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

Effect of combining oral glucose solutions with supportive positions on pain during heel puncture blood sampling in premature infants: A randomized quadruple-blinded experimental study

PURPOSE

The trial aimed to assess the impact on pain scores of the administration of oral glucose solutions at different concentrations and in combination with supportive positions during heel puncture procedures.

DESIGN & METHODS

This trial was structured as a quadruple-blinded experimental study conducted at a single center - a Level II and IVa NICU between June 2022-2023. Included in the study were 128 premature infants born with a gestational age of between 33 and 36 weeks and a postnatal age of <7 days. For the heel puncture procedures, four distinct interventions were employed, each involving supportive positions and oral solutions. All interventions were recorded on video for analysis, and data were collected using the "Infant Information and Observation Form" and "Neonatal Pain, Agitation and Sedation Scale (N-PASS)". The N-PASS was rated by two independent nurses. The data were analyzed with the two-way repeated measures ANOVA and post-hoc Bonferroni tests.

RESULTS

The descriptive and clinical characteristics were similar in all groups (p > 0.05). The pain scores, physiological variables and total crying times of the premature infants differed significantly depending on the interventional groups and times, and the interaction between the groups and times (p < 0.05).

CONCLUSIONS

Combining glucose solutions with supportive positions led to a reduction in pain scores, a decrease in total crying time when compared to the use of supportive positions alone.

PRACTICE IMPLICATIONS

Combining an oral 20% glucose solution with supportive positions can be recommended to reduce pain during unplanned heel puncture procedures in the absence of a parent in the unit.

Improving Arterial Puncture Success in Neonatal Patients Using Transillumination

BACKGROUND

Arterial punctures are a common procedure used to obtain blood samples for lab tests that guide treatment of neonatal patients. These punctures can be painful and have associated risks, emphasizing the importance of keeping attempts to a minimum.

PURPOSE

The purpose of this quality improvement initiative was to determine whether using transillumination to visualize arteries before and while obtaining a blood sample would improve outcomes in neonatal patients.

METHODS

Quantitative data were collected pre- and postimplementation of education for the use of a transillumination device for arterial punctures on neonates in a level III neonatal intensive care unit (NICU). Outcomes followed included the success rate, average time to obtain a blood sample, and the average number of sticks to obtain a blood sample. Data were collected on 47 blood draw attempts in the control group (preimplementation) and 19 blood draw attempts in the experimental group (postimplementation).

RESULTS

A statistical analysis concluded that the use of the studied transillumination device does positively affect the incidence of successful blood draws, particularly for the novice NICU nurse. In addition, the average number of sticks to obtain a blood sample significantly decreased in the experimental group. Finally, the average time to obtain a blood sample using the device was not impacted in this study.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Use of a transillumination device does appear to result in improved outcomes for arterial punctures in neonatal patients. More research is needed to confirm these findings due to the small sample size of the study.

Infant pain vs. pain with parental suppression: Immediate and enduring impact on brain, pain and affect

BACKGROUND

In the short term, parental presence while a human infant is in pain buffers the immediate pain responses, although emerging evidence suggests repeated social buffering of pain may have untoward long-term effects.

METHODS/FINDING

To explore the short- and long-term impacts of social buffering of pain, we first measured the infant rat pup's [postnatal day (PN) 8, or 12] response to mild tail shock with the mother present compared to shock alone or no shock. Shock with the mother reduced pain-related behavioral activation and USVs of pups at both ages and reduced Fos expression in the periaqueductal gray, hypothalamic paraventricular nucleus, and the amygdala at PN12 only. At PN12, shock with the mother compared to shock alone differentially regulated expression of several hundred genes related to G-protein-coupled receptors (GPCRs) and neural development, whereas PN8 pups showed a less robust and less coherent expression pattern. In a second set of experiments, pups were exposed to daily repeated Shock-mother pairings (or controls) at PN5-9 or PN10-14 (during and after pain sensitive period, respectively) and long-term outcome assessed in adults. Shock+mother pairing at PN5-9 reduced adult carrageenan-induced thermal hyperalgesia and reduced Fos expression, but PN10-14 pairings had minimal impact. The effect of infant treatment on adult affective behavior showed a complex treatment by age dependent effect. Adult social behavior was decreased following Shock+mother pairings at both PN5-9 and PN10-14, whereas shock alone had no effect. Adult fear responses to a predator odor were decreased only by PN10-14 treatment and the infant Shock alone and Shock+mother did not differ.

CONCLUSIONS/SIGNIFICANCE

Overall, integrating these results into our understanding of long-term programming by repeated infant pain experiences, the data suggest that pain experienced within a social context impacts infant neurobehavioral responses and initiates an altered developmental trajectory of pain and affect processing that diverges from experiencing pain alone.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

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.

The effectiveness of massage interventions on procedural pain in neonates: A systematic review and meta-analysis

BACKGROUND

The painful procedures experienced by neonates during hospitalization have short-term or long-term effects on neonates. While the limitations of previous interventions make it imperative to explore effective interventions that are readily available. This systematic review and meta-analysis was conducted to evaluate the safety and effectiveness of massage for pain management in neonates.

METHODS

This systematic review was registered in PROSPER. PubMed, Embase, Cochrane Library, and the Clinical Trials Registry were searched to December 2021. Two reviewers independently carried out study selection, data extraction, bias risk assessment. Continuous data were analyzed by mean differences (MD). Dichotomous data were reported using relative risk. If at least two studies reported identical results by the same pain assessment tool, a meta-analysis was conducted using random effect model and inverse variance.

RESULTS

Total 11 included studies involving 755 neonates investigated the effects of massage on neonatal pain response compared to standard care. The meta-analysis showed that massage could effectively improve pain response in neonates compared to standard care no matter whether neonatal infant pain scale (NIPS) or premature infant pain profile (PIPP) was used as an assessment tool. Besides, massage was also effective for crying duration, blood oxygen saturation both during and after the procedure, but non-effective for the variation of respiratory rate after the procedure, and heart rate both during and after the procedure.

CONCLUSIONS

Massage may have a positive effect on pain relief of neonate, and rigorous trials are needed in the future to determine the most effective massage method.

Quality Improvement Initiative in the NICU for Improved Practice of Cuff Blood Pressure Measurements

BACKGROUND

Extreme preterm infants face lengthy hospitalizations and are often subjected to painful stimuli. These stimuli may be related to routine caregiving that may negatively impact long-term developmental outcomes. Frequently obtained cuff blood pressure (BP) measurements are an example of a potentially noxious stimulus to preterm infants that may have a cumulating impact on development.

PURPOSE

The primary aim was to explore the frequency of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the neonatal intensive care unit (NICU). Our secondary aim was to reduce the number of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the NICU.

METHODS

Quality improvement methodologies per the Institute for Healthcare Improvement were used combined with a multidisciplinary approach. Participants were infants born less than 27 weeks of gestation and discharged home. The baseline period was 2015 through Q2-2018 and the intervention period was Q3-2018 through Q1-2020. The electronic medical record was used to collect data and Minitab Statistical Software was used for data analysis.

FINDINGS/RESULTS

A baseline of 5.0% of eligible patients received the desired number of cuff BP measurements and increased to 63.2% after the intervention period.

IMPLICATIONS FOR PRACTICE

Findings demonstrate that using quality improvement methodology can improve clinical care. Findings suggest the feasibility and safety of reducing the number of cuff BP measurements obtained on hemodynamically stable infants in the NICU.

IMPLICATIONS FOR RESEARCH

Future endeavors should aim to reduce the quantity of painful stimuli in the NICU. Long-term developmental outcomes should be correlated in these patients.

Benefits of Kangaroo Mother Care on the Physiological Stress Parameters of Preterm Infants and Mothers in Neonatal Intensive Care

It is well documented that the stress of separation of mother and baby can lead to short-term physiological instability as well as neurological, sociological or psychological consequences that may last a lifetime. Objective: The goal was to estimate the effect of kangaroo mother care (KMC) on physiological and biochemical parameters of preterm infant stress and maternal stress in neonatal intensive care. Methods: The investigation involved 112 preterm infants. Two groups were compared according to the mean duration of KMC during 12 days of study: the KMC group (mean duration more than 90 min daily) and the control group (less than 90 min). Results: Kangaroo mother care for more than 90 min on average per day in preterm infants is associated 12 days after the intervention with lower mean cortisol levels (p = 0.02), greater weight gain and less need for parenteral nutrition in preterm infants, as well as less postpartum depression (p = 0.02) and lower cortisol levels (p = 0.002) in the mothers of preterm infants. Conclusions: This study suggests that KMC can be used to improve the stress of preterm infants and their mothers, and that the greater weight gain observed in these preterm infants could contribute to a shorter average hospital stay and lower healthcare expenditure.

Efficacy of Breast Milk Olfactory and Gustatory Interventions on Neonates’ Biobehavioral Responses to Pain during Heel Prick Procedures

This study aimed to evaluate the efficacy of breast milk odor either alone or in combination with breast milk taste (via syringe-feeding) to alleviate neonates’ biobehavioral responses to pain during heel-prick procedures. This prospective randomized controlled trial recruited 114 neonates by convenience sampling from a newborn unit of a medical center in Taiwan. Neonates were randomly assigned to three groups: control (gentle touch + human voice), control + breast milk odor, and control + breast milk odor + breast milk taste. Heart rate, oxygen saturation, and voice recordings of crying were measured across heel-prick procedures: baseline, no stimuli (stage 0); during heel prick (Stages 1–4); and recovery (Stages 5–10). Generalized estimating equations and Kaplan–Meier survival analysis compared differences in changes between groups for heart rate, oxygen saturation, and time to crying cessation. Changes in mean heart rate and oxygen saturation in neonates receiving breast milk odor or breast milk odor + breast milk taste were significantly less than those at the corresponding stage for the control group. Among neonates receiving breast milk odor or breast milk odor + breast milk taste, hazard rate ratios for crying cessation were 3.016 and 6.466, respectively. Mother’s breast milk olfactory and gustatory interventions could stabilize the biobehavioral responses to pain during heel prick procedures in neonates.

Effects of a tripartite intervention on biological stress in preterm infants during heel pricks for newborn screening: A randomized controlled trial

This prospective randomized trial examined the effects of a tripartite intervention (behavioral state modulation + nonnutritive sucking + tucking) on stress from procedural pain during heel pricks. Blood samples for routine screening were collected by heel pricks 48 h after birth (Stage 1) and at ≥37 weeks' gestation (Stage 2); salivary cortisol levels (SCLs) pre-prick (T0) and 20 min post-prick (T1) assessed stress. Preterm infants (n = 64) sampled by convenience at Level III neonatal care units were randomly assigned to the control condition (usual care) or intervention condition (tripartite intervention). Generalized estimating equations examined differences in salivary cortisol between conditions. After adjusting for effects of gestational age, postmenstrual age, and baseline SCLs, (1) at Stage 1, the change in salivary cortisol from T0 to T1 in preterm infants who received the tripartite intervention was, on average, significantly lower by 0.431 units (log scale) than the change in preterm infants who received the control condition (p < 0.001); (2) in the tripartite intervention condition, the difference between the change in mean SCLs from T0 to T1 at Stages 1 and 2 was significantly lower by 0.287 units (log scale), on average than between the change at Stages 1 and 2 in the control condition (p = 0.026). The provision of a tripartite intervention during heel prick significantly decreased the raise of SCLs compared with infants receiving usual care, suggesting lower stress. Clinicians could easily implement the tripartite intervention for heel-stick support; however, replication is needed before recommending its incorporation into routine heel stick and other stressful procedures.