Non-pharmacological management of infant and young child procedural pain

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

AUTHORS' CONCLUSIONS

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

Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article I): a systematic review and description of methods

ABSTRACT

Blinding is challenging in randomised controlled trials of physical, psychological, and self-management therapies for pain, mainly because of their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently used sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham-controlled randomised clinical trials of physical, psychological, and self-management treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods, and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (eg, duration and frequency of treatments) than others (eg, physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations.

Effects of complementary spiritual therapy on stress, anxiety, burnout syndrome and hematological parameters of professionals in a public hospital: a randomized controlled trial

OBJECTIVES

This randomized controlled trial evaluated the stress, anxiety, and burnout of professionals exposed to complementary spiritist therapy (CST), which consists in therapeutic resources as prayer, Spiritist passe, fluidic water and spiritual education or control.

METHODS

Seventy-six professionals were randomized to CST or control: to maintain the routine for 5 weeks. The ISSL scale, anxiety and depression Beck's indices, Maslach instrument, subjective well-being and WHOQOL-BREF were used at baseline and five-week. Blood count and cytokine dosage were collected at baseline, one-week and five-week. Analysis using the intention to treat approach.

RESULTS

The means of variation of stress (exhaustion phase) between baseline and five-week were -1.50 ± 3.31 in the CST and 0.72 ± 3.50 in the control (p=0.036), effect size for CST group was d=0.65, which is considered medium effect. CST showed decrease in emotional exhaustion and negative affects, and increase in lymphocytes, erythrocyte parameters and platelets between the baseline and five-week (p<0.05). Reduction in IL-1β and increase in total lymphocyte count were observed with 2-3 sessions per week, but that does not maintain when the number of sessions is decreased. Participants receiving ≥7 sessions reduced emotional exhaustion, depersonalization and stress, and improved hematological parameters throughout the study (p<0.05).

CONCLUSIONS

CST may be effective in reducing stress (exhaustion phase) compared to control. Higher frequency of interventions promotes better psychic state, evidenced by large effect size for emotional exhaustion in burnout, and improves hematological parameters of professionals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03356691.

Effects of the laying on of hands on anxiety, stress and autonomic response of employees in a hospital: A double-blind randomized controlled trial

Mental and behavioral disorders result in increased absenteeism and abandonment of work. The objective of this study was to evaluate the anxiety, stress, depression, negative and positive affects, and hematological and autonomic responses of employees in a public hospital exposed to laying on of hands with (LHS) or without Spiritual connection (control-LHW).

METHODOLOGY

Eighty-four employees with anxiety/stress were enrolled and randomly allocated into two groups of intervention LHS by Spiritist "passe" and control-LHW by volunteers with healing intent. Anxiety, stress and depression were evaluated by Depression Anxiety and Stress Scale (DASS21). Negative and positive affects by Subjective Well-being Scale (SWS), cardiac autonomic modulation by heart rate variability and cytokines and blood count were assessed by blood sample.

RESULTS

Our study showed a significant improvement in the neutrophils (p = 0.041; d = 0.70) and cardiac parasympathetic activity, and reduction in VLF (p < 0.005) in the LHS. There was reduction in erythrocyte parameters and interleukin 10 (p < 0.005) in the control-LHW. In both groups there was a significant reduction in anxiety, stress, depression and negative affects after one session (p < 0.005).

CONCLUSION

Laying on of hands with Spiritual connection by Spiritist "passe" appears to be effective in increasing cardiac vagal activity and regulation of immune responses of employees in a public hospital with stress/anxiety.

Effect of laying on of hands as a complementary therapy for pain and functioning in older women with knee osteoarthritis: A randomized controlled clinical trial

AIM

To assess the effects of laying on of hands (LooH) as a complementary therapy to kinesiotherapy, on pain, joint stiffness, and functional capacity of older women with knee osteoarthritis (KOA) compared to a control group.

METHODS

In this randomized controlled clinical trial, participants were assigned into 3 groups: LooH with a spiritual component ("Spiritist passe" Group - SPG), LooH without a spiritual component (LooH Group - LHG), and a control group receiving no complementary intervention (Control Group - CG). Patients were assessed at baseline, 8 weeks, and 16 weeks. Primary outcomes were joint stiffness and functional capacity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), and pain (WOMAC and visual analog scale). Secondary outcomes were anxiety, depression, mobility, and quality of life. Differences between groups were evaluated using an intention-to-treat approach.

RESULTS

A total of 120 women (mean age = 69.2 ± 5.2 years) with KOA were randomized (40 participants per group). At 8 weeks, SPG differed significantly from the LHG for WOMAC Functional Status (between-group difference in the change = 0.97; 95% CI: 0.35 to 1.59, P = .001); Anxiety levels (between-group difference in the change = 1.38; 95% CI: 0.11 to 2.65, P = .027); and also from the CG for all outcomes with exception of WOMAC Stiffness. After 16 weeks, SPG differed significantly from the LHG only for WOMAC Functional Status (between-group difference in the change = 0.92; 95% CI: 0.32 to 1.52, P = .001]) and also from the CG for all outcomes with exception of WOMAC Stiffness and timed up-and-go.

CONCLUSION

Our results suggest that LooH with a "spiritual component" may promote better long-term functional outcomes than both LooH without a "spiritual component" and a control group without LooH.

Effect of Spiritist "Passe" on Preoperative Anxiety of Surgical Patients: A Randomized Controlled Trial, Double-Blind

The objective of this study was to evaluate the preoperative anxiety of hospitalized patients exposed to Spiritist "passe," laying on of hand with the intention of healing (Sham) and without laying on of hand. Other variables as depression, pain, physiological parameters, muscle tension, and well-being were assessed. Patients in the Spiritist "passe" intervention group showed greater reductions in anxiety (p < 0.05) and muscle tension (p < 0.01) and increases in well-being (p < 0.01). More marked reductions in preoperative anxiety and muscle tension and improvement in well-being were observed in patients exposed to Spiritist "passe" compared to Sham or standard medical care.Trial registration: ClinicalTrials.gov Identifier NCT03356691.

Effects of Maharishi Light Technology with Gems: A random-assignment, placebo-controlled, blinded pilot study

OBJECTIVES

This blinded random-assignment, placebo-controlled pilot study investigated the effects of Maharishi Light Technology with Gems on three self-report measures: a questionnaire with a 5-point Likert-type scale, the Profile of Mood States (POMS), and an open-ended question. This pilot is the beginning of a research program to test the effects of this therapy.

METHODS

In total, 18 meditating subjects received two treatments on consecutive days, randomly either Maharishi Light Technology or placebo, then 2 weeks rest, and then the other treatment on consecutive days.

RESULTS

In comparison to placebo treatments, Maharishi Light Technology treatments were (1) rated as being significantly more settled, (2) higher on the Positive Self-Esteem subscale of the POMS and (3) described by the terms: healing, wholeness, and bliss.

CONCLUSION

These treatments lead to significant improvements on self-report measures. Future research could assess their effects across both meditating and nonmeditating populations, using physiological measures to probe possible mechanisms of the effects.