A Prospective Study of Pain Experience in a Neonatal Intensive Care Unit of China

Pain and heart rate variability in neonates receiving dexmedetomidine

INTRODUCTION

Neonates in a NICU experience pain. Based on the cardiovascular and nociceptive systems link, a Newborn Infant Parasympathetic Evaluation (NIPE) monitor was designed to assess pain. The use of α2-agonists as analgesic-sedative drugs has increased in neonates. Given their effect on the autonomic system, we hypothesized that their use may alter NIPE's measurement capacity.

METHODS

Data were prospectively collected. The included patients were evaluated using combined pain assessment systems.

RESULTS

Sixteen newborns requiring sedoanalgesia underwent a total of 84 pain assessments. A good correlation was found between the NIPE-index and the COMFORT-neo and the crSO2 (cerebral regional oxygen saturation). No correlation was found in premature infants. By sedation group, the correlation remained in those receiving α2-agonist.

CONCLUSION

NIPE is a reliable tool for pain assessment. Further studies in premature infants are needed. The use of α2-agonist does not alter the measuring capacity of NIPE. The correlation between NIPE-index and crSO2 was also demonstrated.

A scoping review of the epidemiology and treatment of painful procedures in hospitalized neonates: What has changed in the past three decades?

BACKGROUND

Care of newborns hospitalized in the neonatal intensive care unit (NICU) includes multiple painful procedures/day. Epidemiologic studies have reported the frequency and nature of procedures and treatment interventions. However, evidence on the changing trends in the nature and frequency of neonatal pain procedures or treatments over time is absent or inconclusive. We aimed to determine the frequency and nature of painful procedures/neonate/day in the NICU.

DATABASES AND DATA TREATMENT

MEDLINE and Embase searches were conducted from database inception to July 2023. Studies that reported the nature and frequency of painful procedures and associated pain treatments in neonates were included. Standard inverse-variance random-effects meta-analyses were used to combine studies. Heterogeneity between studies was quantified using the I2 statistic.

RESULTS

Of 2622 unique citations, 64 full-text articles were reviewed; 23 were included. Six additional studies identified in a previous review, and six publications from reference lists were added, resulting in 35 studies. The mean number of painful procedures/neonate/day was 7.38 (95% CI 5.60, 9.17; range <2 to 17). Although the frequency of painful procedures in more recent studies was reduced, it was not statistically significant (p = 0.16). Painful procedures were more frequent during longer observation periods. Needle-related procedures were most common and did not change over time. Procedure-related treatment was suboptimal and inconsistently reported.

CONCLUSIONS

Frequency of painful procedures in the NICU has shown a clinically important decrease but has not significantly changed over time. A paradigm shift moving responsibility from providers to systems in changing pain practices in the NICU is required.

SIGNIFICANCE STATEMENT

The decrease in the daily frequency of painful procedures in hospitalized neonates might be clinically relevant but is not yet statistically significant. Pain treatment is insufficiently documented and reported. This lack of progress in neonatal care might be a result of the complexity of defining pain and stress; inconsistencies in determining the burden of procedural pain; the influence of barriers and facilitators on practice change; and the focus on an individual rather than system responsibility for pain prevention and treatment.

Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates

BACKGROUND

Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations. Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain.

OBJECTIVES

To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention.

SEARCH METHODS

We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals.

DATA COLLECTION AND ANALYSIS

Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates. Facilitated tucking versus standard care (four studies) Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD -2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence). Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD -3.06 beats per minute (bpm), 95% CI -9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI -1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD -1.20, 95% CI -3.47 to 1.07; 1 study, 20 infants; low-certainty evidence). Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence). No studies reported intraventricular haemorrhage (IVH). Familiar odour versus standard care (one study) Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD -0.30, 95% CI -2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD -6.30 bpm, 95% CI -16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD -0.80, 95% CI -4.82 to 3.22; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. White noise (one study) White noise during endotracheal suctioning probably has little or no effect on PIPP (MD -0.65, 95% CI -2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD -1.85 bpm, 95% CI -11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI -2.03 to 6.53; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH.

AUTHORS' CONCLUSIONS

Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning. Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.

Sucrose analgesia for heel-lance procedures in neonates

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.

Effect of combined procedural pain interventions during neonatal intensive care on sleep, cognitive development, and internalizing behavior: a follow-up analysis of a randomized controlled trial

ABSTRACT

Repeated procedural pain can cause preterm infants to spend excessive time awake at the cost of sleep and can have a detrimental impact on later cognitive and behavioral development. What's more, poor sleep may be correlated with worse cognitive development and more internalizing behaviors in infants and toddlers. In a randomized controlled trial (RCT), we found that combined procedural pain interventions (sucrose, massage, music, nonnutritive sucking, and gentle human touch) during neonatal intensive care could improve preterm infants' early neurobehavioral development. Here, we followed up the participants who were enrolled in the RCT to evaluate the effect of combined pain interventions on later sleep, cognitive development, and internalizing behavior and to determine whether sleep may moderate the effect of combined pain interventions on the cognitive development and internalizing behavior. Total sleep time and night awakenings at 3, 6, and 12 months old; the cognitive development (adaptability, gross motor, fine motor, language, and personal-social domains) at 12 and 24 months old measured by the Chinese version of Gesell Development Scale; and the internalizing behavior at 24 months old measured by the Chinese version of Child Behavior Checklist were assessed. Our findings showed the potential benefits of combined pain interventions during neonatal intensive care for preterm infant's later sleep, motor and language development, and internalizing behavior, and the effect of combined pain interventions on motor development and internalizing behavior might be moderated by the mean total sleep duration and night awakenings at 3, 6, and 12 months old.

Reduced BDNF expression in the auditory cortex contributed to neonatal pain-induced hearing impairment and dendritic pruning deficiency in mice

INTRODUCTION

Procedural pain in neonates is associated with impaired neurodevelopment. Whether hearing development is impaired, however, remains unknown. This study examined potential cause-and-effect relationship between neonatal pain and subsequent hearing loss in mice.

METHODS

Male C57BL/6J mouse pups received an intra-plantar injection of complete Freund's adjuvant on postnatal day 7 or repetitive needle prick stimuli from postnatal days 0-7. Mechanical and thermal pain thresholds were tested between postnatal days 14 and 49. The auditory brainstem response test was used to determine hearing thresholds. The inner ear structures and dendritic morphology in auditory cortex were assessed using immunofluorescence and Golgi-staining. The effects of oxycodone, tropomyosin receptor kinase B agonists and antagonists were tested.

RESULTS

Neonatal pain resulted in impaired hearing in adulthood of both pain models No damage or synapse loss was found in the cochlea but increased dendritic spine density and reduced brain-derived neurotrophic factor level were found in auditory cortex in neonatal pain group. Oxycodone attenuated hearing loss and the associated changes in dendritic spine density and brain-derived neurotrophic factor changes in auditory cortex. A tropomyosin receptor kinase B agonist reversed neonatal pain-induced hearing impairment and decreased caspase 3 expression in auditory cortex. Administration of tropomyosin receptor kinase B antagonist in naïve mouse pups impaired hearing development suppressed phosphorylated-AKT, and increased caspase 3 expression.

CONCLUSION

Chronic pain during the neonatal period resulted in impaired hearing in adulthood in mice, possibly via the brain-derived neurotrophic factor signaling pathway and dendritic spine pruning deficiency in auditory cortex.

Assessment of neonatal pain: uni- and multidimensional evaluation scales

Neonatal pain is a problem that is easily overlooked. According to the status quo of neonatal pain management, commonly 9 scales are used for evaluation of neonatal pain; details of the specific indicators, such as the applicable neonatal gestational age range, score, and the type of pain, for the domestic references are provided so as to provide reference for the proper evaluation and standardized management of neonatal pain, as well as to promote the management level of neonatal pain.

Enriched environment rescues neonatal pain induced cognitive deficits and the impaired hippocampal synaptic plasticity later in life

Although extensive and untreated pain that occurs during a critical developmental window may impair cognition later in life, environmental interventions at early might promote. However, the underlying mechanism is poorly understood. Our current study utilized a rat model of "repetitive needle pricks" from the day of birth (P0) to postnatal day 7 (P7) to mimic the painful experience of preterm neonates in the Neonatal intensive care unit (NICU). Enriched environment (EE) during development period (from P15 to P70) was implemented as a nonpharmacological intervention approach. Electrophysiological recording, behavioral tests and biochemical analysis were performed after the end of EE (between P71 and P80). Results showed neonatal repetitive pain resulted in a reduction in mechanical withdrawal thresholds by the von Frey test in P70 (P < 0.001). Furthermore, neonatal repetitive pain impaired spatial learning and memory (P < 0.05) and even led to dysfunction in fear memory (P < 0.01). In contrast, EE rescued neonatal pain induced cognitive deficits and normalized hippocampal long-term potentiation in rats exposed to neonatal pain (P < 0.05). The beneficial effect of EE might be the improvements in hippocampal synaptic plasticity via up-regulating neurotrophic factors and N-methyl-D-aspartate (NMDA) receptors in the hippocampus. Our findings provide evidence that early environmental intervention might be a safe strategy to overcome neurodevelopmental abnormalities in preterm infants who experienced multiple procedural painful events during the early critical period. This article is protected by copyright. All rights reserved.

Breast milk vs 24% sucrose for procedural pain relief in preterm neonates: a non-inferiority randomized controlled trial

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).

Neonatal Nurse and Midwife Competence Regarding Pain Management in Neonates: A Systematic Review

BACKGROUND

Neonates in need of intensive care are often subjected to numerous painful procedures. Despite the growing scientific research, hospitalized neonates continue to experience unrelieved pain. Enhancing the competence of neonatal intensive care nurses is an integral component of effective pain management.

PURPOSE

The purpose of this article is to identify and synthesize the existing evidence on nurses' and midwives' competence regarding neonatal pain management internationally.

METHODS/SEARCH STRATEGY

The review was guided by Whittemore and Knafl's 5-stage framework, with 8 databases searched in June 2020 including PubMed, CINAHL Complete (via EBSCOhost), MEDLINE (via EBSCOhost), PsycINFO (via Ovid), EMBASE, Scopus, Cochrane Library, and Google Scholar. Reference lists of selected articles were also hand-searched. Studies were reviewed independently for methodology and inclusion and exclusion criteria. The initial search yielded 3037 articles; 19 met the inclusion criteria and were included for analysis: qualitative (n = 5) and quantitative (n = 14).

FINDINGS/RESULTS

Nurses' and midwives' competence regarding neonatal pain management in the neonatal intensive care unit is discussed in relation to knowledge, attitudes, behaviors, and perceptions of competence by most studies. The barriers to effective neonatal pain management were found to relate to nurses' and midwives' factors, underutilized pain assessment tools, and organizational factors. Potential facilitators to effective neonatal pain management included clear evidence-based guidelines/protocols, adequate training, and the use of appropriate and accurate pain assessment tools. Parent involvement and a team approach to neonatal pain management were also identified.

IMPLICATIONS FOR PRACTICE AND RESEARCH

These findings suggest that further research is necessary to address the barriers and promote facilitators to improve neonatal pain management.

The practice of procedural pain assessment and management in neonatal intensive care unit in Ethiopia: Cross‐sectional study

Background and Aims

Neonates in intensive care units undergo frequent painful procedures for diagnostic or care‐related purposes. Untreated pain has serious short‐term and long‐term complications. This study aims to evaluate the frequency of painful procedures, pain assessment, and their analgesic management practice among neonates admitted to the NICU.

Methods

The present study is a hospital‐based cross‐sectional study of neonates admitted at level II NICU of St. Paul hospital millennium medical college in Ethiopia between March and August 2019. Data were collected from medical charts of neonates and bedside observation using a checklist. The parameters included were demographic characteristics, types of painful procedures, pain assessment practice, and analgesic intervention provided during painful procedures. Descriptive statistics, Mann‐Whitney U‐test, and Kruskal‐Wallis test were used to compare the number of painful procedures and influencing factors. P‐value < .05 was considered statistically significant.

Results

Of the 325 neonates included in this study, a median of 4 (3‐7) painful procedures were performed per neonate in the first 24 hours of NICU stay. Heel lance 280 (20.7%) and Venipuncture 249 (18.41%) were the most commonly performed painful procedures. Of the 1352 painful procedures, none of the neonates received any form of analgesic intervention and none of the neonate's pain scores were documented on their medical chart. The higher number of painful procedures were associated with gestational age between 28 and 31 weeks, birth weight less than 1500 g, and use of CPAP respiratory support P‐value <.001, <.001, and .0015, respectively.

Conclusion

Painful procedures were frequently performed in NICU without any form of analgesic intervention. Strategies to introduce neonatal pain assessment and their analgesic management for clinical practice are necessary.

An investigation on the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit

OBJECTIVES

To investigate the current status of the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit (NICU).

METHODS

A self-made scale was developed according to "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)" and was used to distribute questionnaires to the medical staff in the NICU from the member units of Jiangsu Province Medical Quality Control Centre of Neonatal Department to evaluate their levels of understanding the basic knowledge, assessment, and management of neonatal pain.

RESULTS

A total of 957 questionnaires (from 383 doctors and 574 nurses) were collected. Doctors and nurses had mean correct rates of 38% and 39% respectively in answering the questions on the basic knowledge of neonatal pain. They had median correct rates of 0% and 50% respectively in answering the questions on neonatal pain assessment, and mean correct rates of 73% and 68% respectively in answering on analgesia management. Compared with those who did not receive the training on neonatal pain, the medical staff who received such training had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment (P<0.05). The medical staff from tertiary hospitals had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment than those from secondary hospitals (P<0.05).

CONCLUSIONS

The medical staff in the NICU have insufficient cognition of neonatal pain, and thus it is necessary to carry out the special training on neonatal pain, focusing on the promotion and practical application of "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)", in order to improve the level of neonatal pain assessment and analgesia management among medical staff in the NICU.

Dexmedetomidine Alleviates Microglia-Induced Spinal Inflammation and Hyperalgesia in Neonatal Rats by Systemic Lipopolysaccharide Exposure

Noxious stimulus and painful experience in early life can induce cognitive deficits and abnormal pain sensitivity. As a major component of the outer membrane of gram-negative bacteria, lipopolysaccharide (LPS) injection mimics clinical symptoms of bacterial infections. Spinal microglial activation and the production of pro-inflammatory cytokines have been implicated in the pathogenesis of LPS-induced hyperalgesia in neonatal rats. Dexmedetomidine (DEX) possesses potent anti-neuroinflammatory and neuroprotective properties through the inhibition of microglial activation and microglial polarization toward pro-inflammatory (M1) phenotype and has been widely used in pediatric clinical practice. However, little is known about the effects of DEX on LPS-induced spinal inflammation and hyperalgesia in neonates. Here, we investigated whether systemic LPS exposure has persistent effects on spinal inflammation and hyperalgesia in neonatal rats and explored the protective role of DEX in adverse effects caused by LPS injection. Systemic LPS injections induced acute mechanical hyperalgesia, increased levels of pro-inflammatory cytokines in serum, and short-term increased expressions of pro-inflammatory cytokines and M1 microglial markers in the spinal cord of neonatal rats. Pretreatment with DEX significantly decreased inflammation and alleviated mechanical hyperalgesia induced by LPS. The inhibition of M1 microglial polarization and microglial pro-inflammatory cytokines expression in the spinal cord may implicate its neuroprotective effect, which highlights a new therapeutic target in the treatment of infection-induced hyperalgesia in neonates and preterm infants.

Measurement of Cumulative Preterm Neonatal and Maternal Stressors During Neonatal Intensive Care Unit Admission

OBJECTIVES

By nature, the neonatal intensive care unit (NICU) environment is stressful for both infants and mothers. This study aimed to explore and quantify the severity of early life stressors in premature infants admitted to the NICU and evaluate the effect of cumulative neonatal stressors on maternal mental health.

METHODS

This cross-sectional study included 100 preterm infants admitted to the NICU for at least 10 days. Daily experiences with painful/stressful procedures for 10 days were determined using the Neonatal Infant Stressor Scale. The included mothers were assessed for their psychological well-being 1 week after NICU admission using the Parental Stressor Scale: NICU and Edinburgh Postnatal Depression Scale.

RESULTS

During the first 10 days of NICU admission, preterm infants experienced an average of 350.76 ± 84.43 acute procedures and an average of 44.84 ± 11.12 cumulative hours of chronic events, with the highest scores recorded on first 3 days of admission. Although intravenous flushing for patency was the most frequent acute procedure, blood gas sampling was the most painful. Forty-five percent of the mothers showed significant depressive symptoms, with the maternal role alteration reported as the most stressful experience, especially for young and new mothers (p < .001). The cumulative stressors experienced by infants were significantly associated with elevated maternal perception of psychological maladjustment (p < .001).

CONCLUSION

This study confirmed that the NICU environment is stressful for both infants and mothers, with the total cumulative stressors experienced by preemies in the NICU having an negative impact on maternal mental health.

Available Instruments to Assess Pain in Infants

Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.

Using Social Media to Disseminate Effective Pain Treatments for Newborns During Needle-Related Painful Procedures in China

Social media has become a powerful approach to disseminating evidence to knowledge users. The BSweet2Babies video was developed in multiple languages showing the effectiveness of sweet solutions, skin-to-skin care, and breastfeeding during newborn painful procedures. This study aimed to disseminate the BSweet2Babies video in Chinese through social media platform of WeChat in China; evaluate the reach, acceptability, and recommendation of the video; and assess viewers' previous knowledge and experience of using the 3 strategies and intention to use these strategies in the future. Multiple dissemination strategies were used to maximize views for a 6-month dissemination period. The video received 19 812 views, 4306 "thumbs," and 671 participants completed surveys. Of the survey respondents, 393 were parents. Most respondents did not know these strategies and did not use or help parents use any of them. More healthcare professionals than parents intended to use or advocate for sweet solutions and breastfeeding. More healthcare professionals rated that the 3 strategies were easy to apply in real-life situations, but more parents evaluated that the length of the video was too long. Social media in China can be a promising approach to disseminating evidence on neonatal procedural pain treatments to healthcare professionals and the public.

Newborn Infant Parasympathetic Evaluation Index for the Assessment of Procedural Pain in Nonanesthetized Infants: A Multicenter Pilot Study

OBJECTIVE

The aim of this study is to evaluate the ability of the Newborn Infant Parasympathetic Evaluation (NIPE) index to detect the response to nociceptive stimuli in nonanesthetized infants and to compare these results to simultaneous scoring by behavioral scales.

STUDY DESIGN

Thirty-six nonanesthetized infants admitted to neonatal/pediatric intensive care unit (N/PICUs) were enrolled to the study. Due to faulty records of the data, three patients had to be excluded. To detect pain caused by noxious stimuli, the heart-rate-variability-derived NIPE index and behavioral pain scales designed for measuring procedural pain in nonverbal children were used.

RESULTS

Forty-one painful events were available for analysis. We observed in the whole group a statistically significant decrease in NIPE values at 1, 2, and 3 minutes after a painful stimulus, in comparison to the NIPE value at rest and the statistically significant differences between the minimum NIPE value within 3 minutes after the stimulus in comparison to NIPE value at rest in the whole group, as well as in the subgroups of moderate and severe pain. Receiver operating characteristic (ROC) analysis has shown the strong sensitivity and specificity of the NIPE in detecting the noxious stimuli (ROC AUC: 0.767). We also found that the stronger the sensation of pain was, the more rapidly NIPE reached its lowest value.

DISCUSSION

Our study indicates that the painful procedures are associated with a significant decrease in the NIPE value within 3 minutes after a noxious stimulus. Based on our observation, the minimum value within 3 minutes from the painful procedure seems to be the most distinctive value.

An Initiative to Decrease Laboratory Testing in a NICU

BACKGROUND AND OBJECTIVES

Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period.

METHODS

We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time.

RESULTS

Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months.

CONCLUSIONS

Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects.

The validity of skin conductance for assessing acute pain in mechanically ventilated infants: A cross-sectional observational study

BACKGROUND

Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants.

METHODS

A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12 months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures.

RESULTS

From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman's rho = 0.4-0.62) and the four-item NFCS (Spearman's rho = 0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve = 0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain.

CONCLUSIONS

SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation.

SIGNIFICANCE OF THE STUDY

Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.

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.

Assessment of four pain scales for evaluating procedural pain in premature infants undergoing heel blood collection

BACKGROUND

Procedural pain is underestimated in hospitalized preterm infants. The aim of this study was to assess the reliability, validity, and clinical utility of the Neonatal Facial Coding System (NFCS), Douleur Aiguë du Nouveau-né (DAN) scale, Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP) in premature infants undergoing heel blood collection. We assume that the four scales were similar in reliablility and validity (but different in clinical utility).

METHODS

The pain assessments were performed on 111 premature infants using the four scales. Internal consistency was determined by Cronbach's α, and the reliability was determined by the intraclass correlation coefficients. Concurrent validity was evaluated by Spearman's rank correlations. Bland-Altman plots were used to investigate the convergent validity.

RESULTS

The internal consistency and their reliability of the scales were high (p < 0.001). Scores were significantly higher at the time of blood collection (p < 0.001). Mean scores of clinical utility of PIPP were significantly higher than NFCS and DAN (p < 0.05) but not higher than the NIPS (p > 0.05).

CONCLUSIONS

The four scales were reliable and valid. This study suggests that the PIPP and NIPS has good clinical utility and are better choice for evaluating procedural pain in premature infants.

IMPACT

The aim of this study was to assess the reliability, validity, and clinical utility of NFCS, DAN, NIPS, and PIPP in premature infants undergoing heel blood collection. The results showed that the four scales have high reliability and internal consistency; the PIPP and NIPS have good clinical utility and are better choice for evaluating procedural pain in premature infants. Our study results provided a reference for clinical workers in choosing pain assessment scales and conduction intervention.

Procedural Pain in Hospitalized Neonates in Kenya

PURPOSE

The study was conducted to understand the nature and frequency of painful procedures and use of analgesia in neonatal units in Kenya.

DESIGN AND METHODS

Descriptive prospective study was conducted in a regional Level I and a university-affiliated Level II neonatal unit in Western Kenya. Two hundred term and preterm neonates who were hospitalized during the first day of life were recruited. A validated checklist was used to audit medical charts of hospitalized neonates. Painful procedures and pain treatment interventions accompanying all procedures performed during the first seven days of hospitalization were documented. Descriptive statistics, t-tests and χ² were usedto determine frequency and factors influencing the frequency of procedures.

RESULTS

A total of 1693 painful procedures (mean = 1.6 ± 1.1) were performed with most of them being tissue-damaging (n = 1291) including intravenous cannulation and intramuscular injection. Neonates were less likely to undergo procedures if there were born at term (RR 0.85; 95% CI, 0.76-0.95, p = .003) but more likely to experience procedures if admitted in a higher level of care (RR 1.57, 95% CI, 1.43-1.74, p < .001). Only one procedure was accompanied by analgesia.

CONCLUSIONS

Neonates underwent few but highly invasive procedures without analgesia. Prematurity and a high level of care predisposed neonates to a higher burden of pain.

IMPLICATIONS

Our findings underscore the urgent need for development of context-specific clinical practice guidelines on procedural pain treatment in sub-Saharan Africa.

Morphine use in the neonatal period and later neuropsychological development: a systematic review

AIM

To identify and evaluate the evidence documenting the association between neonatal morphine and later childhood neuropsychological development.

METHOD

We conducted a systematic literature search of eight electronic databases from inception until June 2019. We included all randomized controlled trials (RCTs) and cohort studies recruiting neonates who received morphine treatment, and measuring neuropsychological development outcomes with a minimum follow-up of 6 months.

RESULTS

Twelve separate reports from three RCTs and five cohort studies met our inclusion criteria. Owing to the small number of the included trials and the variable study designs, a meta-analysis was not performed. The findings from this review indicated that neonatal morphine use had no adverse effects on behaviour, cognition, motor, and executive function development at 8 to 9 years and earlier; except for the inconsistent conclusions on internalizing behavioural problems at 5 to 7 years and cognitive and motor developments at 18 months.

INTERPRETATION

Why a child needs morphine may have a more profound impact on later neuropsychological development than morphine itself. The small number, high heterogeneity, and limitations of the included studies limit confidence in the result of this systematic review.

Procedural Pain in Hospitalized Children in a Chinese Children's Hospital

BACKGROUND

Pain prevalence in pediatric hospitals has been investigated in many developed countries, but little is known about this topic in China.

AIMS

This study sought to describe the frequency and pain intensity of procedures for medical care in hospitalized children in a Chinese children's hospital.

DESIGN

A cross-sectional study was designed to include interviews with children, their parents and the nurses.

SETTINGS

This survey was administered in a teaching hospital in southeast China.

PARTICIPANTS/SUBJECTS

Infants and children up to 16 years old who were admitted to the study units for more than 6 days were eligible for inclusion.

METHODS

Information regarding patient demographics, painful procedures and pain management strategies was obtained during the day shifts of the children's hospitalization.

RESULTS

A total of 3886 procedures were performed on 342 children during the data collection period. The reuse of intravenous indwelling needles ( n = 577), removal of tape from the skin (n = 420) and venipuncture on the back of the hand ( n = 401) were the most frequently performed procedures on children. A total of 1941 procedures, accounting for 49.9% (1941/3886) of painful procedures caused moderate to severe pain (pain score ≥4.0). However, only 25.3% (984/3886) received a valid pain assessment, and only 14.4% (560/3886) received pain interventions.

CONCLUSIONS

Most children, especially those who are younger (<4 years old), experienced moderate or severe pain during their hospitalization, but did not receive appropriate interventions.

Repetitive Pain in Neonatal Male Rats Impairs Hippocampus-Dependent Fear Memory Later in Life

Preterm infants in neonatal intensive care units are inevitably subjected to numerous painful procedures. However, little is known about the consequences of early pain experience on fear memory formation later in life. We hypothesized that exposure to repetitive pain in early life triggered hippocampal synaptic plasticity and resulted in memory deficiency in prepubertal and adult rats. From the day of birth (P0) to postnatal day 7 (P7), neonatal male rat pups were randomly assigned to either needle pricks or tactile touches repetitively every 6 h. Trace fear conditioning was performed on rats on P24-P26 and P87-P89. On P24 and P87, rats were sacrificed for molecular and electrophysiological studies. On P24-26 and P87-89, rats that experienced neonatal needle treatment showed a significant reduction in freezing time in the contextual fear conditioning (P < 0.05) and trace fear conditioning tests (P < 0.05). Moreover, repetitive neonatal procedural pain caused a significant decrease in the magnitude of hippocampal long-term potentiation induced by high-frequency stimulation. Furthermore, rats that experienced neonatal needle treatment demonstrated sustained downregulation of NR1, NR2A, NR2B, and GluR1 expression in the hippocampus. Therefore, neonatal pain is related to deficits in hippocampus-related fear memory later in life and might be caused by impairments in hippocampal synaptic plasticity.

Factors influencing the occurrence of neonatal procedural pain

OBJECTIVES

The objective of this study was to describe the occurrence of neonatal procedural pain and explore the factors that influence the frequency of painful procedures.

DESIGN

A descriptive prospective epidemiologic study.

SETTING

NICU at a general hospital in China.

METHODS

A demographic and diagnosis or illness information questionnaire and an occurrence of procedural pain questionnaire specifically designed for this study were used to record the current status of neonatal procedural pain. The neonatal infant pain scale (NIPS) was used to measure pain intensity. A multiple linear regression model was used to explore the factors influencing the frequency of painful procedures.

RESULTS

One hundred and twenty neonates experienced a total of 16,840 painful procedures. Each neonate was exposed to a median (IQR) of 66.5(27,154.75) painful procedures during hospitalization and a median (IQR) of 13(11, 19) painful procedures. All 27 different procedures were considered painful, and 70.37% (19/27) of these procedures caused severe pain. Overall, the mean NIPS score of the 27 procedures was 5.04 ± 1.52 with a range from 0 to 7. Respiratory support, age, and length of hospital stay were factors influencing the frequency of painful procedures.

CONCLUSIONS

NICU neonates experience pain at a high frequency and intensity during hospitalization. Respiratory support, age, and length of hospital stay were factors influencing the frequency of painful procedures. Strategies are needed to bridge the gap between practice and the evidence-based guidelines.

Evaluation of the Reliability and Validity of the Behavioral Indicators of Infant Pain Scale in Chinese Neonates

BACKGROUND

Behavioral Indicators of Infant Pain scale (BIIP) has been shown to be a good tool to assess pain in infants.

AIMS

This paper aimed to translate BIIP into Chinese and evaluate its reliability and validity for neonates in China.

DESIGN

A prospective observational study. SETTING AND PARTICIPANTS: A convenience sample of 396 neonates (preterm and term infants) were recruited from neonatal intensive care units in China from July to October 2016.

METHODS

The BIIP was translated and adjusted for semantic adaption.396 neonates were assessed during 3 phases of blood collection from an artery/vein. A video camera was positioned for a close-up view of the face and body. The neonates' pain was rated independently by 2 nurses who were trained and familiar with the Chinese version of BIIP (C-BIIP)and FLACC (Facial expression, Legs, Activity, Crying and Consolability).

RESULTS

The internal consistency were 0.904 (preterm) and 0.895 (term). The test-retest reliability were 0.947 (preterm) and 0.938 (term) and the interclass correlation coefficients were 0.921 to 0.959 (preterm) and 0.921 to 0.959 (term). The correlations between the C-BIIP and FLACC were high (preterm: r = 0.948, term: r = 0.896). Using the C-BIIP, the 3 phases of blood collection were found to be statistically different (preterm: F = 635.76, term: F = 675.54; P < 0.001), which showed that the construct validity of C-BIIP was good.

CONCLUSION

The BIIP is a reliable and valid tool to assess pain in term and preterm neonates in China.

Mothers' Perceptions about Pain in Hospitalized Newborn Infants in Kenya

PURPOSE

Explore views of mothers about pain and pain treatment practices in hospitalized newborn infants.

DESIGN AND METHODS

A Qualitative descriptive study using photo-elicitation technique was conducted in a level I and a level II neonatal units in Kenya. Fifteen semi-structured interviews were conducted with mothers of hospitalized infants. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis approach.

RESULTS

Mothers described the experience of witnessing their infants undergo painful procedures as emotionally and psychologically traumatic. Participants felt helpless for not being able to protect their infants from pain a situation which was made worse by health care providers who appeared less concerned about pain relief during procedures. Mothers' views demonstrated a good understanding of pain-relief strategies; they identified strategies that health care providers should routinely use to relief pain in hospitalized infants. Furthermore, participants desired to be involved in comforting their infants during clinical procedures.

CONCLUSION

Repeated and untreated painful procedures continue to define the hospitalisation experience of newborn infants despite the presence of mothers who desire to be involved in comforting their infants during procedures.

PRACTICE IMPLICATION

Minimizing the burden of pain and using pain-relieving interventions could reduce parental stress and optimize parental role attainment following hospitalisation.

Evaluation of three pain assessment scales used for ventilated neonates

AIMS AND OBJECTIVES

To compare and evaluate the reliability, validity, feasibility, clinical utility, and nurses' preference of the Premature Infant Pain Profile-Revised, the Neonatal Pain, Agitation, and Sedation Scale, and the Neonatal Infant Acute Pain Assessment Scale used for procedural pain in ventilated neonates.

BACKGROUND

Procedural pain is a common phenomenon but is undermanaged and underassessed in hospitalised neonates. Information for clinician selecting pain measurements to improve neonatal care and outcomes is still limited.

DESIGN

A prospective observational study was used.

METHODS

A total of 1,080 pain assessments were made at 90 neonates by two nurses independently, using three scales viewing three phases of videotaped painful (arterial blood sampling) and nonpainful procedures (diaper change). Internal consistency, inter-rater reliability, discriminant validity, concurrent validity and convergent validity of scales were analysed. Feasibility, clinical utility and nurses' preference of scales were also investigated.

RESULTS

All three scales showed excellent inter-rater coefficients (from 0.991-0.992) and good internal consistency (0.733 for the Premature Infant Pain Profile-Revised, 0.837 for the Neonatal Pain, Agitation, and Sedation Scale and 0.836 for the Neonatal Infant Acute Pain Assessment Scale, respectively). Scores of painful and nonpainful procedures on the three scales changed significantly across the phases. There was a strong correlation between the three scales with adequate limits of agreement. The mean scores of the Neonatal Pain, Agitation, and Sedation Scale for feasibility and utility were significantly higher than those of the Neonatal Infant Acute Pain Assessment Scale, but not significantly higher than those of the Premature Infant Pain Profile-Revised. The Neonatal Pain, Agitation, and Sedation Scale was mostly preferred by 55.9% of the nurses, followed by the Neonatal Infant Acute Pain Assessment Scale (23.5%) and the Premature Infant Pain Profile-Revised (20.6%).

CONCLUSIONS

The three scales are all reliable and valid, but the Neonatal Pain, Agitation, and Sedation Scale and the Neonatal Infant Acute Pain Assessment Scale perform better in reliability. The Neonatal Pain, Agitation, and Sedation Scale appears to be a better choice for frontier nurses to assess procedural pain in ventilated neonates based on its good feasibility, utility and nurses' preference.

RELEVANCE TO CLINICAL PRACTICE

Choosing a valid, reliable, feasible and practical measurement is the key step for better management of procedural pain for ventilated newborns. Using the right and suitable tool is helpful to accurately identify pain, ultimately improve the neonatal care and outcomes.

Trial of Music, Sucrose, and Combination Therapy for Pain Relief during Heel Prick Procedures in Neonates

OBJECTIVE

To compare the effectiveness of music, oral sucrose, and combination therapy for pain relief in neonates undergoing a heel prick procedure.

STUDY DESIGN

This randomized, controlled, blinded crossover clinical trial included stable neonates >32 weeks of postmenstrual age. Each neonate crossed over to all 3 interventions in random order during consecutive heel pricks. A video camera on mute mode recorded facial expressions, starting 2 minutes before until 7 minutes after the heel prick. The videos were later analyzed using the Premature Infant Pain Profile-Revised (PIPP-R) scale once per minute by 2 independent assessors, blinded to the intervention. The PIPP-R scores were compared between treatment groups using Friedman test.

RESULTS

For the 35 participants, the postmenstrual age was 35 weeks (SD, 2.3) with an average weight of 2210 g (SD, 710). The overall median PIPP-R scores following heel prick over 6 minutes were 4 (IQR 0-6), 3 (IQR 0-6), and 1 (IQR 0-3) for the music, sucrose, and combination therapy interventions, respectively. The PIPP-R scores were significantly lower at all time points after combination therapy compared with the groups given music or sucrose alone. There was no difference in PIPP-R scores between the music and sucrose groups.

CONCLUSIONS

In relatively stable and mature neonates, the combination of music therapy with sucrose provided better pain relief during heel prick than when sucrose or music was used alone. Recorded music in isolation had a similar effect to the current gold standard of oral sucrose.

TRIAL REGISTRATION

www.anzctr.org.au ACTRN12615000271505.

Knowledge of healthcare professionals on the evaluation and treatment of neonatal pain

OBJECTIVE

to identify knowledge of healthcare professionals on the management, evaluation and treatment of pain in a neonatal unit in a municipality of Rio de Janeiro.

METHOD

descriptive, exploratory study with quantitative analysis. Data were analyzed using the software R. Core Team Results: of the 96 healthcare professionals who participated in the study, 42 nursing aides/technicians responded, along with 22 nurses, 20 physicians and 2 physical therapists. The results showed that 40.5% of the nursing aides/technicians, 50% of the physicians and 50% of the physical therapists confirmed that they coordinate/perform/assist in the care of babies' pain while performing procedures (lumbar puncture, chest tube insertion and central line). There was a significant difference of agreement in relation to the nursing aides/technicians and physicians. Most (69.8%) of the healthcare professionals knew of some non-pharmacological measure effective for relief of acute pain.

CONCLUSION

there is a need for an educational intervention program, with participation of those involved, in the process to change professional practice.

Effects of combined oral sucrose and nonnutritive sucking (NNS) on procedural pain of NICU newborns, 2001 to 2016: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Both oral sucrose (OS) and nonnutritive sucking (NNS) are effective nonpharmacological methods to alleviate procedures pain in neonatal intensive care unit (NICU) newborns when they were used alone, but the combined effect of OS+NNS remains controversial. So, we conducted this study to evaluate the efficiency of NNS combined with oral sucrose on pain relief in NICU newborns undergoing painful procedures.

METHODS

We searched PubMed, Ovid (Medline), Embase (Medline), Cochrane Central Library, and other resources such as Google Scholar, bibliographies of included literatures for all available articles. Two reviewers screened literatures and extracted data independently. The fixed effects model was used to pool the results using Reviewer Manager (RevMan) 5.3. As each study included in our meta-analysis had been approved by Ethics Committee or institutional review board, thus our study did not need ethical approval.

RESULTS

Seven randomized controlled trials, including 599 participants, were contained in our meta-analysis. The combination of oral sucrose and NNS is associated with reduced pain scores (mean difference [MD], -0.52; 95% confidence interval [CI], -0.68 to -0.36); shortened crying time (MD,-0.92; 95% CI, -1.39 to -0.44); but the 2 groups did not differ significantly in reducing bradycardia (MD, 0.73; 95% CI, 0.32-1.68), tachycardia (MD, 0.65; 95% CI, 0.38-1.10), or desaturations (MD, 0.73; 95% CI, 0.32-1.68).

CONCLUSION

The pooled evidence indicates that the combination measures may serve as an evidence-based guideline for pain relief among patients having minor pain. Besides, it also indicates that OS combined with NNS can be an alternative for better prevention and management of procedure pain in NICU newborns. Nevertheless, the results may be limited due to incomplete data, and thus, more randomized controlled trials or well-designed studies are required to determine the effects of OS+NNS in the future.

Neonatal repetitive pain in rats leads to impaired spatial learning and dysregulated hypothalamic-pituitary-adrenal axis function in later life

Preterm birth is a major health issue. As part of their life-saving care, most preterm infants require hospitalization and are inevitably exposed to repetitive skin-breaking procedures. The long-term effects of neonatal repetitive pain on cognitive and emotional behaviors involving hypothalamic-pituitary-adrenal (HPA) axis function in young and adult rats are unknown. From P8 to P85, mechanical hypersensitivity of the bilateral hindpaws was observed in the Needle group (P < 0.001). Compared with the Tactile group, the Needle group took longer to find the platform on P30 than on P29 (P = 0.03), with a decreased number of original platform site crossings during the probe trial of the Morris water maze test (P = 0.026). Moreover, the Needle group spent more time and took longer distances in the central area than the Tactile group in the Open-field test, both in prepubertal and adult rats (P < 0.05). The HPA axis function in the Needle group differed from the Tactile group (P < 0.05), with decreased stress responsiveness in prepuberty and puberty (P < 0.05) and increased stress responsiveness in adulthood (P < 0.05). This study indicates that repetitive pain that occurs during a critical period may cause severe consequences, with behavioral and neuroendocrine disturbances developing through prepuberty to adult life.

Sucrose for analgesia in newborn infants undergoing painful procedures

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.

Parents' perceptions of microneedle-mediated monitoring as an alternative to blood sampling in the monitoring of their infants

OBJECTIVES

Microneedle (MN) arrays could offer a pain-free, minimally invasive approach to monitoring. This is envisaged to be particularly beneficial for younger patients, but parents' views to date are unknown. The aim of this study was to explore parental perceptions of MN-mediated ISF monitoring, as an alternative to the use of conventional blood sampling, and to understand the important factors for technique approval.

METHODS

Semi-structured interviews were conducted with parents with recent experience of a premature birth. Recruitment was through the Northern Ireland premature infant charity, Tinylife. Interviews progressed until data saturation was reached and thematic analysis employed.

KEY FINDINGS

The study included 16 parents. Parental support for MN-mediated monitoring was evident, alongside the unpopularity of traditional blood sampling in neonates. Factors facilitating MN approval included the opportunity for pain reduction, the simplicity of the procedure, the potential for increased parental involvement and the more favourable appearance, owing to the minute size of MNs and similarities with a sticking plaster. Confirmation of correct application, a pain-free patch removal and endorsement from trusted healthcare professionals were important.

CONCLUSION

These findings will inform researchers in the field of MN development and enlighten practitioners regarding parental distress resulting from conventional blood sampling. Further work is necessary to understand MN acceptability among practitioners. This work should assist in the development of an acceptable MN device and facilitate the reduction of parental distress.

AUTHOR

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Perceptions on pain management among Korean nurses in neonatal intensive care units

PURPOSE

The present survey was conducted to investigate the perceptions among nurses of neonatal pain and the associated use of pharmacologic measures (PMs) and nonpharmacologic comfort measures (CMs) in neonatal intensive care units (NICUs). Pain perception, the necessity and actual use of PMs and CMs, and their relationships were investigated and compared according to nurses' positions, educational levels, the existence of guidelines, and prior education on neonatal pain management.

METHODS

Participants were 141 nurses from five NICUs at university hospitals. A questionnaire was developed by researchers based on previous studies of neonatal pain management and current practices in surveyed NICUs. Five-point Likert scales were used to assess nurses' perceptions of pain, the necessity of PMs and CMs, and their actual use in 29 painful procedures.

RESULTS

The mean scores of perceived pain and the necessity of PMs and CMs were 3.68, 2.96, and 3.79 points, respectively. The actual use of PMs and CMs was 1.67 and 2.63 points, respectively. The perceived necessity of PMs correlated with the actual use of PMs (r = .316, p < .001), and CMs were performed (r = .390, p < .001). Keeping or reading guidelines, or receiving education on pain management resulted in a higher perception of the necessity of PMs.

CONCLUSION

Korean nurses in NICUs often underestimate the necessity of pain relief measures and use few PMs or CMs. Therefore, systematic approaches to implement guidelines, such as adaptation of guidelines for each NICU, dissemination of guideline content to all NICU staff, and regular measurements of compliance with the guidelines, are recommended.

Procedural pain in neonatal units in Kenya

OBJECTIVES

To determine the nature and frequency of painful procedures and procedural pain management practices in neonatal units in Kenya.

DESIGN

Cross-sectional survey.

SETTING

Level I and level II neonatal units in Kenya.

PATIENTS

Ninety-five term and preterm neonates from seven neonatal units.

METHODS

Medical records of neonates admitted for at least 24 h were reviewed to determine the nature and frequency of painful procedures performed in the 24 h period preceding data collection (6:00 to 6:00) as well as the pain management interventions (eg, morphine, breastfeeding, skin-to-skin contact, containment, non-nutritive sucking) that accompanied each procedure.

RESULTS

Neonates experienced a total of 404 painful procedures over a 24 h period (mean=4.3, SD 2.0; range 1-12); 270 tissue-damaging (mean=2.85, SD 1.1; range 1-6) and 134 non-tissue-damaging procedures (mean=1.41, SD 1.2; range 0-6). Peripheral cannula insertion (27%) and intramuscular injections (22%) were the most common painful procedures. Ventilated neonates and neonates admitted in level II neonatal units had a higher number of painful procedures than those admitted in level I units (mean 4.76 vs 2.96). Only one procedure had a pain intensity score documented; and none had been performed with any form of analgesia.

CONCLUSIONS

Neonates in Kenya were exposed to numerous tissue-damaging and non-tissue-damaging procedures without any form of analgesia. Our findings suggest that education is needed on how to assess and manage procedural pain in neonatal units in Kenya.