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Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S, DiLorenzo-Klas M, Racine NM, Ahola Kohut S, Lisi D, Turcotte K, Stevens B, Uman LS. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 2023; 6:CD006275. [PMID: 37314064 PMCID: PMC10265939 DOI: 10.1002/14651858.cd006275.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
| | - Oana Bucsea
- Department of Psychology, York University, Toronto, Canada
| | - Ilana Shiff
- Department of Psychology, York University, Toronto, Canada
| | - Cheryl Chow
- Department of Psychology, York University, Toronto, Canada
| | | | | | | | - Nicole M Racine
- Department of Psychology, University of Calgary, Calgary, Canada
| | - Sara Ahola Kohut
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Diana Lisi
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Kara Turcotte
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Bonnie Stevens
- Nursing Research, The Hospital for Sick Children, Toronto, Canada
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de Oliveira NRG, Formiga CKMR, Ramos BA, dos Santos RN, Moreira NNDS, Marçal PGE, do Amaral WN. Gentle Touch and Sucrose for Pain Relief during Suctioning in Preterm Newborns-A Randomized Clinical Trial. CHILDREN (BASEL, SWITZERLAND) 2023; 10:158. [PMID: 36670708 PMCID: PMC9857169 DOI: 10.3390/children10010158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
Pain management is challenging in neonatal care. We aimed to compare the effects of gentle touch and sucrose on pain relief during suctioning in premature newborns (PTNB). This crossover randomized clinical trial enrolled PTNBs with low birth weight, hemodynamically stable, and requiring suctioning during hospitalization in the neonatal intensive care unit. PTNBs underwent three different suctioning procedures. The first was performed without intervention (baseline). Right after, PTNBs were randomly allocated (sucrose and gentle touch or vice versa) to the next two suctioning procedures. Two validated scales assessed pain: the Neonatal Infant Pain Scale (NIPS) and the Premature Infant Pain Profile-Revised (PIPP-R). We evaluated 50 PTNBs (mean of 28 weeks) with a mean low birth weight of 1050 g; most were under continuous positive airway pressure 37 (74%) and mechanical ventilation 41 (82%). Gentle touch was efficacious for pain relief since NIPS (p = 0.010) compared to baseline. Sucrose was also effective in reducing pain NIPS and PIPP-R (p < 0.001). Although the two interventions reduced pain, no difference was observed between gentle touch and sucrose.
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Affiliation(s)
| | | | - Bruna Abreu Ramos
- Graduate Program in Health Sciences, Medical School, Federal University of Goiás (UFG), Goiânia 74690-900, GO, Brazil
| | - Rafaela Noleto dos Santos
- Program in Sciences Applied to Health Products, Department of Physical Therapy, State University of Goiás (UEG), Goiânia 74690-900, GO, Brazil
| | - Nayara Nubia de Sousa Moreira
- Graduate Program in Health Sciences, Medical School, Federal University of Goiás (UFG), Goiânia 74690-900, GO, Brazil
| | | | - Waldemar Naves do Amaral
- Graduate Program in Health Sciences, Medical School, Federal University of Goiás (UFG), Goiânia 74690-900, GO, Brazil
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Gautheyrou L, Durand S, Jourdes E, De Jonckheere J, Combes C, Cambonie G. Facilitated tucking during early neonatologist-performed echocardiography in very preterm neonates. Acta Paediatr 2018; 107:2079-2085. [PMID: 30144169 DOI: 10.1111/apa.14555] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/04/2018] [Accepted: 08/22/2018] [Indexed: 11/27/2022]
Abstract
AIM To assess the effect of facilitated tucking (FT), a nonpharmacologic nursing intervention, on echocardiographic parameters and infant comfort collected prospectively during neonatologist-performed echocardiography. METHODS Echocardiography was performed twice, in standard conditions and with FT; the order was randomised by computer. Echocardiography provided data on pulmonary artery flow and pressure, right and left ventricular function, and persistent ductus arteriosus. Comfort was assessed by a behavioural scale of pain, variations in heart rate (HR) and SpO2 , and a newborn infant parasympathetic evaluation index based on the high-frequency variability in HR. RESULTS Fifty newborns, with mean gestational age of 28 [26.6-29.0] weeks and mean birthweight of 950 [780-1190] g, were studied at a postnatal age of 13 [9-27] hours. FT was associated with longer acceleration time/right ventricular ejection time in the main pulmonary artery (p = 0.006), reduced averaged HR variations (p = 0.03) and lower pain scores (p < 0.001). The other haemodynamic parameters and the parasympathetic index were not influenced by FT. CONCLUSION Echocardiography performed soon after birth in very premature neonates may generate mild discomfort. FT during echocardiography is associated with lower pulmonary artery pressures and improves infant's comfort during this examination.
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Affiliation(s)
- Laurène Gautheyrou
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Sabine Durand
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Emilie Jourdes
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Julien De Jonckheere
- EA 4489, Perinatal Growth and Environment; Lille University; Montpellier Cedex 5 France
- CIC-IT 1403; Lille University Hospital; Lille France
| | - Clémentine Combes
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
| | - Gilles Cambonie
- Neonatal Intensive Care Unit; Arnaud de Villeneuve Hospital; Montpellier University Hospital; Montpellier Cedex 5 France
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Harrison D, Larocque C, Bueno M, Stokes Y, Turner L, Hutton B, Stevens B. Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta-analysis. Pediatrics 2017; 139:peds.2016-0955. [PMID: 27986905 DOI: 10.1542/peds.2016-0955] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Abundant evidence of sweet taste analgesia in neonates exists, yet placebo-controlled trials continue to be conducted. OBJECTIVE To review all trials evaluating sweet solutions for analgesia in neonates and to conduct cumulative meta-analyses (CMAs) on behavioral pain outcomes. DATA SOURCES (1) Data from 2 systematic reviews of sweet solutions for newborns; (2) searches ending 2015 of CINAHL, Medline, Embase, and psychINFO. DATA EXTRACTION AND ANALYSIS Two authors screened studies for inclusion, conducted risk-of-bias ratings, and extracted behavioral outcome data for CMAs. CMA was performed using random effects meta-analysis. RESULTS One hundred and sixty-eight studies were included; 148 (88%) included placebo/no-treatment arms. CMA for crying time included 29 trials (1175 infants). From the fifth trial in 2002, there was a statistically significant reduction in mean cry time for sweet solutions compared with placebo (-27 seconds, 95% confidence interval [CI] -51 to -4). By the final trial, CMA was -23 seconds in favor of sweet solutions (95% CI -29 to -18). CMA for pain scores included 50 trials (3341 infants). Results were in favor of sweet solutions from the second trial (0.5, 95% CI -1 to -0.1). Final results showed a standardized mean difference of -0.9 (95% CI -1.1 to -0.7). LIMITATIONS We were unable to use or obtain data from many studies to include in the CMA. CONCLUSIONS Evidence of sweet taste analgesia in neonates has existed since the first published trials, yet placebo/no-treatment, controlled trials have continued to be conducted. Future neonatal pain studies need to select more ethically responsible control groups.
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Affiliation(s)
- Denise Harrison
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada; .,School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Catherine Larocque
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada.,School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Mariana Bueno
- Departamento Enfermagem Materno-Infantil e Psiquiátrica (ENP), University of São Paulo, São Paulo, Brazil
| | - Yehudis Stokes
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada.,School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Lucy Turner
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Bonnie Stevens
- The Hospital for Sick Children, Toronto, Ontario, Canada; and.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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