procedure heart rate (HR) and oxygen saturation (SatO2), crying time, and NIPS score. Neonates were randomized into "experimental" and "control" group. In both groups, we performed swaddling, administered oral sucrose, and let the newborn suck for 2 min. We placed a gauze pad with one drop of LEO (control group) or of VEO (experimental group) under the neonate's nose for 2 min prior to and during the frenotomy. We enrolled 142 neonates (71 per group). Both groups showed similar NIPS scores (2.02 vs 2.38) and crying times (15.3 vs 18.7 s). We observed no differences in HR increase or in SatO2 decrease between both groups. We observed no side effects in either of the groups. CONCLUSIONS We observed no appreciable difference between LEO and VEO; therefore, we cannot conclude which of them was more effective in treating pain in neonates who underwent a frenotomy. TRIAL REGISTRATION This clinical trial is registered with www. CLINICALTRIALS gov with NCT04867824. WHAT IS KNOWN • Pain management is one of the most important goals of neonatal care as it can have long-term neurodevelopmental effects. • Lavender essential oil can help relieve pain due to its sedative, antispasmodic, and anticolic properties. WHAT IS NEW • Lavender and vanilla essential oils are safe, beneficial, easy to use, and cheap in relieving pain in neonates who undergo a frenotomy for type 3 tongue-ties.
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Affiliation(s)
- Silvia Maya-Enero
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003, Barcelona, Spain.
| | - Montserrat Fàbregas-Mitjans
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Rosa Maria Llufriu-Marquès
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Júlia Candel-Pau
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Jordi Garcia-Garcia
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - María Ángeles López-Vílchez
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
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Maya-Enero S, Fàbregas-Mitjans M, Llufriu-Marquès RM, Candel-Pau J, Garcia-Garcia J, López-Vílchez MÁ. Analgesic effect of inhaled lavender essential oil for frenotomy in healthy neonates: a randomized clinical trial. World J Pediatr 2022; 18:398-403. [PMID: 35377106 PMCID: PMC8978507 DOI: 10.1007/s12519-022-00531-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/21/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Neonatal pain may affect long-term neurodevelopment and must be treated. Frenotomy is a painful procedure wherein a common strategy to relieve pain (sucking) cannot be used because the technique is performed on the tongue. Lavender essential oil (LEO) has sedative and antispasmodic properties and has been successfully used to treat pain during heel puncture and vaccination. Our aim was to demonstrate if the use of inhaled LEO is effective in reducing pain during frenotomy in healthy, full-term neonates. METHODS We conducted a randomized clinical trial in neonates who underwent a frenotomy between August 2020 and April 2021. We assessed pain using pre and post-procedure heart rate and oxygen saturation, crying time and Neonatal Infant Pain Scale (NIPS) score. Patients with type 3 tongue tie were randomized into the "experimental group" and "control group". In both groups, we performed swaddling, administered oral sucrose, and let the newborn suck for two minutes. In the experimental group, we also placed a gauze pad with one drop of LEO under the neonate's nose for two minutes prior to and during the frenotomy. RESULTS We enrolled 142 patients (71 per group). The experimental group showed significantly lower NIPS scores (1.88 vs 2.92) and cried almost half the amount of time (14.8 vs. 24.6 seconds, P = 0.006). Comparing with the control group, we observed no side effects in either of the groups. CONCLUSIONS We observed a significant decrease in crying time and lower NIPS scores in the neonates who received inhaled LEO and underwent a frenotomy for type 3 tongue-ties. Thus, we recommend using inhaled LEO during neonatal frenotomies.
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Affiliation(s)
- Silvia Maya-Enero
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003, Barcelona, Spain.
| | - Montserrat Fàbregas-Mitjans
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Rosa Maria Llufriu-Marquès
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Júlia Candel-Pau
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Jordi Garcia-Garcia
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - María Ángeles López-Vílchez
- Department of Neonatology, Service of Pediatrics, Hospital del Mar, Parc de Salut Mar, Universitat Pompeu Fabra, Passeig Marítim 25-29, 08003 Barcelona, Spain
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Effect of combined pharmacological, behavioral, and physical interventions for procedural pain on salivary cortisol and neurobehavioral development in preterm infants: a randomized controlled trial. Pain 2021; 162:253-262. [PMID: 32773596 DOI: 10.1097/j.pain.0000000000002015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Razaghi N, Aemmi SZ, Sadat Hoseini AS, Boskabadi H, Mohebbi T, Ramezani M. The effectiveness of familiar olfactory stimulation with lavender scent and glucose on the pain of blood sampling in term neonates: A randomized controlled clinical trial. Complement Ther Med 2020; 49:102289. [DOI: 10.1016/j.ctim.2019.102289] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 11/28/2022] Open
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Repeating a dose of sucrose for heel prick procedure in preterms is not effective in reducing pain: a randomised controlled trial. Eur J Pediatr 2020; 179:293-301. [PMID: 31728675 DOI: 10.1007/s00431-019-03509-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/12/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Oral sucrose is included in almost all recommendations for treatment of pain in newborns, but evidence if multiple doses might be more effective than a single standard dose is lacking. We designed a single-centre, double-blind, randomised, controlled trial. We enrolled preterm infants needing the heel prick procedure. Each enrolled infant was randomised to receive a single standard dose of sucrose 2 min before or a double dose of sucrose 2 min before, and 30 s after heel prick. Primary outcome was the efficacy of the two interventions tested by the premature infant pain profile-PIPP scale obtained at 30 s, 60 s, and 120 s after heel prick. Secondary outcome was the evaluation of the concordance between the PIPP scale and other pain scores more feasible in clinical practice. Seventy-two infants were randomised. No difference in pain perception as measured by the PIPP scale was found between the groups: median PIPP values 4.0(IQR 3.0-4.0) vs 3.0(IQR 3.0-4.0) at baseline; 6.0(IQR 5.0-10.0) vs 6.0(IQR 4.0-8.5) at 30 s; 6.0(IQR 4.0-7.0) vs 5.0(IQR 4.0-8.5) at 60 s and 5.0(IQR 4.0-7.0) vs 5.0(IQR 4.0-7.5) at 2 min, in the experimental and standard treatment groups, respectively (p = 0.9020). There was no correlation between PIPP scores and other pain scales.Conclusion: We do not recommend doubling the dose during heel prick.What is Known:• Oral sucrose is included in almost all international position papers and recommendations for the treatment of mild to moderate pain in newborns, associated with non-nutritive sucking and facilitated tucking• Premature infant pain profile (PIPP) scale is the gold standard for evaluation of pain in preterms but it is difficult to use in clinical practiceWhat is New:• Repeating a dose of 24% sucrose is not effective in reducing pain during the recovery phase of a skin breaking procedure• Other pain scales, easier to use in clinical practice, are not comparable with PIPP for the evaluation of procedural pain in preterms.
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Effect of non-nutritive sucking and sucrose alone and in combination for repeated procedural pain in preterm infants: A randomized controlled trial. Int J Nurs Stud 2018; 83:25-33. [DOI: 10.1016/j.ijnurstu.2018.04.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/13/2022]
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The Energy Costs of Prematurity and the Neonatal Intensive Care Unit (NICU) Experience. Antioxidants (Basel) 2018; 7:antiox7030037. [PMID: 29498645 PMCID: PMC5874523 DOI: 10.3390/antiox7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/16/2018] [Accepted: 02/23/2018] [Indexed: 12/13/2022] Open
Abstract
Premature neonates are in an energy deficient state due to (1) oxygen desaturation and hypoxia events, (2) painful and stressful stimuli, (3) illness, and (4) neurodevelopmental energy requirements. Failure to correct energy deficiency in premature infants may lead to adverse effects such as neurodevelopmental delay and negative long-term metabolic and cardiovascular outcomes. The effects of energy dysregulation and the challenges that clinicians in the Neonatal Intensive Care Unit (NICU) face in meeting the premature infant's metabolic demands are discussed. Specifically, the focus is on the effects of pain and stress on energy homeostasis. Energy deficiency is a complex problem and requires a multi-faceted solution to promote optimum development of premature infants.
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The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial. BMC Pediatr 2018; 18:85. [PMID: 29475433 PMCID: PMC5824554 DOI: 10.1186/s12887-018-1026-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 01/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Orally administered sucrose is effective and safe in reducing pain intensity during single, tissue-damaging procedures in neonates, and is commonly recommended in neonatal pain guidelines. However, there is wide variability in sucrose doses examined in research, and more than a 20-fold variation across neonatal care settings. The aim of this study was to determine the minimally effective dose of 24% sucrose for reducing pain in hospitalized neonates undergoing a single skin-breaking heel lance procedure. Methods A total of 245 neonates from 4 Canadian tertiary neonatal intensive care units (NICUs), born between 24 and 42 weeks gestational age (GA), were prospectively randomized to receive one of three doses of 24% sucrose, plus non-nutritive sucking/pacifier, 2 min before a routine heel lance: 0.1 ml (Group 1; n = 81), 0.5 ml (Group 2; n = 81), or 1.0 ml (Group 3; n = 83). The primary outcome was pain intensity measured at 30 and 60 s following the heel lance, using the Premature Infant Pain Profile-Revised (PIPP-R). The secondary outcome was the incidence of adverse events. Analysis of covariance models, adjusting for GA and study site examined between group differences in pain intensity across intervention groups. Results There was no difference in mean pain intensity PIPP-R scores between treatment groups at 30 s (P = .97) and 60 s (P = .93); however, pain was not fully eliminated during the heel lance procedure. There were 5 reported adverse events among 5/245 (2.0%) neonates, with no significant differences in the proportion of events by sucrose dose (P = .62). All events resolved spontaneously without medical intervention. Conclusions The minimally effective dose of 24% sucrose required to treat pain associated with a single heel lance in neonates was 0.1 ml. Further evaluation regarding the sustained effectiveness of this dose in reducing pain intensity in neonates for repeated painful procedures is warranted. Trial registration ClinicalTrials.gov: NCT02134873. Date: May 5, 2014 (retrospectively registered).
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The Needle-Less Treatment of Pain and Anxiety in the Pediatric Patient. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
India contributes to the highest neonatal mortality globally. Birth asphyxia is one of the leading causes of neonatal mortality in India. A large number of neonates who suffer from birth asphyxia progress to Hypoxic Ischemic Encephalopathy (HIE). The risk of a neonate progressing to severe form of HIE is many times higher in the low and middle income countries (LMICs) with ill developed health infrastructure. Till date LMICs have had a low institutional delivery rate, poor regionalization of care, lack of adequate transport facilities and ill equipped neonatal intensive care facilities. This has lead to a tremendous burden on the health care systems with a cohort of developmentally challenged neonates surviving into adulthood. Recently, Therapeutic Hypothermia (TH) has emerged as an evidence based intervention to reduce mortality and neurodevelopmental disability associated with asphyxia induced encephalopathy. TH has become the gold standard in the management of such cases in the western world. Extension of this knowledge to the LMICs and countries like India require a better understanding of the unique sociocultural issues associated with asphyxial brain injury in neonates. The high incidence of sepsis and presence of economic constraints make this problem more complex in such countries. The current review has tried to address these issues and looked at the basics of this complex topic from the perspective of a general pediatrician.
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Kumari S, Datta V, Rehan H. Comparison of the Efficacy of Oral 25% Glucose with Oral 24% Sucrose for Pain Relief during Heel Lance in Preterm Neonates: A Double Blind Randomized Controlled Trial. J Trop Pediatr 2017; 63:30-35. [PMID: 27435886 DOI: 10.1093/tropej/fmw045] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIM To study the analgesic effect of oral 25% glucose as compared with oral 24% sucrose during heel lance in preterm neonates. METHODS Stable preterm neonates within first 48 hours of life were randomized to receive either 24% sucrose or 25% glucose before heel lance. Primary outcome assessed was painful response by the Premature Infant Pain Profile (PIPP) score at 30 seconds after heel lance, and the secondary outcome was immediate adverse events associated with the administration of two solutions and duration of crying immediately following the procedure. RESULTS A total of 94 neonates were randomly assigned into 24% sucrose and 25% glucose group. The baseline characteristics between the two groups were comparable. No significant difference was observed between the two study groups with respect to PIPP scores, duration of crying and rate of adverse events. CONCLUSIONS When assessed by PIPP score, 25% glucose and 24% sucrose provided comparable analgesia during heel lance in preterm neonates.
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Affiliation(s)
- Sweta Kumari
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi 110001, India
| | - Vikram Datta
- Department of Neonatology, Lady Hardinge Medical College, New Delhi 110001, India
| | - Harmeet Rehan
- Department of Pharmacology, Lady Hardinge Medical College, New Delhi 110001, India
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Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2016; 7:CD001069. [PMID: 27420164 PMCID: PMC6457867 DOI: 10.1002/14651858.cd001069.pub5] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Administration of oral sucrose with and without non-nutritive sucking is the most frequently studied non-pharmacological intervention for procedural pain relief in neonates. OBJECTIVES To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin - TcpO2, TcpCO2), near infrared spectroscopy (NIRS), electroencephalogram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long-term neurodevelopmental outcomes. SEARCH METHODS We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016). We did not impose language restrictions. SELECTION CRITERIA RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. DATA COLLECTION AND ANALYSIS Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I(2) test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. MAIN RESULTS Seventy-four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta-analyses and for most analyses the GRADE assessments indicated low- or moderate-quality evidence. There was high-quality evidence for the beneficial effect of sucrose (24%) with non-nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD -1.70 (95% CI -2.13 to -1.26; I(2) = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD -2.14 (95% CI -3.34 to -0.94; I(2) = 0% (no heterogeneity; 2 studies, n = 164). There was high-quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD -2.79 (95% CI -3.76 to -1.83; I(2) = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD -1.05 (95% CI -1.98 to -0.12; I(2) = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan-analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long-term neurodevelopmental outcomes are unknown. AUTHORS' CONCLUSIONS Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate-quality evidence that sucrose in combination with other non-pharmacological interventions such as non-nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long-term (neurodevelopmental) outcomes.
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Affiliation(s)
- Bonnie Stevens
- The Hospital for Sick ChildrenNursing Research555 University AvenueTorontoONCanadaM5G 1X8
- The Hospital for Sick ChildrenResearch InstituteTorontoONCanada
- University of TorontoLawrence S Bloomberg Faculty of Nursing Faculties of Medicine and DentistryTorontoONCanada
- University of TorontoCentre for the Study of PainTorontoONCanada
| | - Janet Yamada
- Ryerson UniversityDaphne Cockwell School of NursingTorontoONCanada
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1X5
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