Procedural Pain Management in Neonates, Infants and Children

Nurses' knowledge and practice about neonatal pain management in public hospitals in West Oromia, Ethiopia, 2022: multi-centered cross-sectional study

BACKGROUND

In low-and middle-income countries inadequate neonatal pain management persists as a significant public health issue despite the availability of guidelines. Newborns often experience pain from routine medical and surgical procedures, with limited nurses' knowledge and suboptimal practices posing common obstacles to effective neonatal pain management in hospital settings. Hence, this study aimed to evaluate nurses' knowledge and practices related to neonatal pain management and the factors influencing them in public hospitals in West Oromia, Ethiopia, in 2022.

METHODS

A multicenter cross-sectional study was conducted among 203 nurses working in public hospitals in West Oromia from 8th May-6th June 2022. Data was gathered using structured, self-administered questionnaire and sampled through simple random sampling. The collected data were coded and entered into a computer using Epi-Data version 4.6 Statistical Software. They were analyzed using the Statistical Package for Social Science (SPSS; IBM Corporation) version 26. Binary logistic regression was used to identify significant independent variables at p < 0.05.

FINDINGS

In this study, 127 (62.6%) exhibited adequate knowledge, while 33 (16.3%) nurses demonstrated good practice in neonatal pain management. Attending lectures or receiving training about neonatal pain management was found to be significantly associated with nurses' knowledge of neonatal pain management [AOR, 2.31, 95%CI; 1.29-4.27]. On the other, having adequate knowledge of neonatal pain management [AOR, 3.3, 95%CI; 1.14-9.32]; the presence of a pain management policy in place [AOR, 5.44, 95% CI; 1.92-15.37] and attending lectures on neonatal pain management [AOR, 2.55, 95% CI; 1.09-5.97] were found to be significantly associated to nurses' practices.

CONCLUSION

Given the substandard level of nurses' practice in neonatal pain management. It is suggested to enhance the nurses' knowledge and practice about neonatal pain management by providing refreshment courses, training sessions, or facilitating nurses' opportunity access to reading resources about neonatal pain management.

Comparison of Sucrose vs. Swaddling in Pain Management during Birth Dose of Hepatitis B Vaccine: A Randomized Control Trial

OBJECTIVES

To evaluate the efficacy of pain management of 1 ml of 24% sucrose given orally compared to routine care given one minute before vaccination for reduction of pain.

METHODS

This double-blind randomized controlled trial included term neonates visiting Pediatric OPD for immunization. Neonates were randomly assigned into two groups (Group A- Sucrose, Group B- Swaddling). Commercially available sucrose solution (StayHappi solution 24%) was given in a dose of 1 ml to the neonates. Video recording of the neonate's facial expression was done during the procedure. Duration of cry, latency of onset of cry as well Modified Neonatal Facial Coding Score (MFCS) were the outcome variables.

RESULTS

The mean (SD) of birth weight and gestational age was 2729 (321.6) g and 38.24 (0.84) d, respectively. Analysis showed significant difference in total MFCS across the groups (P <0.001). Total MFCS was significantly lower in sucrose group [4.88 (1.07) vs. 7.17 (0.95)]. The duration of cry (in seconds) was also found to be significantly lower in sucrose group.

CONCLUSIONS

Administration of 1 ml 24% sucrose one minute prior to immunization is efficacious in pain management during injectable immunization.

Clotted blood samples in the neonatal intensive care unit: A retrospective, observational study to evaluate interventions to reduce blood sample clotting

BACKGROUND

Blood draws for laboratory investigations are essential for patient management in neonatal intensive care units (NICU). When blood samples clot before analysis, they are rejected, which delays treatment decisions and necessitates repeated sampling.

AIMS

To decrease the incidence of rejected blood samples taken for laboratory investigation as a result of clotted sample.

STUDY DESIGN

This retrospective observational study used routine data on blood draws from preterm infants collected between January 2017 and June 2019 in a 112-cot NICU in Qatar. Quality improvement interventions to reduce the rate of clotted blood samples included: awareness raising and safe sampling workshops with NICU staff, involvement of the neonatal vascular access team, development of a complete blood count (CBC) sample collection pathway, review of sample collection equipment, introducing the Tenderfoot® heel lance, establishment of benchmarks and provision of dedicated blood extraction equipment.

RESULTS

First attempt blood draw occurred in 10 706 cases, representing a 96.2% success rate. In 427 (3.8%) cases, the samples were clotted requiring repeat collection. The overall rate of clotted specimens decreased from 4.8% in 2017 and 2018 to 2.4% in 2019, with odds ratios of 1.42 (95% confidence interval [CI] 1.13-1.78, p = .002), 1.46 (95% CI 1.17-1.81, p < .001) and 0.49 (95% CI 0.39-0.63, p < .001), respectively. The majority (87%-95%) of blood samples were by venepuncture using an intravenous (IV) catheter or the NeoSafe™ blood sampling device. Heel prick sampling was the second (2%-9%) most common method. Clotted samples were most frequently associated with needle use, 228 of 427 (53%), and IV cannula, 162 of 427 (38%), with odds ratios of 4.14 (95% CI 3.34-5.13, p < .001) and 3.11 (95% CI 2.51-3.86, p < .001), respectively.

CONCLUSIONS

Our interventions over 3 years were associated with reduced rates of sample rejection due to clotting, and this led to improved patient experience through fewer repeated samplings.

RELEVANCE TO CLINICAL PRACTICE

The insights gained from this project can help to improve patient care. Interventions that reduce the rate of blood sample rejection by clinical laboratories can lead to economic savings, timelier diagnostic and treatment decisions, and contribute to an improved quality care experience for all critical care patients, irrespective of age, by reducing the need for repeated phlebotomy and the risk of related complications.

Non-opioid analgesics for procedural pain in neonates

BACKGROUND

Neonates are an extremely vulnerable patient population, with 6% to 9% admitted to the neonatal intensive care unit (NICU) following birth. Neonates admitted to the NICU will undergo multiple painful procedures per day throughout their stay. There is increasing evidence that frequent and repetitive exposure to painful stimuli is associated with poorer outcomes later in life. To date, a wide variety of pain control mechanisms have been developed and implemented to address procedural pain in neonates. This review focused on non-opioid analgesics, specifically non-steroidal anti-inflammatory drugs (NSAIDs) and N-methyl-D-aspartate (NMDA) receptor antagonists, which alleviate pain through inhibiting cellular pathways to achieve analgesia.  The analgesics considered in this review show potential for pain relief in clinical practice; however, an evidence summation compiling the individual drugs they comprise and outlining the benefits and harms of their administration is lacking. We therefore sought to summarize the evidence on the level of pain experienced by neonates both during and following procedures; relevant drug-related adverse events, namely episodes of apnea, desaturation, bradycardia, and hypotension; and the effects of combinations of drugs.  As the field of neonatal procedural pain management is constantly evolving, this review aimed to ascertain the scope of non-opioid analgesics for neonatal procedural pain to provide an overview of the options available to better inform evidence-based clinical practice.  OBJECTIVES: To determine the effects of non-opioid analgesics in neonates (term or preterm) exposed to procedural pain compared to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL), PubMed, Embase, and two trial registries in June 2022. We screened the reference lists of included studies for studies not identified by the database searches.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs), quasi-RCTs, and cluster-RCTs in neonates (term or preterm) undergoing painful procedures comparing NSAIDs and NMDA receptor antagonists to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our main outcomes were pain assessed during the procedure and up to 10 minutes after the procedure with a validated scale; episodes of bradycardia; episodes of apnea; and hypotension requiring medical therapy.

MAIN RESULTS

We included two RCTs involving a total of 269 neonates conducted in Nigeria and India.  NMDA receptor antagonists versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention One RCT evaluated using oral ketamine (10 mg/kg body weight) versus sugar syrup (66.7% w/w at 1 mL/kg body weight) for neonatal circumcision.  The evidence is very uncertain about the effect of ketamine on pain score during the procedure, assessed with the Neonatal Infant Pain Scale (NIPS), compared with placebo (mean difference (MD) -0.95, 95% confidence interval (CI) -1.32 to -0.58; 1 RCT; 145 participants; very low-certainty evidence). No other outcomes of interest were reported on. Head-to-head comparison of different analgesics One RCT evaluated using intravenous fentanyl versus intravenous ketamine during laser photocoagulation for retinopathy of prematurity. Neonates receiving ketamine followed an initial regimen (0.5 mg/kg bolus 1 minute before procedure) or a revised regimen (additional intermittent bolus doses of 0.5 mg/kg every 10 minutes up to a maximum of 2 mg/kg), while those receiving fentanyl followed either an initial regimen (2 μg/kg over 5 minutes, 15 minutes before the procedure, followed by 1 μg/kg/hour as a continuous infusion) or a revised regimen (titration of 0.5 μg/kg/hour every 15 minutes to a maximum of 3 μg/kg/hour). The evidence is very uncertain about the effect of ketamine compared with fentanyl on pain score assessed with the Premature Infant Pain Profile-Revised (PIPP-R) scores during the procedure (MD 0.98, 95% CI 0.75 to 1.20; 1 RCT; 124 participants; very low-certainty evidence); on episodes of apnea occurring during the procedure (risk ratio (RR) 0.31, 95% CI 0.08 to 1.18; risk difference (RD) -0.09, 95% CI -0.19 to 0.00; 1 study; 124 infants; very low-certainty evidence); and on hypotension requiring medical therapy occurring during the procedure (RR 5.53, 95% CI 0.27 to 112.30; RD 0.03, 95% CI -0.03 to 0.10; 1 study; 124 infants; very low-certainty evidence). The included study did not report pain score assessed up to 10 minutes after the procedure or episodes of bradycardia occurring during the procedure. We did not identify any studies comparing NSAIDs versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention or different routes of administration of the same analgesics. We identified three studies awaiting classification.  AUTHORS' CONCLUSIONS: The two small included studies comparing ketamine versus either placebo or fentanyl, with very low-certainty evidence, rendered us unable to draw meaningful conclusions. The evidence is very uncertain about the effect of ketamine on pain score during the procedure compared with placebo or fentanyl. We found no evidence on NSAIDs or studies comparing different routes of administration. Future research should prioritize large studies evaluating non-opioid analgesics in this population. As the studies included in this review suggest potential positive effects of ketamine administration, studies evaluating ketamine are of interest. Furthermore, as we identified no studies on NSAIDs, which are widely used in older infants, or comparing different routes of administration, such studies should be a priority going forward.

The Clinical Suitability of an Artificial Intelligence-Enabled Pain Assessment Tool for Use in Infants: Feasibility and Usability Evaluation Study

BACKGROUND

Infants are unable to self-report their pain, which, therefore, often goes underrecognized and undertreated. Adequate assessment of pain, including procedural pain, which has short- and long-term consequences, is critical for its management. The introduction of mobile health-based (mHealth) pain assessment tools could address current challenges and is an area requiring further research.

OBJECTIVE

The purpose of this study is to evaluate the accuracy and feasibility aspects of PainChek Infant and, therefore, assess its applicability in the intended setting.

METHODS

By observing infants just before, during, and after immunization, we evaluated the accuracy and precision at different cutoff scores of PainChek Infant, which is a point-of-care mHealth-based solution that uses artificial intelligence to detect pain and intensity based solely on facial expression. We used receiver operator characteristic analysis to assess interpretability and establish a cutoff score. Clinician comprehensibility was evaluated using a standardized questionnaire. Other feasibility aspects were evaluated based on comparison with currently available observational pain assessment tools for use in infants with procedural pain.

RESULTS

Both PainChek Infant Standard and Adaptive modes demonstrated high accuracy (area under the curve 0.964 and 0.966, respectively). At a cutoff score of ≥2, accuracy and precision were 0.908 and 0.912 for Standard and 0.912 and 0.897 for Adaptive modes, respectively. Currently available data allowed evaluation of 16 of the 17 feasibility aspects, with only the cost of the outcome measurement instrument unable to be evaluated since it is yet to be determined. PainChek Infant performed well across feasibility aspects, including interpretability (cutoff score defined), ease of administration, completion time (3 seconds), and clinician comprehensibility.

CONCLUSIONS

This work provides information on the feasibility of using PainChek Infant in clinical practice for procedural pain assessment and monitoring, and demonstrates the accuracy and precision of the tool at the defined cutoff score.

Multisensory stimulation as a non-pharmacological intervention for neonates undergoing painful procedures: A scoping review

AIM

The aim of this review is to identify available evidence on MSS practices as a pain-relieving intervention among neonates undergoing a repetitive painful procedure.

METHODS

Searches were performed in the following databases: PubMed/ MEDLINE, SCOPUS, CINAHL, and the physiotherapy evidence database (PEDro). A total of eight studies were identified, among them; studies related to MSS in relieving neonatal procedural pain were conducted only in three countries only.

RESULTS

Data collected from the identified studies were extracted by two independent reviewers, and were synthesized quantitatively, and qualitatively. Eight studies involving six hundred and eighty-six neonates in three countries were identified in the search. Among them, six were randomized controlled trials, and two were observational studies. The study results highlighted that implementation of MSS as a non-pharmacological pain-relieving intervention follows a similar protocol among the reviewed articles, but varies by who administers MSS (Physiotherapists/ Nurses/Mothers) in neonates undergoing repetitive painful procedures.

INTERPRETATION

Standardized MSS protocol should be followed globally along with its implementation for reducing procedural pain among neonates and also to promote good clinical practice in neonatal intensive care unit (NICU) settings. Future research could determine the effects of standardized MSS protocol either with or without other non-pharmacological interventions among neonates undergoing painful procedures.

Virtual Reality Animal Rescue World: Pediatric virtual reality analgesia during just noticeable pressure pain in children aged 2-10 years old (crossover design)

BACKGROUND AND AIMS

Excessive pain during medical procedures is a worldwide medical problem. Most scald burns occur in children under 6, who are often undermedicated. Adjunctive Virtual Reality (VR) distraction has been shown to reduce pain in children aged 6-17, but little is known about VR analgesia in young children. This study tests whether desktop VR (VR Animal Rescue World) can reduce the just noticeable pressure pain of children aged 2-10.

METHODS

A within-subject repeated measures design was used. With treatment order randomized, each healthy volunteer pediatric participant underwent brief cutaneous pressure stimuli under three conditions: (1) no distraction, (2) a verbal color naming task (no VR), and (3) a large TV-based desktop VR distraction. A hand-held Wagner pressure pain stimulation device was used to generate just noticeable pain sensations. Participants indicated when a steadily increasing non-painful pressure stimulus first turned into a painful pressure sensation (just noticeable pain).

RESULTS

A total of 40 healthy children participated (43% aged 2-5 years; and 57% aged 6-10 years). Compared to the no distraction condition, the 40 children showed significant VR analgesia (i.e., a significant reduction in pain sensitivity during the VR Animal Rescue World condition), t(39) = 9.83, p < 0.001, SD = 6.24. VR was also significantly more effective at reducing pain sensitivity vs. an auditory color naming task, t(39) = 5.42, p < 0.001, SD = 5.94. The subset of children aged 2-5 showed significant reductions in pain during VR. Children under 6 showed greater sensitivity to pain during no distraction than children aged 6-10.

CONCLUSION

During no distraction, children under 6 years old were significantly more sensitive to pain than children aged 6-10. Virtual reality (VR) significantly reduced the "just noticeable" pressure pain sensitivity of children in both age groups.

Procedural Pain Management During Tenotomy for Congenital Talipes Equinovarus

The majority of infants with congenital talipes equinovarus (CTEV) require tenotomy of the tendoachilles. The pain response of this procedure in the awake infant has not been previously reported. In this observational study, multimodal pain management strategies, including oral sucrose, oral paracetamol, topical anesthetic, local anesthetic, a pacifier (dummy), and swaddling, were used. Physiological responses and pain were recorded. Pain was rated out of 10 at regular intervals, using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Ninety-one infants (65 men, mean age = 53 days, range = 19-217 days) were observed. At baseline, median FLACC, heart rate (HR), and oxygen saturation (Spo₂) were 1, 159, and 97% respectively. Peak median FLACC and HR were 9 and 200, respectively, and lowest median Spo₂ was 92%. The median (interquartile range) time for FLACC to return to 3 or less was 2 (2-5) minutes. Achilles tenotomy for CTEV in the awake infant is associated with high pain levels despite provision of multimodal pain relief measures.

Effectiveness of two extended-release buprenorphine formulations during postoperative period in neonatal rats

Information on the effectiveness of a new long-lasting buprenorphine formulation, extended-release buprenorphine, in the neonatal rat is very limited. This study compares whether a high dose of extended-release buprenorphine (XR-Hi) attenuates thermal hypersensitivity for a longer period than a low dose of extended-release buprenorphine (XR-Lo) in a neonatal rat incisional pain model. Two experiments were performed. Experiment one: Male and female postnatal day-5 rat pups (n = 38) were randomly assigned to 1 of 4 treatment groups and received a subcutaneous administration of one of the following: 1) 0.9%NaCl (Saline), 0.1 mL; 2) sustained release buprenorphine (Bup-SR), 1 mg/kg; 3) XR-Lo, 0.65 mg/kg; and 4) XR-Hi, 1.3 mg/kg. Pups were anesthetized with sevoflurane in 100% O₂ and a 5 mm long skin incision was made over the left lateral thigh and underlying muscle dissected. The skin was closed with surgical tissue glue. Thermal hypersensitivity testing (using a laser diode) and clinical observations were conducted 1 hour (h) prior to surgery and subsequently after 1, 4, 8, 24, 48, 72 h of treatment. Experiment two: The plasma buprenorphine concentration level was evaluated at 1, 4, 8, 24, 48, 72 h on five-day-old rat pups. Plasma buprenorphine concentration for all treatment groups remained above the clinically effective concentration of 1 ng/mL for at least 4 h in the Bup-SR group, 8 h in XR-Lo and 24 h in XR-Hi group with no abnormal clinical observations. This study demonstrates that XR-Hi did not attenuate postoperative thermal hypersensitivity for a longer period than XR-Lo in 5-day-old rats; XR-Hi attenuated postoperative thermal hypersensitivity for up to 4 h while Bup-SR and XR-Lo for at least 8 h in this model.

Development and refinement of Rel@x:A training in hypnosis-derived communication for pediatric nurses to prevent procedural pain

Introduction

Studies in pediatric oncology have shown that hypnosis effectively reduces patients' pain and distress during painful procedures. This remains underutilized in the healthcare system due to the staff cost and availability of hypnotherapists. To develop the use of hypnosis-derived communication, we aimed to train nurses to use hypnosis-derived communication while they perform painful procedures.

Objectives

This study aimed to (1) develop a brief training in hypnosis-derived communication for pediatric nurses named Rel@x, (2) pretest the training with experienced pediatric oncology nurses, and (3) refine the training based on nurses' suggestions.

Methods

The Rel@x training consists of two 4-h sessions: one related to relational aspects and another one presenting one of two selected hypnotic communication techniques ("pleasant place" or "magic glove"). Rel@x makes use of manuals, cue card reminders, visual aids, videos, and an e-learning platform. To refine Rel@x, a complete training cycle was conducted with seven female pediatric oncology nurses. A mixed method study with an evaluation questionnaire and a post-training focus group interview was conducted.

Results

Quantitative data showed that nurses overall positively rated the training program: relevance and acceptability (median average of 5.4/6); use of hypnotic communication (median average of 5.2/6); expected effects (median average of 5.4/6); program implementation (5.6/6). Two general themes emerged from the qualitative data: perceptions of hypnotic communication and the evaluation of the Rel@x training program. Based on nurses' suggestions, Rel@x was refined by adding more practical components, more time for practice, more time between the two sessions and additional tools (cue card reminders, keywords, virtual e-learning recap module).

Conclusion and clinical implications

The use of hypnosis-derived communication during painful procedures and the Rel@x training were viewed favorably amongst pediatric nurses. Rel@x offers a complete training in hypnosis-derived communication for pediatric nurses. This training fosters the optimal use of hypnosis-derived communication during care and may significantly reduce children's procedural pain and distress.

Kangaroo mother care (KMC) for procedural pain in infants: A meta-analysis from the current evidence of randomized control trials and cross-over trials

Background:

Kangaroo mother care (KMC), which is also known as Skin-to-skin (STS) care, is supposed to be effective in alleviating the pain of the neonates occurring during various procedures carried out in routine medical care or during the medical examination.

Objectives:

The meta-analysis aimed to determine the effect of the kangaroo mother care method on procedural pain in infants receiving KMC to those receiving only standard care (SC).

Search Strategy:

For this meta-analysis, a systematic literature search was conducted in online database PubMed, Medline, Web of Science, Google Scholar, and the CENTRAL database using MESH terms such as kangaroo mother care method/classification, kangaroo mother care method, kangaroo mother care method/instrumentation, kangaroo mother care method/methods, pain threshold, pain, pain management/methods, pain management/instrumentation, pain management/therapy, and pain management/therapeutic with the help of Boolean terms.

Selection Criteria:

Only randomized control trials or cross-over trials published within ten years and reporting pain assessment during or within five minutes of the pain stimulating procedure assessed using Premature Infant Pain Profile (PIPP) score were considered.

Data Collection and Analysis:

The primary outcome measures were procedural pain assessed by PIPP score and reported in mean and standard deviation along with 95% confidence interval (CI). In cross-over trials, data were taken from the first phase, i.e., before cross-over.

Main Results:

The pooled estimate of the six studies revealed a potential statistically significant benefit of KMC over SC in pain reduction following a pain stimulating procedure (P = 0.01, Mean difference = -2.04, 95% CI: -3.65, -0.43, Chi² = 69.86, I² = 93%). A high level of heterogeneity was found, i.e., 93%.

Conclusion:

Kangaroo mother care seems to be an effective intervention in alleviating the procedural pain due to routine procedures or medication examination.

Nurses' perceptions of infants' procedural pain assessment and alleviation with non-pharmacological methods in Estonia

PURPOSE

The purpose of this study was to describe nurses perceptions of infants' procedural pain assessment and alleviation with non-pharmacological methods including parental guidance in departments of neonatal and infant medicine and Neonatal Intensive Care (NICUs).

DESIGN AND METHODS

A descriptive cross-sectional survey was carried out among all nurses (n= 149) who were working in neonatal and infant departments or NICUs in Estonian hospitals. Altogether, 128 questionnaires were returned and 111 respondents were eligible (75% response rate). The data were analysed using statistical methods.

RESULTS

More than half of the nurses agreed that systematic documentation of the measurement of pain is necessary for nursing care and that it affects pain alleviation in infants. Half of the respondents (51%) confirmed that pain scales are important in the measurement of infants' pain, but 58% claimed they were able to assess pain in a reliable way without using pain assessment scales. Nurses also reported that they were unfamiliar with most pain scales and they were not routinely used in everyday practice. Nurses said that the most useful non-pharmacological pain alleviation methods were touching (83%) and positioning infants (78%), the most rarely used were skin-to-skin care (12%) and encouraging mothers to breastfeed the infant (34%). The majority of respondents (79%) reported that they do not know or do not have written instructions on pain assessment in their workplace, and only a few (10%) reported that they have participated in pain management courses during the last year.

CONCLUSIONS

There is a need to increase the use of pain assessment scales and pain documentation in everyday practice in those hospitals in Estonia. The use of scales in pain assessment was valued by few nurses. It seems that there is a lack of knowledge on non-pharmacological methods, and nurses reported using only a few non-pharmacological pain alleviation methods and guided parents on using them.

PRACTICE IMPLICATIONS

Nurses need pain management guidelines for everyday work, and in addition to nurses, written guidelines for parents are needed.

Clinical Trials, Potential Mechanisms, and Adverse Effects of Arnica as an Adjunct Medication for Pain Management

Arnica has traditionally been used in treating numerous medical conditions, including inflammation and pain. This review aims to summarize the results of studies testing Arnica products for pain management under different conditions, including post-operation, arthritis, low back pain, and other types of musculoskeletal pain. Based on data from clinical trials, Arnica extract or gel/cream containing Arnica extract shows promising effects for pain relief. These medical benefits of Arnica may be attributed to its chemical components, with demonstrated anti-inflammatory, antioxidant, anti-microbial, and other biological activities. In conclusion, Arnica could be an adjunct therapeutical approach for acute and chronic pain management.

Assessing procedural pain in infants: a feasibility study evaluating a point-of-care mobile solution based on automated facial analysis

BACKGROUND

The management of procedural pain in infants is suboptimal, in part, compounded by the scarcity of a simple, accurate, and reliable method of assessing such pain. In this study, we aimed to evaluate the psychometric properties of the PainChek Infant, a point-of-care mobile application that uses automated facial evaluation and analysis in the assessment of procedural pain in infants.

METHODS

Video recordings of 40 infants were randomly chosen from a purposely assembled digital library of 410 children undergoing immunisation as part of their standard care in Prishtina, Kosovo, between April 4, 2017, and July 11, 2018. For each infant recording, four 10 s video segments were extracted, corresponding to baseline, vaccine preparation, during vaccination, and recovery. Four trained assessors did pain assessments on the video segments of 30 infants, using PainChek Infant standard, PainChek Infant adaptive, the Neonatal Facial Coding System-Revised (NFCS-R) single, the NFCS-R multiple, and the Observer administered Visual Analogue Scale (ObsVAS), on two separate occasions. PainChek Infant's performance was compared to NFCS-R and ObsVAS using correlation in changes in pain scores, intra-rater and inter-rater reliability, and internal consistency.

FINDINGS

4303 pain assessments were completed in two separate testing sessions, on Aug 31, and Oct 19, 2020. The study involved videos of 40 infants aged 2·2-6·9 months (median age 3·4 months [IQR 2·3-4·5]). All pain assessment tools showed significant changes in the recorded pain scores across the four video segments (p≤0·0006). All tools were found to be responsive to procedure-induced pain, with the degree of change in pain scores not influenced by pre-vaccination pain levels. PainChek Infant pain scores showed good correlation with NFCS-R and ObsVAS scores (r=0·82-0·88; p<0·0001). PainChek Infant also showed good to excellent inter-rater reliability (ICC=0·81-0·97, p<0·001) and high levels of internal consistency (α=0·82-0·97).

INTERPRETATION

PainChek Infant's use of automated facial expression analysis could offer a valid and reliable means of assessing and monitoring procedural pain in infants. Its clinical utility in clinical practice requires further research.

FUNDING

PainChek.

The effect of playing games with toys made with medical materials in children with cancer on pain during intravenous treatment

OBJECTIVE

This research aims to examine the effect of playing games with toys made of medical materials in children with cancer on pain that occurs during intravenous (IV) treatment.

METHODS

The randomized controlled clinical trial was conducted between May 2016 and February 2018. The study sample comprised 110 children (experimental group 55; control group 55), determined using power analysis from the study population. The data were collected by the researcher, using face-to-face interview techniques, the Information Form, and Wong-Baker FACES Pain Rating Scale (WBS).

RESULTS

The pre- and post-test pain mean scores of patients in the experimental group were 2.27 ± 0.91 and 0.43 ± 0.66, respectively (p = 0.0001). The pre- and post-test pain mean scores of patients in the control group were 1.72 ± 0.82 and 3.34 ± 0.77, respectively (p = 0.0001).

SIGNIFICANCE OF RESULTS

The experience of playing with toys made from materials used for invasive procedures relieves pain the during IV treatment.

Nonpharmacological Methods for Reducing Parental Concern for Infant Vaccine-Associated Pain

INTRODUCTION

Numerous studies demonstrate that parental concern for infant pain contributes to vaccine hesitancy. The purpose of this project was to alleviate parental concern for pain and facilitate infant immunization.

METHOD

Pediatric nurses at an urban ambulatory clinic implemented evidence-based nonpharmacological methods (breastfeeding or 24% sucrose solution) for managing vaccine pain in infants aged up to 6 months. A validated survey measured parental concern for vaccine-related pain before and after the implementation of pain relief interventions.

RESULTS

There was a statistically significant decrease in parental concern for vaccine pain from pre- to postintervention between both treatment groups (p = .035).

DISCUSSION

Nurses can effectively use nonpharmacological methods to alleviate the pain of infants undergoing routine vaccination while reducing the parental concern for vaccine-associated pain. Reducing infant pain and parental concern may increase vaccination rates.

Sustained release buprenorphine effectively attenuates postoperative hypersensitivity in an incisional pain model in neonatal rats (Rattus norvegicus)

Despite the need for safe and effective postoperative analgesia in neonates, research regarding pain management in neonatal rodents is relatively limited. Here, we investigate whether sustained release buprenorphine (Bup SR) effectively attenuates thermal hypersensitivity in a neonatal rat model of incisional pain. Male and female postnatal day 3 Sprague Dawley rat pups (n = 34) were randomly assigned to one of four treatment groups: 1) saline (control), 0.1 mL, once subcutaneously (SC); 2) buprenorphine HCl (Bup HCl), 0.05 mg/kg, once SC; 3) low dose Bup SR (low-SR), 0.5 mg/kg, once SC; 4) high dose Bup SR (high-SR), 1 mg/kg, once SC. Pups were anesthetized with sevoflurane and a 0.5-cm long skin incision was made over the left lateral thigh. The underlying muscle was dissected and closed using surgical glue. Thermal hypersensitivity testing was performed at 24 h prior to surgery and subsequently at 1, 4, 8, 24, and 48 h post-surgery using an infrared diode laser. Thermal hypersensitivity was attenuated at 1 h post-surgery in the Bup HCl group, while it was attenuated through the entire postoperative period in both low-SR and high-SR groups. This data suggests that a single dose of low-SR (0.5 mg/kg) or high-SR (1 mg/kg) effectively attenuates thermal hypersensitivity for at least 8 h in neonatal rat pups.

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

BACKGROUND

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

AIMS

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

DESIGN

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

SETTINGS

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

PARTICIPANTS/SUBJECTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis

Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings.

METHODS

We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620.

FINDINGS

Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible.

INTERPRETATION

We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings.

FUNDING

Wellcome Trust Research Programme, and the Africa-Oxford Initiative.

Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled Trial

BACKGROUND

Premature infants hospitalized in the neonatal intensive care unit are routinely exposed to many painful procedures. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates, hence pain in infants should be reduced. Kangaroo care and oral sucrose are some of the methods that can help reduce pain.

AIM

This study aimed to compare the effects of kangaroo care and oral sucrose on pain relief in preterm infants during heel lancing.

METHODS

Our study involved 64 infants. The infants were randomly divided into two groups using a randomized block design of drawing out slips from a thick, non-transparent envelope. There were 64 slips in this envelope (32 for kangaroo care and 32 for oral sucrose). Kangaroo care was given to the preterm infants in the first group and oral sucrose to those in the second group. In both groups, heart rate and oxygen saturation were measured and pain score was evaluated by two observers using the Premature Infant Pain Profile (PIPP) before, during, and 2 minutes after blood sampling by heel lancing.

RESULTS

There was a statistically significant difference between the groups in favor of the kangaroo group in terms of change in the PIPP values after heel lancing. Kangaroo care is more effective than oral sucrose in pain relief during heel lancing in preterm infants.

CONCLUSIONS

In addition to many benefits it offers to infants, kangaroo care can be used to reduce pain during painful procedures in premature infants.

Modified Sensory Stimulation Using Breastmilk for Reducing Pain Intensity in Neonates in Indonesia: A Randomized Controlled Trial

PURPOSE

Several studies have shown that oral sucrose reduces pain in newborns. However, sucrose has no efficacy in eliminating pain and long-term effects remain unclear. Breast milk may be useful as an alternative, safe sweet solution. Sensorial saturation (SS) is a multisensory analgesic non-pharmacological treatment, which includes touch and sounds as distractors. This study aimed to compare the analgesic effects of SS with sucrose (SSS), SS with breast milk (SSB), and oral sucrose alone (S24%) in neonates undergoing venipuncture.

DESIGN AND METHODS

This was a randomized controlled trial conducted on 108 neonates who underwent venipuncture at neonatology wards. All babies were randomly assigned to one of three groups: two intervention groups and one control group. Pain response was assessed using the premature infant pain profile-revised (PIPP-R). Data analysis was conducted using the Kruskal-Wallis test and Mann-Whitney U test.

RESULTS

SSB and SSS were more effective than S24% (p = 0.001). No difference was observed between SSB and SSS (p = 0.669).

CONCLUSION

Multisensory stimulation is more effective in reducing pain than unimodal (oral sucrose) analgesia. Breast milk can be used as a sensory gustatory stimulus in multisensory stimulation to reduce pain intensity in neonates, and demonstrates a similar analgesic effect to sucrose.

PRACTICE IMPLICATIONS

The study findings suggest that neonatal nurses could use SSB for management of pain. This intervention could serve as an effective, inexpensive, and safe non-pharmacological analgesic. Additional testing of this intervention is warranted to support its use as an evidence-based pain reduction approach.

The effect of gentle human touch during endotracheal suctioning on procedural pain response in preterm infant admitted to neonatal intensive care units: a randomized controlled crossover study

Background: Neonates in the neonatal intensive care unit are frequently subjected to painful procedures. Non-pharmacological pain control techniques are useful for reducing procedural pain. Touch as one of the aspects of developmental care used to reduce neonatal pain. The purpose of this study was to determine the effect of gentle human touch during endotracheal suctioning on procedural pain response in preterm neonates.Methods: This was a clinical trial study with a crossover design. The study was conducted in a level III NICU in a hospital, affiliated to Iran University of Medical Sciences. Thirty-four neonates were enrolled in this study based on inclusion criteria. The samples were randomly received a sequence of suctioning with/without or suctioning without/with gentle human touch. Preterm Infant Pain Profile (PIPP) was used to collect the data. SPSS version 22 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.Results: 85.3% of neonates experienced moderate and 8.8% severe pain during suctioning without intervention, and only 64.7% of them experienced moderate and 2.9% severe pain during suctioning with intervention. The results of the paired t-test show that there is a statistically significant difference between the mean scores of pain in nonintervention and intervention cases (p < .002), and the mean pain score substantially reduced in cases with intervention.Conclusions: Results from this study showed that the pain due to suctioning procedure is considerably reduced by applying Gentle Human Touch. And nurses can use this method as one of the non-pharmacological methods of pain management.

The Operant Plantar Thermal Assay: A Novel Device for Assessing Thermal Pain Tolerance in Mice

Pain is a multidimensional experience of sensory-discriminative, cognitive, and affective processes; however, current basic research methods rely heavily on response to threshold stimuli, bypassing the supraspinal processing that ultimately gives rise to the pain experience. We developed the operant plantar thermal assay (OPTA), which utilizes a novel, conflict-based operant task requiring evaluation and active decision-making to obtain reward under thermally aversive conditions to quantify thermal pain tolerance. In baseline measures, male and female mice exhibited similar temperature preferences, however in the OPTA, female mice exhibited greater temperature-dependent tolerance, as defined by choice time spent in an adverse thermal condition to obtain reward. Increasing reward salience (4% vs 10% sucrose solution) led to increased thermal tolerance for males but not females. To determine whether neuropathic and inflammatory pain models alter thermal tolerance, animals with chronic constriction injury (CCI) or complete Freund's adjuvant (CFA), respectively, were tested in the OPTA. Surprisingly, neuropathic animals exhibited increased thermal tolerance, as shown by greater time spent in the reward zone in an adverse thermal condition, compared with sham animals. There was no effect of inflammation on thermal tolerance. Administration of clonidine in the CCI model led to increased thermal tolerance in both injured and sham animals. In contrast, the non-steroidal anti-inflammatory meloxicam was anti-hyperalgesic in the CFA model, but reduced thermal pain tolerance. These data support the feasibility of using the OPTA to assess thermal pain tolerance to gain new insights into complex pain behaviors and to investigate novel aspects of analgesic efficacy.

Sustainable, healthy cities: protocol of a mixed methods evaluation of a cluster randomized controlled trial for Aedes control in Brazil using a community mobilization approach

Background

Dengue is increasing in its global presence with an estimated 4 billion people at-risk of infection in at least 128 countries. Despite the promising results of EcoHealth and community mobilization approaches to Aedes reduction, more evidence of their efficacy on reducing dengue risk is needed. The principal research question is to determine if interventions based upon community mobilization reduce the risk of dengue virus infection among children 3 to 9 years old compared to usual dengue control practice in Fortaleza, Brazil.

Methods

The present study will follow a pragmatic cluster randomized controlled trial (cRCT) design with randomization at the census tract level with equal allocation to the two arms. In each arm, there will be 34 clusters of 86 children between 3 to 9 years old for an expected total of 5848 children enrolled in the study, assuming a risk reduction of 29.5% based upon findings from a previous multi-site cRCT. The primary outcomes are rates of anti-dengue Immunoglobulin G (IgG) seroconversion and adult female Aedes density. The intervention is based upon a participatory health research approach, Socializing Evidence for Participatory Action (SEPA), where the research evidence is used to foster community engagement and ownership of the health issue and solution. Following allocation, intervention communities will develop and implement their own solutions that will likely include a wide variety of collective events and media approaches. Data collection activities over a period of 3 years include household visits for blood collection, household surveys, and entomological surveys; and qualitative activities including focus groups, in-depth interviews, and document analysis to evaluate the process, acceptability, fidelity, and sustainability of the intervention. Study participants will be aware of their assignment and all research staff will be blinded although the intervention assignment will likely be revealed to field staff through interaction with participants.

Discussion

The results of our study will provide evidence on community mobilization as an intervention for dengue control. We anticipate that if community mobilization is effective in Fortaleza, the results of this study will help develop evidence-based vector control programs in Brazil, and also in other countries struggling with Aedes-transmitted diseases.

Trial registration

ISRCTN66131315, registration date: 1 October 2018.

Effects of plant-derived analgesic compounds sinomenine and salvinorin A in infant rats

OBJECTIVE

Premature and ill neonates undergo painful but medically necessary procedures while hospitalized. Although opiate drugs are administered as analgesics, problems associated with their side effects, tolerance, and potential dependence necessitate research into alternative pain-relieving medications. Here we test two plant-derived compounds in infant rats: sinomenine, which targets the Mas-related G-protein-coupled receptor member X2 opioid receptor; and salvinorin A, which is a κ opioid receptor agonist. In adult animals both sinomenine and salvinorin A are analgesic, but neither has been tested in infants.

METHODS

We used the formalin and thermal plantar tests in rats 7 and 21 days of age (PN7 and PN21) for behavioral signs of pain. In addition, brain sections were stained using Fos immunohistochemistry to examine patterns of brain activation in the midbrain periaqueductal gray and the paraventricular nucleus of the hypothalamus.

RESULTS

Sinomenine was analgesic in both the formalin and thermal tests on animals 21 days of age. At PN7 only the highest dose elevated response latencies in the thermal test and there were no effects of sinomenine in the formalin test. Analysis of Fos expression in the sinomenine-treated animals showed no drug effect, in contrast to the behavioral results. Salvinorin A was analgesic in the formalin test only at the highest dose at 21 days of age but not in the thermal test at either age.

CONCLUSION

The increased modest effectiveness of sinomenine in older animals and the minimum salvinorin A drug effect suggest that the compounds act on sites that develop during the preweaning period (sinomenine) or after weaning (salvinorin A).

Acute pain management in children: a survey of Italian pediatricians

BACKGROUND

Current guidelines recommend assessing and relieving pain in all children and in all instances; yet, in clinical practice, management is frequently suboptimal. We investigated the attitude of Italian family pediatricians towards the evaluation and treatment of different types of acute pain in children aged 7-12 years.

METHODS

This is a cross-sectional study based on a 17-question survey accessible online from October 2017 to October 2018. Responders had to describe cases of children suffering from any type of acute pain among headache, sore throat, musculoskeletal/post-traumatic pain, and earache. Children's characteristics, pain assessment modalities and therapeutic approaches were queried. The following tests were used: Z-proportion to evaluate the distribution of categorical data; chi-squared and Kruskall-Wallis to explore data heterogeneity across groups; Mann-Whitney for head-to-head comparisons.

RESULTS

Overall, 929 pediatricians presented 6335 cases uniformly distributed across the types examined. Pain was more frequently of moderate intensity (42.2%, P < 0.001) and short duration (within some days: 98.4%, P < 0.001). Only 50.1% of responders used an algometric scale to measure pain and 60.5% always prescribed a treatment. In children with mild-moderate pain (N = 4438), the most commonly used first-line non-opioids were ibuprofen (53.3%) and acetaminophen (44.4%). Importantly, a non-recommended dosage was prescribed in only 5.3% of acetaminophen-treated cases (overdosing). Among the misconceptions emerged, there were the following: i) ibuprofen and acetaminophen have different efficacy and safety profiles (when choosing the non-opioid, effectiveness weighted more for ibuprofen [79.7% vs 74.3%, P < 0.001] and tolerability for acetaminophen [74.0% vs 55.4%, P < 0.001]); ii) ibuprofen must be taken after meals to prevent gastric toxicities (52.5%); ibuprofen and acetaminophen can be used combined/alternated for persisting mild-moderate pain (16.1%). In case of moderate-severe pain not completely controlled by opioids, ibuprofen and acetaminophen were the most used add-on medications, with ibuprofen being much more prescribed than acetaminophen (65.2% vs 23.7%, respectively) overall and in all pain types.

CONCLUSIONS

Several gaps exist between the current practice of pain assessment and treatment and recommendations. Further efforts are needed to raise awareness and improve education on the possible exposure of the child to short- and long-term consequences in case of suboptimal pain management.

Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline

OBJECTIVE

Thoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients.

METHODS

Methods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey.

RESULTS

There was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated.

DISCUSSION

This project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.