State of the science: procedural pain management in the neonate

The Effect of Maternal Voice on Venipuncture Induced Pain in Neonates: A Randomized Study

BACKGROUND

Venipuncture is a common procedure in the neonatal intensive care unit (NICU) and causes significant pain for neonates.

AIM

To evaluate the effect of maternal voice on pain caused by venipuncture (including peripheral venipuncture and femoral venipuncture) in neonates hospitalized in the NICU.

DESIGN

Experimental, randomized controlled study.

SETTING

The study was conducted in the NICU of two hospitals in China from November 2017 to January 2019.

METHODS

One hundred and sixteen neonates were randomly assigned to the maternal voice or routine care groups. The maternal voice group received recorded maternal voice intervention before, during, and after venipuncture. Three phases of procedures were videotaped. Neonatal Infant Acute Pain Assessment Scale (NIAPAS) was assessed by the same evaluator at different phases.

RESULTS

The study showed that NIAPAS scores, behavioral indicator scores, and physiological indicator scores in the maternal voice group were significantly lower compared with those in the routine care group.

CONCLUSION

Recorded maternal voice can improve pain caused by venipuncture in neonates. These are simple, rapid, and cost-effective methods that nurses can implement during venipuncture in neonates.

The clinical, operational, and financial worlds of neonatal palliative care: A focused ethnography

OBJECTIVE

Due to multiple issues, integrated interdisciplinary palliative care teams in a neonatal intensive care unit (NICU) may be difficult to access, sometimes fail to be implemented, or provide inconsistent or poorly coordinated care. When implementing an effective institution-specific neonatal palliative care program, it is critical to include stakeholders from the clinical, operational, and financial worlds of healthcare. In this study, researchers sought to gain a multidisciplinary perspective into issues that may impact the implementation of a formal neonatal palliative care program at a tertiary regional academic medical center.

METHOD

In this focused ethnography, the primary researcher conducted semistructured interviews that explored the perspectives of healthcare administrators, finance officers, and clinicians about neonatal palliative care. The perspectives of 39 study participants informed the identification of institutional, financial, and clinical issues that impact the implementation of neonatal palliative care services at the medical center and the planning process for a formal palliative care program on behalf of neonates and their families.

RESULTS

Healthcare professionals described experiences that influenced their views on neonatal palliative care. Key themes included: (a) uniqueness of neonatal palliative care, (b) communication and conflict among providers, (c) policy and protocol discrepancies, and (d) lack of administrative support.

SIGNIFICANCE OF RESULTS

The present study highlighted several areas that are challenging in the provision of neonatal palliative care. Our findings underscored the importance of recognizing and procuring resources needed simultaneously from the clinical, operational, and financial worlds in order to implement and sustain a successful neonatal palliative care program.

Skin-to-skin contact diminishes pain from hepatitis B vaccine injection in healthy full-term neonates

PURPOSE

This study was conducted to test the hypothesis that skin-to-skin contact (SSC) would reduce hepatitis B vaccine injection pain in full-term neonates.

DESIGN

Randomized controlled trial (RCT).

SAMPLE

Thirty-six mother-;neonate dyads were randomly assigned to SSC or control groups.

MAIN OUTCOMES

Cry time (CT ), behavioral state (BSt), and heart rate (HR ) were measured throughout the 16-minute protocol. HR and BSt were measured every 30 seconds; CT was recorded continuously.

RESULTS

SSC neonates cried less compared with controls (23 vs 32 seconds during injection; 16 vs 72 seconds during recovery), reached calmer BSts sooner (M = 2.8 vs M = 6.5 time points), and trended toward more rapid HR decrease. SSC as described was safe and effective and merits further testing.

Expressed breast milk for procedural pain in preterm neonates: a randomized, double-blind, placebo-controlled trial

AIM

To determine whether expressed breast milk (milk) reduces procedural pain associated with heel lancing in preterm neonates.

METHODS

In this placebo-controlled trial, preterm neonates received 5 mL of distilled water as placebo (water, n = 44), 25% glucose water (glucose, n = 39) or milk (n = 40). Heel lancing was performed 2 min later. The primary outcome was the duration of first cry after lancing.

RESULTS

Participants had similar baseline demographic and clinical characteristics. There was a significant difference in the median duration of first cry among the groups: water = 70.5 sec [interquartile range (IQR) = 5.5-104.5]; glucose = 2.0 sec (IQR = 0.0-45.0); milk = 29.5 sec (IQR = 0.0-65.0). Specifically, the duration of first cry was significantly shorter in the glucose group compared with the water group (Bonferroni adjustment, p = 0.011). Pain scores were significantly lower in the glucose and milk groups compared with the water group 1, 2 and 3 min after heel lancing (p < 0.05).

CONCLUSIONS

Although milk did not significantly reduce crying time, our finding that pain scores were significantly lower in the milk group suggests that milk may reduce pain associated with heel lancing in preterm neonates.

Effect of skin-to-skin contact on preterm infant skin barrier function and hospital-acquired infection

Background

The preterm infants' skin is structurally and functionally immature at birth because of immature stratum corneum barrier function, leading to problems with fluid loses, thermoregulation, and infection. Two parameters of barrier function can be non-invasively assessed: Stratum Corneum Hydration (SCH) and Transepidermal Water Loss (TEWL). Skin-to-Skin Care (SSC) is the proposed independent variable that might affect barrier function by decreasing TEWL and increasing SCH, thereby improving stratum corneum barrier function and consequently decreasing the rate of infection. No study of SSC's effects on TEWL and SCH of preterm infants could be found. The purpose of the study was to determine the effect of 5 daily Skin-to-Skin Contact sessions on infant skin hydration (SCH), transepidermal evaporated water loss (TEWL), and on SCH when TEWL was controlled, and on the presence of hospital acquired infection.

Methods

A one-group pretest-test-posttest design with 10 preterm infants (28 - 30 wks GA < 32 wks postmenstrual age, and no infection at entry). Test = 90 minutes of SSC; pre-test and post-test = 30 minutes each of prone positioning in an incubator. SCH and TEWL were taken on Days 1 and 5 at the beginning, middle and end of each period using Multi-Probe Adaptor. A 3 X 3 X 2 Repeated Measures Mixed Models Design, including a covariate, was used to analyze level of Skin Hydration. Specifically, the model tested comparisons in SCH made across repetitions, time, and days, as well as all possible interactions while controlling for TEWL. Descriptive statistics described the number of positive blood cultures during hospitalization and the presence of infections four weeks post-discharge.

Results

Significant differences in skin hydration were found across TIME (Pre-SSC, SSC, Post-SSC) (F = 21.86; p < 0.001). One infant had a positive blood culture during hospitalization; no infants had signs of infection by 4 weeks post-discharge.

Conclusions

The study has begun fulfilling the recommendation that SSC be tested as a strategy to improve skin hydration, but reveals that evaporative loss may be higher during SSC than during incubator care, and that the higher transepidermal evaporated water loss values may not necessarily be detrimental because few infections occurred even in its presence. A definitive randomized controlled trial is recommended.

Keywords

Skin-to-skin contact; Skin hydration; Transepidermal water loss; Infection; Preterm

Procedural pain management: a position statement with clinical practice recommendations

The American Society for Pain Management Nursing (ASPMN) has developed a position statement and clinical practice recommendations related to procedural preparation and comfort management. Procedures potentially produce pain and anxiety, both of which should be assessed and addressed before the procedure begins. This position statement refers to "comfort management" as incorporating the management of pain, anxiety, and any other discomforts that may occur with procedures. It is the position of ASPMN that nurses and other health care professionals advocate and intervene based on the needs of the patient, setting, and situation, to provide optimal comfort management before, during, and after procedures. Furthermore, ASPMN does not condone procedures being performed without the implementation of planned comfort assessment and management. In addition to outlining this position with supporting evidence, this paper reviews the ethical considerations regarding procedural comfort management and provides recommendations for nonpharmacologic and pharmacologic management during all phases of the procedure. An appendix provides a summary of this position statement and clinical practice recommendations.

Oral glucose for pain relief during eye examinations for retinopathy of prematurity

AIM

The aim of this study was to determine whether oral glucose could have a pain-relieving effect during the eye examinations that premature neonates undergo in the screening for retinopathy of prematurity.

BACKGROUND

Studies have shown that orally administered sweet-tasting solutions reduce signs of pain during painful procedures such as venepuncture and heel sticks on premature and full-term infants. This effect has not yet been proven during the eye examinations for the screening of retinopathy of prematurity. Design.  Randomised, controlled, double-blind study.

METHOD

Thirty infants born before 32 weeks of gestation and/or weighing <1500 g at birth were randomised to receive 1 ml of either 30% glucose or sterile water before the eye examination. Examinations were videotaped, and the observer was blinded to the intervention. Pain responses were scored using the premature infant pain profile. Heart rate and crying time were also recorded.

RESULTS

There were no statistically significant differences between the two groups, neither in premature infant pain profile score, heart rate changes nor crying time.

CONCLUSION

This study does not support the pain-relieving effect of orally administered glucose during eye examinations in preterm infants.

RELEVANCE TO CLINICAL PRACTICE

Oral glucose should not be used as single measure for pain relief during eye examinations of preterm infants. Other comforting and pain-relieving measures should be used.

Relationship between feeding schedules and gastric distress during retinopathy of prematurity screening eye examinations

PURPOSE

To determine whether a relationship exists between the timing of feeding before retinopathy of prematurity (ROP) eye examinations and gastric side effects or distress associated with this examination.

METHODS

A prospective, randomized, single-masked study was conducted involving infants in the neonatal intensive care unit who required an ROP eye examination and who received normal or full enteral feeding over a 1 year period. Infants were randomly assigned to 1 of 2 study arms: feeding 1 hour before examination (arm 1) or feeding schedule adjusted to ensure no feeding within 2 hours before examination (arm 2). Physiological data, including blood pressure and pulse rate, before, during and after examination, crying time during the examination, presence of vomiting and gastric aspirates, and gastric aspirates volume 24 hours after the examination, were recorded.

RESULTS

A total of 34 infants were enrolled, with 57 separate eye examinations conducted. There was 19% less crying (p = 0.016) in arm 1 versus arm 2. Vomiting was 3-fold less in arm 1 versus arm 2 (4.2% vs 12.5%, p = 0.38). Gastric aspirates was less in arm 1 versus arm 2 (p = 0.18). Diastolic blood pressure was lower and respiratory rate greater during the examination in arm 1 (p < 0.05), whereas pulse rate was greater at the start of the examination in arm 1 (p < 0.05).

CONCLUSIONS

Feeding neonatal intensive care unit infants 1 hour before compared with withholding feeding 2 or more hours before ROP examinations may reduce stress during the examination, as measured by percentage crying during the examination, with no increased incidence of vomiting or gastric aspirates.

Kangaroo Care (skin contact) reduces crying response to pain in preterm neonates: pilot results

Crying commonly occurs in response to heel stick and adversely affects the infant's physiologic stability. Minimal crying in response to pain is desired. "Kangaroo Care," skin contact between mother and infant, reduces pain and may reduce crying in response to pain. The purpose of this pilot study was to test Kangaroo Care's effect on the preterm infant's audible and inaudible crying response to heel stick. Inaudible crying has not been previously studied. A prospective randomized cross-over study with 10 preterm infants 2-9 days old (30-32 weeks' postmenstrual age) was conducted. Infants were randomly assigned to two sequences (sequence A: day 1 heel stick in Kangaroo Care [after 30 min of prone skin contact upright between maternal breasts] and day 2 heel stick in incubator [inclined, nested and prone]; or sequence B: opposite of sequence A) was conducted. Videotapes of baseline, heel warming, heel stick, and recovery phases were scored for audible and inaudible crying times. Audible and inaudible crying times for each subject in each phase were summed and analyzed by repeated-measures analysis of variance. Subject characteristics did not differ between those in the two sequences. Crying time differed between the study phases on both days (p <or= .001). When in Kangaroo Care compared with the incubator, crying time was less during the heel stick (p = .001) and recovery (p = .01) phases, regardless of sequence. Because Kangaroo Care reduced crying in response to heel stick in medically stable preterm infants, a definitive study is merited before making recommendations.

Neonatal end-of-life care: a review of the research literature

While advances in neonatal medicine have increased the possibility of sustaining life for many infants, more infants still die in the neonatal period (birth to 27 days of life) than those in any other time in childhood. Despite this statistic, there still remains much that is unknown about both the needs and the care of these critically ill babies. Palliative care is a viable option for many of these infants and their families. However, palliative care is rarely provided as an option for families. To provide healthcare providers with an overview of palliative and end-of-life care for infants in the neonatal period, we conducted an integrative review of the current research literature. A total of 10 articles were selected for the review. Findings from these studies were summarized in 1 of 4 categories: practices of withdrawing or withholding life-sustaining treatment, pain management during ventilator withdrawal, parents and the decision-making process, and the dying process.