Special needs of preterm infants in the management of pain and discomfort

Study of pain response in neonates during venipuncture with a view to analyse utility of topical anaesthetic agent for alleviating pain

Background

Neonates being nonverbal are unable to express their pain leading to underestimation of their pain and hence insufficient pain relief. Neonatal pain is assessed by pain scales based on the behavioural and physiological changes that occur in response to painful stimuli. This cross sectional study was conducted at a tertiary care centre using Premature Infant Pain Profile (PIPP) score with 4% lidocaine as local anaesthetic agent to produce surface anaesthesia of skin prior to intravenous cannulation.

Methods

Sample size was collected by simple randomisation method. Our study groups included 50 term and 50 preterm neonates with POG of 28-40 weeks requiring IV cannulation. Heart rate (HR), SpO₂, facial expressions and behavioural state were noted before venipuncture and after venipuncture using PIPP scale. Same cohort of patients was assessed for pain response after applying 4% lidocaine cream during future venipuncture with help of PIPP score.

Results

The PIPP score in preterm group before and after anesthesia was 11.28 ± 3.72 and 9.58 ± 3.39. PIPP score in term group before and after anesthesia was 11.54 ± 2.84 and 9.04 ± 2.97. There was reduction in mean PIPP score after using topical anesthetic agent in both study groups and the results were statistically significant.

Conclusion

This study found that topical anesthetic agents were effective in reducing pain during venipuncture. Based on the facts of the study, it is recommended that pain scoring should be a part of routine monitoring in neonatal intensive care units and appropriate measures should be used to reduce pain.

Salivary Cortisol As Indicators of Pain in Preterm Infants

Assessment and management of pain in preterm infants is critical and complicated. The addition of salivary cortisol measurement may improve the specificity of assessment and guide care to alleviate pain. The purpose of this study was fourfold: (a) assess the feasibility of a method of saliva collection in premature infants, (b) assess reliability of a method of measuring salivary cortisol in response to heelstick, (c) identify relationships between salivary cortisol and a measure of pain behavior (using CRIES) following heelstick, and (d) identify peak response times for elevations of salivary cortisol following heelstick in preterm infants. This was a prospective, descriptive pilot study. Serial saliva samples were collected from eight healthy infants 30 to 36 weeks’ gestational age in a Newborn Intensive Care Unit. Cortisol levels were determined using enzyme-immuneassay. Samples were collected without use of stimulants. Sample means supported peak and trough patterns previously described in the literature. Behavioral measures of pain did not correlate well with peak cortisol levels.

Contextual factors associated with pain response of preterm infants to heel-stick procedures

BACKGROUND

Evidence indicates that medical and demographic contextual factors (cFs) impact pain responses in preterm neonates, but the existing evidence is very heterogeneous.

AIM

To explore the effect of cFs on pain responses to heel-stick procedures of preterm infants.

METHODS

This study was a secondary analysis of data collected during a randomized controlled trial examining pain response to non-pharmacological interventions across repeated heel sticks. Five heel sticks across the first 14 days of life were videotaped. Pain response was rated with the Bernese Pain Scale for Neonates (BPSN) by four raters blinded to the heel-stick phases (baseline, heel stick, recovery). Demographic and medical cFs were extracted from medical charts. Mixed single and multiple regression analyses were performed controlling for the intervention group, site and heel-stick phase.

RESULTS

Apgar scores at 1 min were negatively associated with behavioural (p = 0.002) BPSN scores, while Apgar scores at 5 min after birth were positively associated with behavioural (p = 0.006) scores. Accumulated number of painful procedures (p = 0.002) and gender (p = 0.02) were positively associated with physiological scores while continuous positive airway pressure CPAP (p = 0.009) and mechanical ventilation (p = 0.005) were negatively associated.

CONCLUSION

Higher exposure to painful procedures, male infants and having CPAP or mechanical ventilation were cFs associated with physiological response. The only variables significantly associated with behavioural BPSN scores were Apgar scores but these relationships were inconsistent.

O contato pele a pele ao nascimento e o choro de recém-nascidos durante vacinação contra Hepatite B

OBJETIVO: Testar a efetividade do contato pele a pele entre mãe e filho após o nascimento na redução do comportamento de estresse/dor manifestado pelo choro do recém-nascido (RN), decorrente do procedimento de vacinação contra a Hepatite B. MÉTODOS: Estudo comparativo quase-experimental abrangendo 40 RN a termo, divididos em dois grupos, com ou sem contato pele a pele com suas mães após o nascimento, e que foram comparados quanto ao tempo de choro durante a vacinação contra Hepatite B. RESULTADOS: Variações no tempo de choro foram observadas nos dois grupos durante as fases desse procedimento. CONCLUSÃO: O efeito do contato na diminuição do tempo de choro dos RN, não foi demonstrado estatisticamente. Clinicamente, a Síndrome do Chamado pelo Estresse foi observada, bem como a efetividade do período de contato, na modulação do comportamento de choro dos neonatos, enquanto estes estiveram sob o momento terapêutico.

The pain response of infants in Turkey to vaccination in different injection sites

This study was carried out with the aim of comparing pain responses of children who receive intramuscular (IM) vaccination in deltoid muscle versus the pain responses of those who receive IM vaccination in the vastus lateralis. A total of 185 infants were randomly assigned to one of the two study groups. The deltoid group and the vastus lateralis group were vaccinated respectively in the deltoid muscle and the vastus lateralis. Our results indicated that pain response of infants was similar in each group. However, crying duration of the children who received the vastus lateralis vaccination was shorter than that of the deltoid group after the procedure.

Effect of Yakson and Gentle Human Touch versus usual care on urine stress hormones and behaviors in preterm infants: a quasi-experimental study

BACKGROUND

Touching, one of the most developed senses, is proven to relax preterm infants. Yakson is a Korean touching method for healing and relaxation similar to Gentle Human Touch (GHT), which is used in the United States.

OBJECTIVE

The goal of this study was to test the effect of Yakson and GHT on preterm infants' stress and behaviors compared to usual nursing care.

DESIGN

A quasi-experimental study design was used.

PARTICIPANTS

Fifty-nine preterm infants (26-34 weeks gestational age) in the neonatal intensive care unit were chronologically assigned into three groups; Yakson (n=20), GHT (n=20), and control group (n=19).

METHODS

The Yakson and GHT groups each received an intervention for 15min twice a day for 15 days while the control group received usual nursing care. Yakson consists of three five-minute phases: resting the hand on the infant, gentle caressing, and resting the hand again. GHT consists of hand resting for 15min. Twenty-four-hour urine cortisol and norepinephrine samples were collected both before and after the 15-day intervention period. The infants' sleep and awake states were observed before, during, and after each intervention.

RESULTS

Following the intervention period, preterm infants in the Yakson and GHT groups had significantly lower stress hormone levels compared to the control group preterm infants. No significant difference was found in stress hormone levels between Yakson and GHT group preterm infants. After Yakson or GHT, the infants exhibited an increased percentage of sleep states and a decreased percentage of awake and fussy states.

CONCLUSIONS

The findings suggest that Yakson is another touching method that is not aversive or stressful to preterm infants, and which may provide several positive effects on preterm infants.

Evidence-based review of oral sucrose administration to decrease the pain response in newborn infants

Pain assessment and management are important issues for the neonatal nurse today. Clinicians have gradually come to acknowledge that newborn infants (term and preterm) are capable of responding to painful stimuli. This article reviews the evidence regarding the safety and efficacy of oral sucrose administration, to help answer the clinical question of how to manage an infant's pain response to minor invasive procedures that are everyday occurrences in the NICU. This review included information on 1,077 infants enrolled in 16 studies. The evidence presented in the 16 studies reviewed here shows the safety and efficacy of sucrose in decreasing term infants' pain response to a single procedure. In regard to preterm infants, there is insufficient evidence to recommend the use of sucrose as a routine comfort measure. More research is needed to determine the safety and efficacy of repeated doses of oral sucrose given for multiple procedures in preterm infants.

Skin conductance as a measure of pain and stress in hospitalised infants

BACKGROUND

Reliable and valid methods of measuring pain responses in infants continue to be sought as a means of evaluating the effectiveness of pain reduction strategies. Skin conductance has recently been shown to be a promising physiological indicator of pain and stress in premature and term infants.

AIM

To evaluate changes in skin conductance in hospitalised infants under different environmental conditions and during both painful and non-painful procedures.

METHODS

Measurements of skin conductance activity were made in infants under three different environmental temperature conditions (open cot, incubator and overhead radiant heater), during the routine non-painful nursing procedure of either nappy change or oral feeding, and whilst undergoing the painful procedure of heel lancing for blood sampling.

RESULTS

Skin conductance activity in 21 infants was studied on 43 separate occasions. Skin conductance activity was highly variable between infants but did not differ significantly under the three environmental conditions. Routine nursing care did not result in a significant increase in skin conductance activity above baseline; however, on cessation of care there was a significant reduction to levels below baseline (p < 0.05). Conversely, during the heel lance procedure, skin conductance activity significantly increased upon lance (p < 0.05) and remained elevated following completion of the procedure. There were no statistically significant differences between skin conductance activity changes from baseline as a result of routine nursing care compared to that of the heel lance procedure.

CONCLUSION

Due to large variability in skin conductance activity further studies are needed before this technology can be recommended as a clinically useful indicator of pain and stress in neonates.

A dor na unidade neonatal sob a perspectiva dos profissionais de enfermagem de um hospital de Ribeirão Preto-SP

Estudo descritivo qualitativo buscou descrever a compreensão, a avaliação e o manejo da dor no RN sob cuidado intensivo. Dezesseis profissionais de enfermagem identificaram a dor mediante alterações comportamentais e fisiológicas. Consideram ineficaz o uso da escala NIPS na prática clínica. Apontam dificuldades em diferenciar manifestações de dor e estresse no cotidiano profissional. Preocupam-se com o manejo adequado da dor e buscam o conhecimento desta temática ainda de maneira incipiente, em sua maioria, mediante a vivência adquirida no cuidado neonatal e a troca de experiências com outros profissionais. Assim, acredita-se que a instrumentalização através de acesso à literatura específica e cursos de capacitação sobre a temática otimizariam o manejo, contribuindo na melhoria da assistência e qualidade de vida dos bebês.

Effects of facilitated tucking during routine care of infants born preterm

PURPOSE

The purpose of this study was to compare stress responses of infants born preterm during routine nursing assessments performed under two conditions. One condition incorporated a second caregiver supporting the infant in a facilitated tucked position, whereas the second condition did not.

METHODS

A convenience sample of 12 infants born preterm, ages 25 to 34 weeks postconceptual age on the day of testing (mean = 30.9 weeks), were evaluated using the Premature Infant Pain Profile (PIPP), during the two caregiving conditions. For each trial, the infant received a PIPP score. The level of significance was set at p = 0.05.

RESULTS

A significant difference (p = 0.013) existed between the two testing positions as measured by the PIPP. Nine of the 12 infants received a lower PIPP score with facilitated tucking during routine care assessments.

CONCLUSIONS

By incorporating facilitated tucking during routine care events, the stress level of the infants born preterm may be reduced. When the infants' stress levels are reduced, they may be better able to maintain stability in their autonomic, motor, and state systems.

Treatment of neonatal pain without a gold standard: the case for caregiving interventions and sucrose administration

Although many different neonatal pain assessment scales are used in clinical research, no gold-standard instrument exists. The multitude of pain assessment scales used has, in fact, threatened the validity of many studies and confused the construct of pain. This integrative review of the neonatal pain literature provides the recommendations from practice guidelines and the current evidence for modifying the pain response prior to and during common painful procedures.

Pain assessment in the neonate using the Bernese Pain Scale for Neonates

BACKGROUND

Neonates who require treatment in the neonatal intensive care unit (NICU) are subjected to many invasive painful procedures.

AIMS

Assessment of pain in preterm and term neonates with or without ventilation on continuous positive airway pressure using the Bernese Pain-Scale for Neonates (BPSN). The validity and the reliability of the BPSN was established.

STUDY DESIGN AND SUBJECTS

Pain assessments (n=288) were performed by 6 health care workers in different situations of term and preterm neonates. Each neonate (n=12) was observed in four given situations (after feeding, while a foot was being warmed, while a routine capillary blood sample was taken and 15 min after the blood sample was taken). Pain assessments were made by two nurses at the bedside using the BPSN, the Visual-Analogue Scale (VAS) and the Premature Infant Pain Profile (PIPP). At the same time, a video sequence was made which was shown later to four different nurses to assess pain using the BPSN, the PIPP, and the VAS.

RESULTS

The construct validity of the BPSN was very good (F=41.3, p<0.0001). Moreover, concurrent and convergent validity of the BPSN compared to VAS and PIPP was r=0.86, and r=0.91, p<0.0001, respectively. Finally, the study demonstrated high coefficients for interrater (r=0.86-0.97) and intrarater reliability (r=0.98-0.99).

CONCLUSION

The BPSN was shown to be a valid and reliable tool for assessing pain in term and preterm neonates with and without ventilation.

Pain management in nursing procedures on premature babies

BACKGROUND

Pain can be caused to premature babies when nursing and other procedures are carried out. Procedural pain management for these babies raises challenging questions for health care professionals. Optimal pain management for premature babies can be reached by using and further developing existing pharmacological and non-pharmacological pain alleviation methods for procedural pain before, during, and after procedures.

AIMS

The aims of this study were to describe the environment of pain management in nursing procedures and examinations with premature babies; to describe preparation of the baby for the procedure; to describe non-pharmacological pain alleviation methods during and after the procedures; and to develop a process describing procedural pain management in premature babies.

METHOD

The material for this study consisted of journal articles on non-pharmacological procedural pain alleviation in infants published between 1994 and 2002. During this period knowledge of pain management in premature babies has improved considerably. The study was based on the method of content analysis.

FINDINGS

Procedural pain management in premature babies was described by researchers as a process comprising: (1) an environment that is favourable to effective pain management, (2) safe preparation of the baby for the procedure, (3) pain alleviation during the procedure, and (4) restoring the baby's sense of security after the procedure. Pain management is recommended to be used alone or together with pharmacological interventions. Additionally, systematic pain management requires documentation of the whole pain management process.

CONCLUSION

Pain management can be described as a process. It is important to test and assess this process and individual non-pharmacological pain management methods in practical nursing situations. The findings of this review can be used to improve pain management methods in premature babies.

Bedside assessment of heel lance pain in the hospitalized infant

OBJECTIVE

To evaluate a method of pain assessment to be used for hospitalized infants requiring blood test by a heel lance procedure.

DESIGN

Observational study evaluating pain measurement and interrater reliability of pain measurement in hospitalized infants.

SETTING

A Level III neonatal unit and a cardiac surgical unit at a major pediatric teaching hospital.

PARTICIPANTS

20 infants whose gestational age ranged from 28 weeks to full-term.

MAIN OUTCOME MEASURES

Observations included behavioral measurements (facial expressions, body movements, and crying characteristics) and the physiologic measure of heart rate. Interrater reliability and the feasibility of using the procedural pain assessment method at the bedside were considered.

RESULTS

The three behavioral measurements and heart rate were responsive to the heel lance. Interrater reliability was high for facial expressions and crying scores but was low for body movements.

CONCLUSIONS

Modifications have been made to the method of procedural pain assessment to be used in a subsequent study. The modified method is expected to be a reliable measure of procedural pain caused by a heel lance and can easily be used at the bedside during the course of further research.

Factors explaining lack of response to heel stick in preterm newborns

OBJECTIVE

To determine factors explaining lack of response by preterm newborns to heel stick for blood sampling.

DESIGN

A cross-sectional design based on secondary analysis of the control session of a randomized crossover design.

SETTING

Four Level III neonatal intensive-care units of university teaching hospitals.

PARTICIPANTS

120 preterm newborns with an average age of 28 weeks postconceptional age.

INTERVENTION

24 newborns who showed a "no change" response according the Premature Infant Pain Profile were compared to the remaining 96 newborns who had shown a pain response.

MAIN OUTCOME MEASURES

Age (postconceptional age at birth, postnatal age at study), Apgar score at 5 minutes, severity of illness, sex, race, wake/sleep state, previous study sessions, total number of painful procedures since birth, and time since last painful procedure.

RESULTS

After stepwise logistic regression analysis the variables remaining in the final model that explained the difference between the groups were postnatal age at time of study, postconceptional age at birth, time since last painful procedure, and wake/sleep state.

CONCLUSIONS

Newborns who were younger, asleep, and had undergone a painful event more recently were less likely to demonstrate behavioral and physiologic indicators of pain.

Assessment of pain and agitation in critically ill infants

Critically ill infants are subjected to many painful experiences that, if inadequately treated, can have severe physiological and psychological consequences. Optimal management of pain relies on the adequacy of nurses' assessment; this, however, is complicated by another common condition, agitation. A multidimensional assessment is therefore necessary to adequately identify pain and agitation. The aim of this descriptive study was to identify the cues that nurses caring for critically ill infants use to assess pain and agitation. A questionnaire, developed from the literature, was distributed to all registered nurses (85) working in the neonatal and paediatric intensive care units of an Australian teaching hospital. Questionnaires were completed by 41 nurses (a 57 per cent response rate). Results revealed that, except for diagnosis, there were no significant differences between the cues participants used to assess pain and those to assess agitation. Nurses used numerous cues from various sources: most importantly, their own judgement (99 per cent); the parents' judgement (90 per cent); the infant's environment; documentation (78 per cent), and the infant's cues (70 per cent). These findings demonstrate the relevance of the nurse's role in assessment of pain and agitation in critically ill infants. Nurses used cues specific to the critically ill rather than the less sick infant. Results of this study also show the difficulty of differentiating between pain and agitation. Further research on ways of distinguishing between the construct of pain and agitation needs to be undertaken.

Preverbal, Early Verbal Pediatric Pain Scale (PEPPS): development and early psychometric testing

The Pre-Verbal, Early Verbal Pediatric Pain Scale (PEPPS) is conceptualized to measure the established pain response in toddlers, a pediatric group void of pain assessment scales. It consists of seven categories, each with weighted indicators. Scores can range from 0 to 26. Using a blinded, cross-sectional design, 40 children, aged 12 to 24 months, were videotaped throughout their postoperative stay in the postanesthesia care unit. Vignettes were randomly selected and viewed by four experienced pediatric nurses. Results indicated that the PEPPS was easy to use and demonstrated acceptable inter-rater and intrarater reliability. Early evidence of construct validity was established by statistically significant differences in premedication and postmedication pain scores.

The interpretation of infant pain: physiological and behavioral indicators used by NICU nurses

The purpose of this descriptive study was to identify the indicators used by neonatal nurses to interpret the experience of pain in infants in a Neonatal Intensive Care Unit (NICU). A sample of 72 NICU nurses completed a structured questionnaire to identify the physiological and behavioral indicators they used to interpret the experience of pain in the infants entrusted to their care. The 10 pain indicators used by more than 50% of the nurses, listed in decreasing order of frequency, were: fussiness, restlessness, grimacing, crying, increasing heart rate, increasing respirations, wiggling, rapid state changes, wrinkling of forehead, and clenching of fist. These findings are consistent with existing literature, are compatible with the stress cues identified in Als' Synactive Theory of Development, and lend support to the use of such measures for the assessment of infant pain.

Pain scales in children: a review

This is a review of tools that have been developed to assess pain in children, with a brief evaluation of their practicality and validity. There are some suggestions for the direction of future research in the development and use of the scales.