Procedural pain management for neonates using nonpharmacological strategies: Part 1: sensorial interventions

Evaluation of procedural pain for neonates in a neonatal intensive care unit: a single-centre study

BACKGROUND

To evaluate the procedural pain experienced by neonates in a neonatal intensive care unit (NICU) setting and determine the corresponding pain grades.

METHODS

Two experienced nurses independently used the Neonatal Infant Pain Scale (NIPS) to evaluate the neonatal pain during procedures taking place in the tertiary NICU and two level-two neonatal care units in the Children's Hospital of Zhejiang University School of Medicine. The mean and distribution of NIPS pain scores and the corresponding pain grades of participants when experiencing clinical painful procedures were analysed.

RESULTS

A total of 957 neonates exposed to 15 common clinical painful procedures were included in the study. The clinical painful procedures experienced by 957 participants could be divided into three groups: severe pain (NIPS score 5-7: peripheral intravenous cannulation, arterial catheterisation, arterial blood sampling, peripherally inserted central catheter placement and nasopharyngeal suctioning), mild to moderate pain (NIPS score 3-4: finger prick, intramuscular injection, adhesive removal, endotracheal intubation suctioning, heel prick, lumbar puncture and subcutaneous injection) and no pain to mild pain (NIPS score 0-2: gastric tube insertion, enema and intravenous injection).

CONCLUSIONS

The neonatal pain response to clinical procedures in NICU had certain pattern and preintervention drug analgesia could be taken for painful procedures with clustered high NIPS pain scores. Meanwhile, full coverage non-drug pain relief measures could be taken for procedures that are with scattered pain scores, and real-time pain evaluation should be provided to determine whether further drug analgesia is required.

The physiology, assessment, and treatment of neonatal pain

Studies have clearly shown that development of pain receptors starts as early as 20-weeks' gestation. Despite contrary belief, the human fetus develops a similar number of receptive pain fibers as seen in adults. These receptors' maturation is based on response to sensory stimuli received after birth which makes the NICU a critical place for developing central nervous system's pain perception. In practice, the assessment of pain relies mostly on bedside staff. In this review we will discuss the various developing features of pain pathways in the neonatal brain and the modification of pain perception secondary to various interactions immediately after birth. We also discuss the various tools utilized in the NICU for pain assessment that rely on physiological and behavioral patterns. Finally, we address the management of pain in the NICU by either pharmacological or non-pharmacological intervention while highlighting potential benefits, disadvantages, and situations where one may be preferred over another.

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.

State of the Art in Parent-Delivered Pain-Relieving Interventions in Neonatal Care: A Scoping Review

Introduction: Parents' active involvement during painful procedures is considered a critical first step in improving neonatal pain practices. Of the non-pharmacological approaches in use, the biopsychosocial perspective supports parent-delivered interventions, in which parents themselves mediate pain relief, consistent with modern family-integrated care. This scoping review synthesizes the available research to provide an overview of the state of the art in parent-delivered pain-relieving interventions. Methods: A scoping review was performed to achieve a broad understanding of the current level of evidence and uptake of parent-driven pain- and stress-relieving interventions in neonatal care. Results: There is a strong evidence for the efficacy of skin-to-skin contact and breastfeeding, preferably in combination. These parent-delivered interventions are safe, valid, and ready for prompt introduction in infants' pain care globally. Research into parents' motivations for, and experiences of, alleviating infant pain is scarce. More research on combined parent-delivered pain alleviation, including relationship-based interventions such as the parent's musical presence, is needed to advance infant pain care. Guidelines need to be updated to include infant pain management, parent-delivered interventions, and the synergistic effects of combining these interventions and to address parent involvement in low-income and low-tech settings. Conclusions: A knowledge-to-practice gap currently remains in parent-delivered pain management for infants' procedure-related pain. This scoping review highlights the many advantages of involving parents in pain management for the benefit not only of the infant and parent but also of health care.

The use and reporting of neonatal pain scales: a systematic review of randomized trials

ABSTRACT

The burden of pain in newborn infants has been investigated in numerous studies, but little is known about the appropriateness of the use of pain scales according to the specific type of pain or infant condition. This systematic review aimed to evaluate the reporting of neonatal pain scales in randomized trials. A systematic search up to March 2019 was performed in Embase, PubMed, PsycINFO, CINAHL, Cochrane Library, Scopus, and Luxid. Randomized and quasirandomized trials reporting neonatal pain scales were included. Screening of the studies for inclusion, data extraction, and quality assessment was performed independently by 2 researchers. Of 3718 trials found, 352 with 29,137 infants and 22 published pain scales were included. Most studies (92%) concerned procedural pain, where the most frequently used pain scales were the Premature Infant Pain Profile or Premature Infant Pain Profile-Revised (48%), followed by the Neonatal Infant Pain Scale (23%). Although the Neonatal Infant Pain Scale is validated only for acute pain, it was also the second most used scale for ongoing and postoperative pain (21%). Only in a third of the trials, blinding for those performing the pain assessment was described. In 55 studies (16%), pain scales that were used lacked validation for the specific neonatal population or type of pain. Six validated pain scales were used in 90% of all trials, although not always in the correct population or type of pain. Depending on the type of pain and population of infants included in a study, appropriate scales should be selected. The inappropriate use raises serious concerns about research ethics and use of resources.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04341194 ) 10 April 2020.

Pain and distress management in palliative neonatal care

Palliative care concentrates on preventing and relieving suffering by reducing the severity of disease symptoms. Consistent treatment of pain and distress must therefore be an integral component of every palliative care concept. In this review non-pharmacological and pharmacological measures for pain and distress management in the context of palliative neonatal care are summarised. Furthermore, recommendations are given focusing on two special palliative neonatal care settings: compassionate extubation and withdrawing artificial nutrition and hydration.

Pediatric Pain Management

Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.

Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness

Both babies and their parents may experience a stay in the newborn intensive care unit (NICU) as a traumatic or a 'toxic stress,' which can lead to dysregulation of the hypothalamic-pituitary-adrenal axis and ultimately to poorly controlled cortisol secretion. Toxic stresses in childhood or adverse childhood experiences (ACEs) are strongly linked to poor health outcomes across the lifespan and trauma-informed care is an approach to caregiving based on the recognition of this relationship. Practitioners of trauma-informed care seek to understand clients' or patients' behaviors in light of previous traumas they have experienced, including ACEs. Practitioners also provide supportive care that enhances the client's or patient's feelings of safety and security, to prevent their re-traumatization in a current situation that may potentially overwhelm their coping skills. This review will apply the principles of trauma-informed care, within the framework of the Polyvagal Theory as described by Porges, to care for the NICU baby, the baby's family and their professional caregivers, emphasizing the importance of social connectedness among all. The Polyvagal Theory explains how one's unconscious awareness of safety, danger or life threat (neuroception) is linked through the autonomic nervous system to their behavioral responses. A phylogenetic hierarchy of behaviors evolved over time, leveraging the mammalian ventral or 'smart' vagal nucleus into a repertoire of responses promoting mother-baby co-regulation and the sense of safety and security that supports health and well-being for both members of the dyad. Fostering social connectedness that is mutual and reciprocal among parents, their baby and the NICU staff creates a critical buffer to mitigate stress and improve outcomes of both baby and parents. Using techniques of trauma-informed care, as explained by the Polyvagal Theory, with both babies and their parents in the NICU setting will help to cement a secure relationship between the parent-infant dyad, redirecting the developmental trajectory toward long-term health and well-being of the baby and all family members.

Non-pharmacological management of neonatal pain: Research and clinical practice in the Neonatal Intensive Care Unit

Abstract According to the World Health Organization and the International Association for the Study of Pain, pain is a relevant worldwide problem in the healthcare field. The present study aimed to describe the definition of pediatric pain and the main characteristics, and to examine the findings regarding the impact of pain on the development of the child. The best clinical practices in Neonatal Intensive Care Units should include developmental care and specifically implement pain management, aiming to protect the health and development of the infants. The efficacious non-pharmacological management of neonatal pain includes breastfeeding, skin-to-skin, non-nutritive sucking, facilitated-tucking and swaddling. Sweet solutions also have pain relief effects. Psychologists could actively participate in the implementation of non-pharmacological interventions and in the whole process to sensitize and train the professional teams, to alert parents to protection against pain and to support policymakers in the implementation of pain guidelines in the hospital.

The relationship of prenatal maternal depression or anxiety to maternal caregiving behavior and infant behavior self-regulation during infant heel lance: an ethological time-based study of behavior

BACKGROUND

Sensitive and responsive maternal caregiving behavior strengthens infant self-regulatory capacities (HL), but this regulatory role may be diminished in some mothers with second-trimester prenatal exposure to depression and/ or anxiety (MDA). This study examined maternal and infant behavior during infant heel lance (HL) when mothers had or did not have MDA. Ethological methods and micro-analytic approaches capable of distinguishing and comparing time-based patterning in maternal and infant behavior were used to clarify biological mechanisms, such as MDA, that may underlie observed behavior. Aims were to examine group differences in caregiving behavior between mothers with and without MDA 5 min Pre-HL and 5 min Post-H, and relationships between MDA, maternal caregiving behavior and infant pain behavior self-regulation, concurrently.

METHODS

At second trimester, mothers were assessed for symptoms of mild-severe depression or anxiety. Mothers whose scores exceeded predetermined cut-off scores on one or more of the mental health measures were allocated to the MDA-exposure group, those below to the non-MDA-exposure group. Reliable observers, blinded to MDA status and study phases, coded video records of the caregiving behavior of each study mother for the full duration of the 5 min Pre-HL and 5 min Post-HL study phases. Group differences and associations between mean measures of maternal mental health scores, time-based measures of maternal behavior, and time-based measures of infant pain behavior regulation (previously coded) were concurrently analyzed using comparative and correlational statistics.

RESULTS

MDA-exposed mothers spent significantly more time not embracing, engaging or responding to infant cues than maternal controls Pre-HL and Post-HL. MDA was associated with atypical maternal caregiving behavior, which in turn was related to atypical infant pain behavior self-regulation during and after the HL.

CONCLUSION

Our findings have implication for practice. We recommend inclusion of mothers with MDA and their infants in interventions that strengthen the early mother-infant interaction and mother's regulatory caregiving role. MDA and maternal caregiving behavior must be considered in future infant pain studies to examine if they confound effectiveness of mother driven caregiving interventions for neonatal pain. We highlight the importance of examining maternal mental health throughout the perinatal and postnatal trajectory, and particularly the newborn period.

Rationing of nursing care interventions and its association with nurse-reported outcomes in the neonatal intensive care unit: a cross-sectional survey

BACKGROUND

Evidence internationally suggests that staffing constraints and non-supportive work environments result in the rationing of nursing interventions (that is, limiting or omitting interventions for particular patients), which in turn may influence patient outcomes. In the neonatal intensive care unit (NICU), preliminary studies have found that discharge preparation and infant comfort care are among the most frequently rationed nursing interventions. However, it is unknown if the rationing of discharge preparation is related to lower perceptions of parent and infant readiness for NICU discharge, and if reports of increased rationing of infant comfort care are related to lower levels of perceived neonatal pain control. The purpose of this study was to assess these relationships.

METHODS

In late 2014, a cross-sectional survey was mailed to 285 Registered Nurses (RNs) working in one of 7 NICUs in the province of Quebec (Canada). The survey contained validated measures of care rationing, parent and infant readiness for discharge, and pain control, as well as items measuring RNs' characteristics. Multivariate regression was used to examine the association between care rationing, readiness for discharge and pain control, while adjusting for RNs' characteristics and clustering within NICUs.

RESULTS

Overall, 125 RNs completed the survey; a 44.0 % response rate. Among the respondents, 28.0 and 40.0 % reported rationing discharge preparation and infant comfort care "often" or "very often", respectively. Additionally, 15.2 % of respondents felt parents and infants were underprepared for NICU discharge, and 54.4 % felt that pain was not well managed on their unit. In multivariate analyses, the rationing of discharge preparation was negatively related to RNs' perceptions of parent and infant readiness for discharge, while reports of rationing of parental support and teaching and infant comfort care were associated with less favourable perceptions of neonatal pain control.

CONCLUSIONS

The rationing of nursing interventions appears to influence parent and infant readiness for discharge, as well as pain control in NICUs. Future investigations, in neonatal nursing care as well as in other nursing specialties, should address objectively measured patient outcomes (such as objective pain assessments and post-discharge outcomes assessed through administrative data).

Skin-to-skin contact reduces near-infrared spectroscopy pain responses in premature infants during blood sampling

AIM

This study investigated if skin-to-skin contact could provide pain relief, measured with near-infrared spectroscopy (NIRS), during venepuncture in premature infants.

METHODS

Ten infants born at 26-35 weeks of gestation were examined during a blood-sampling procedure with venepuncture under two different conditions: in skin-to-skin contact with their mother or lying in their incubator or crib. A double-channel NIRS device was used, and oxygen saturation and heart rate were measured using pulse oximetry. The infant's face and the pulse oximetry values were videotaped throughout the procedures, so that we could carry out a pain assessment using the Premature Infant Pain Profile-Revised (PIPP-R).

RESULTS

We found a significantly smaller increase in oxygenated haemoglobin on the contralateral side during venepuncture when the infants were in skin-to-skin contact with their mothers, compared to when they were laying in their incubator or crib. When venepuncture was compared with a sham procedure, oxygenated haemoglobin increased significantly more with the infant in the incubator or crib than held skin-to-skin, but no significant differences could be seen in the PIPP-R results between the two groups.

CONCLUSION

This study showed that skin-to-skin contact between premature infants and their mothers during venepuncture had a pain-relieving effect.

The Assessment and Non-Pharmacologic Treatment of Procedural Pain From Infancy to School Age Through a Developmental Lens: A Synthesis of Evidence With Recommendations

The 2011 IOM report stated that pain management in children is often lacking especially during routine medical procedures. The purpose of this review is to bring a developmental lens to the challenges in assessment and non-pharmacologic treatment of pain in young children.

METHOD

A synthesis of the findings from an electronic search of PubMed and the university library using the keywords pain, assessment, treatment, alternative, complementary, integrative, infant, toddler, preschool, young, pediatric, and child was completed. A targeted search identified additional sources for best evidence.

RESULTS

Assessment of developmental cues is essential. For example, crying, facial expression, and body posture are behaviors in infancy that indicate pain: however in toddlers these same behaviors are not necessarily indicative of pain. Preschoolers need observation scales in combination with self-report while for older children self-report is the gold standard. Pain management in infants includes swaddling and sucking. However for toddlers, preschoolers and older children, increasingly sophisticated distraction techniques such as easily implemented non-pharmacologic pain management strategies include reading stories, watching cartoons, or listening to music.

DISCUSSION

A developmental approach to assessing and treating pain is critical. Swaddling, picture books, or blowing bubbles are easy and effective when used at the appropriate developmental stage and relieve both physical and emotional pain. Untreated pain in infants and young children may lead to increased pain perception and chronic pain in adolescents and adults. Continued research in the non-pharmacological treatment of pain is an important part of the national agenda.

Comforting strategies and perceived barriers to pediatric pain management during IV line insertion procedure in Uganda's national referral hospital: A descriptive study

BACKGROUND

Venipuncture and intravenous (IV) cannula insertions are the two common sources of pain in hospitalized children and health care today. The WHO asserts that, pain relief is a basic fundamental right and requires a multidisciplinary approach. Nonpharmacological comforting strategies when implemented are important to relive pain related distress in children during peripheral IV line insertion. However, evidence to date that suggests implementation of such strategies and their barriers in Uganda remains very limited. This study aimed at establishing the current practices in regard to the use of comforting strategies and the perceived barriers faced by health care providers to implement pediatric pain management during IV line insertion procedure in Uganda's national referral hospital, Mulago.

METHOD

A cross sectional and descriptive study was conducted between December 1, 2012 and February 28, 2013 involving doctors, nurses and interns in six pediatric wards of Mulago Hospital in Uganda. A pre-tested self- administered and semi- structured questionnaire was used to collect the data. Data was entered into SPSS and descriptive statistics run on all the variables.

RESULTS

Of the 120 questionnaires distributed, 105 (RR = 87.5%) were returned and completed. The evidence based comforting strategies used for pain management during IV line insertion by the majority of health care professionals were; skin to skin (51%) and appropriate upright positioning of the child on mother's lap (69%). The least used comforting strategies were; allowing the child to suck his thumb or hand (70%), use of distraction (69%) and directing the child to suck one of his fingers into his mouth (90%). The identified barriers to implementing comforting strategies were; lack of time (42%), having emergency situations (18%), and not knowing the right method to use (11%). Of 105, 100 (95%) reported that there is need for continuous professional development on comforting strategies.

CONCLUSIONS

Findings demonstrated that fewer health care providers used some evidence based comforting strategies of pain relief during pediatric peripheral IV line insertion. Distraction and other evidence based strategies for pain and distress relieve are less often used by the majority of the health care providers. Incorporating pediatric pain management content in all health professionals training curricula could improve the current practices for better health outcomes.

Early repetitive pain in preterm infants in relation to the developing brain

Infants born preterm (<37 weeks of gestation) are particularly vulnerable to procedural stress and pain exposure during neonatal intensive care, at a time of rapid and complex brain development. Concerns regarding effects of neonatal pain on brain development have long been expressed. However, empirical evidence of adverse associations is relatively recent. Thus, many questions remain to be answered. This review discusses the short- and long-term effects of pain-related stress and associated treatments on brain maturation and neurodevelopmental outcomes in children born preterm. The current state of the evidence is presented and future research directions are proposed.

Identifying and ensuring optimal care for all children at risk of developing serious respiratory syncytial virus disease: a Canadian nurses' perspective

Globally, respiratory syncytial virus (RSV) infection causes substantial morbidity in infants and young children, particularly those with specific risk factors (e.g., prematurity, chronic lung and congenital heart disease). Supportive measures are the mainstay of care for RSV-related disease. In the absence of medical treatments, RSV prophylaxis (RSVP) with palivizumab is recommended for high-risk patients to help reduce the risk of developing serious disease. Geographic distances, language and cultural barriers, and other factors can impede effective education of caregivers regarding the potential impact of RSV disease and benefits of RSVP compliance. We present our experiences developing successful Canadian RSVP programs, organized through a dedicated coordinator or small group of health care staff. These programs focus on identifying all infants and young children eligible for RSVP, effectively educating health care staff and family caregivers, developing educational tools that consider language and cultural factors, and interdisciplinary collaboration and networking throughout the health care system.

Analgesia in newborns: a case-control study of the efficacy of nutritive and non-nutritive sucking stimuli

PURPOSE

To verify the nutritive and non-nutritive stimuli efficacy in the newborn's response to pain during venipuncture.

METHODS

The main sample was composed of 64 newborns that were randomly divided into three groups. The first group (n=20) received nutritive sucking stimulus that was performed through maternal breastfeeding. The second group (n=21) received non-nutritive sucking stimulus that was performed through the introduction of the researcher little finger in the newborn's oral cavity. The third group or control group (n=23) did not receive any analgesia stimulus. The newborns were evaluated using the Neonatal Infant Pain Scale, and the responses to painful stimuli were compared.

RESULTS

The nutritive as well as non-nutritive suction methods provided a comforting effect, resulting in lower pain response scores (p<0.05). There was no difference between the analgesia provided by both methods (p>0.05).

CONCLUSION

The nutritive and the non-nutritive sucking stimuli proved to be efficacious tools in relieving pain among newborns.