Effects of Massage on Postoperative Pain in Infants With Complex Congenital Heart Disease

Effects of White Noise on Pain Scores and Salivary Cortisol Levels in Surgical Neonates: A Randomized Controlled Trial

BACKGROUND

Neonates experience varying intensities of pain after surgery. While white noise has been used for postoperative pain relief in infants, its effects on neonates after surgery need further exploration.

PURPOSE

This study aimed to evaluate the effects of white noise on pain scores and salivary cortisol levels in surgical neonates.

METHODS

In this randomized controlled trial, 64 neonates scheduled for surgery were recruited and assigned by block randomization into 2 groups. The intervention group listened to white noise at 50 dB, while the control group listened to white noise at 0 dB, for 30 minutes 6 times for 48 hours postoperatively. Pain scores, measured by the COMFORTneo Scale, and salivary cortisol levels were compared.

RESULTS

Although pain scores decreased after surgery in all subjects, no statistically significant difference was observed between the 2 groups (P = .937). There was a significant difference between pre- and postintervention pain scores in the intervention group only (P = .006). Salivary cortisol levels decreased after intervention in the intervention group, but there was no significant difference between pre- and postintervention levels in the 2 groups (P = .716).

IMPLICATIONS FOR PRACTICE

Given the reduction in pain scores and salivary cortisol concentrations after white noise intervention, white noise shows potential as an adjunctive soothing measure for neonates after surgery.

IMPLICATIONS FOR RESEARCH

Future studies are needed to confirm the efficacy and utility of white noise intervention in clinical settings.

A Systematic Review of the Effectiveness of Non-Pharmacological Therapies Used by Nurses in Children Undergoing Surgery

OBJECTIVE

The aim of this study was to identify non-pharmacological pain relief therapies in children undergoing surgery.

DESIGN AND DATA SOURCES

Using keywords extracted from Medical Subject Headings and "Descriptores en Ciencias de la Salud" we searched for articles in the Web of Science, Scopus, Cuiden, PubMed, and CINHAL databases from the last five years, and performed a reverse search. We assessed the documentary quality of the articles using various standardized instruments.

RESULTS

The final review included eleven studies. In terms of cognitive-behavioral techniques, there is evidence that both music and video therapy are effective in reducing postoperative pain in children in seven studies, and therapeutic play in five studies. Other methods used less frequently but found to be effective included laughter therapy in one study and deep breathing in another. Regarding physical methods of pain relief, massage was found to be an effective non-pharmacological therapy for reducing pediatric postoperative pain in two studies and ineffective in another.

CONCLUSIONS

In this study, we highlight the importance of non-pharmacological therapies in pediatric postoperative pain management. Cognitive-behavioral techniques, especially music therapy, video therapy, and therapeutic play, reduce pediatric postoperative pain. They are therefore effective therapies that nurses can use in this area. Further research into the effectiveness of storytelling is necessary, as the evidence is not entirely conclusive. More evidence is also needed on physical methods of pain relief, particularly massage.

Neurodevelopmental Outcomes for Individuals With Congenital Heart Disease: Updates in Neuroprotection, Risk-Stratification, Evaluation, and Management: A Scientific Statement From the American Heart Association

Over the past decade, new research has advanced scientific knowledge of neurodevelopmental trajectories, factors that increase neurodevelopmental risk, and neuroprotective strategies for individuals with congenital heart disease. In addition, best practices for evaluation and management of developmental delays and disorders in this high-risk patient population have been formulated based on literature review and expert consensus. This American Heart Association scientific statement serves as an update to the 2012 statement on the evaluation and management of neurodevelopmental outcomes in children with congenital heart disease. It includes revised risk categories for developmental delay or disorder and an updated list of factors that increase neurodevelopmental risk in individuals with congenital heart disease according to current evidence, including genetic predisposition, fetal and perinatal factors, surgical and perioperative factors, socioeconomic disadvantage, and parental psychological distress. It also includes an updated algorithm for referral, evaluation, and management of individuals at high risk. Risk stratification of individuals with congenital heart disease with the updated categories and risk factors will identify a large and growing population of survivors at high risk for developmental delay or disorder and associated impacts across the life span. Critical next steps must include efforts to prevent and mitigate developmental delays and disorders. The goal of this scientific statement is to inform health care professionals caring for patients with congenital heart disease and other key stakeholders about the current state of knowledge of neurodevelopmental outcomes for individuals with congenital heart disease and best practices for neuroprotection, risk stratification, evaluation, and management.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

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.

The effect of regional massage performed before blood collection on pain and vital signs in newborns

AIM

This randomised-controlled trial aims to examine the effect of regional massage performed before blood collection on pain and vital signs in term newborns.

METHODS

The study sample consisted of a total of 96 term newborns, 49 in the experimental group and 47 in the control group, in the neonatal intensive care unit (NICU). Before the blood collection process, those in the experimental group received two (2) minutes of massage on their blood collection region, and their pain levels and vital signs were observed. Data were collected using a newborn information form, an intervention follow-up form, and the Neonatal Infant Pain Scale (NIPS). Statistical analyses of the collected data included descriptive statistics, Chi-squared test, independent-samples t test, paired-samples t test and Cohen's kappa statistic. A value of P < 0.05 was considered statistically significant.

RESULTS

While 51% (n = 49) of the newborns were included in the experimental group, 38.5% (n = 37) were born at the 38th gestational week. Their mean post-natal age was 4.82 ± 4.04 days. The newborns in the experimental and control groups had similar demographic characteristics and blood collection experiences, and there was no statistically significant difference between them (P > 0.05). The mean crying time in the control group (56.9 ± 25.4 s) was significantly longer than that in the experimental group (30.6 ± 29.3 s) (P < 0.05). The newborns in the experimental group had shorter crying times, lower pain levels and heart rate, and higher oxygen saturation than those in the control group.

CONCLUSION

The regional massage intervention reduced pain in term newborns. Therefore, neonatal nurses can be trained to use massage as an alternative infant care practice.

Developmental Care for Hospitalized Infants With Complex Congenital Heart Disease: A Science Advisory From the American Heart Association

Developmental disorders, disabilities, and delays are a common outcome for individuals with complex congenital heart disease, yet targeting early factors influencing these conditions after birth and during the neonatal hospitalization for cardiac surgery remains a critical need. The purpose of this science advisory is to (1) describe the burden of developmental disorders, disabilities, and delays for infants with complex congenital heart disease, (2) define the potential health and neurodevelopmental benefits of developmental care for infants with complex congenital heart disease, and (3) identify critical gaps in research aimed at evaluating developmental care interventions to improve neurodevelopmental outcomes in complex congenital heart disease. This call to action targets research scientists, clinicians, policymakers, government agencies, advocacy groups, and health care organization leadership to support funding and hospital-based infrastructure for developmental care in the complex congenital heart disease population. Prioritization of research on and implementation of developmental care interventions in this population should be a major focus in the next decade.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

BACKGROUND

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.

METHODS

A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus.

RESULTS

60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.

CONCLUSIONS

Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

The effect of massage therapy on pain after surgery: A comprehensive meta-analysis

BACKGROUND

Findings on the usefulness of massage therapy (MT) in postoperative pain management are often inconsistent among studies.

OBJECTIVES

This study's aim is to conduct a meta-analysis of randomized controlled trials (RCT) to clarify the effects of massage therapy in the treatment of postoperative pain.

METHODS

Three databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) were searched for RCTs published from database inception through January 26, 2021. The primary outcome was pain relief. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. The random-effect model was used to calculate the effect sizes and standardized mean difference (SMD) with 95 % confidential intervals (CIs) as a summary effect. The heterogeneity test was conducted through I². Subgroup and sensitivity analyses were used to explore the source of heterogeneity. Possible publication bias was assessed using visual inspection of funnel plot asymmetry.

RESULTS

The analysis included 33 RCTs and showed that MT is effective in reducing postoperative pain (SMD, -1.32; 95 % CI, -2.01 to -0.63; p = 0.0002; I² = 98.67 %). A similar significant effect was found for both short (immediate assessment) and long terms (assessment performed 4-6 weeks after the MT). Remarkably, we found neither the duration per session nor the dose had an impact on the effect of MT and there seemed to be no difference in the effects of different MT types. In addition, MT seemed to be more effective for adults. Furthermore, MT had better analgesic effects on cesarean section and heart surgery than orthopedic surgery.

LIMITATIONS

Publication bias is possible due to the inclusion of studies in English only. Additionally, the included studies were extremely heterogeneous. Double-blind research on MT is difficult to implement, and none of the included studies is double-blind. There was some heterogeneity and publication bias in the included studies. In addition, there is no uniform evaluation standard for the operation level of massage practitioners, which may lead to research implementation bias.

CONCLUSIONS

MT is effective in reducing postoperative pain in both short and long terms.

Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease

Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.

Effects of Infant Massage: A Systematic Review

Infant massage is performed in various international contexts. There is a need for an updated literature review on this topic. The purpose of the current review was to investigate the effects of infant massage. A systematic literature review was conducted to investigate the effects of infant massage on the following outcomes: pain relief, jaundice, and weight gain. The inclusion criteria were infants from 0–12 months. The literature search was performed until January 2022, using the CINAHL, PubMed, and PsycINFO databases, and included studies published from 2017–2021, returning 16 RCT/CCT studies with a total of 1416 participating infants. A review template was used by two independent reviewers to assess the risk of bias in the included studies. The results were synthesized and presented in the form of tables and narratives. In five of seven studies (n = 422 resp. n = 717) investigating pain relief, infant massage was found to alleviate pain. In all six studies (n = 455) investigating effects on infant massage and jaundice, beneficial effects were found on bilirubin levels. In all four studies (n = 244) investigating weight gain, increased weight gain was found among participants who received infant massage. The present literature review provides an indication of the current state of knowledge about infant massage and identifies its positive effects; however, the results must be interpreted with caution. Infant massage may be effective at relieving pain, improving jaundice, and increasing weight gain. Although statistically significant differences were not found between all experimental and control groups, no adverse effects of infant massage were observed. By placing the aforementioned effects in the context of child health care, infant massage may prove beneficial on these outcomes. Given the dearth of research on infant massage in the context of child health care, further research is warranted.

Individualized Family-Centered Developmental Care for Infants With Congenital Heart Disease in the Intensive Care Unit

BACKGROUND

Individualized family-centered developmental care (IFDC) is considered the standard of care for premature/medically fragile newborns and their families in intensive care units (ICUs). Such care for infants with congenital heart disease (CHD) varies.

OBJECTIVE

The Consortium for Congenital Cardiac Care- Measurement of Nursing Practice (C4-MNP) was surveyed to determine the state of IFDC for infants younger than 6 months with CHD in ICUs.

METHODS

An electronic survey was disseminated to 1 nurse at each participating center. The survey included questions on IFDC-related nursing practice, organized in 4 sections: demographics, nursing practice, interdisciplinary practice, and parent support. Data were summarized by using descriptive statistics. Differences in IFDC practices and IFDC-related education were assessed, and practices were compared across 3 clinical scenarios of varying infant acuity by using the χ2 test.

RESULTS

The response rate was 66% (25 centers). Most respondents (72%) did not have IFDC guidelines; 63% incorporated IFDC interventions and 67% documented IFDC practices. Only 29% reported that their ICU had a neurodevelopmental team. Significant differences were reported across the 3 clinical scenarios for 11 of 14 IFDC practices. Skin-to-skin holding was provided least often across all levels of acuity. Nurse education related to IFDC was associated with more use of IFDC (P < .05).

CONCLUSION

Practices related to IFDC vary among ICUs. Opportunities exist to develop IFDC guidelines for infants with CHD to inform clinical practice and nurse education. Next steps include convening a C4-MNP group to develop guidelines and implement IFDC initiatives for collaborative evaluation.