Assessing postoperative pain in neonates: a multicenter observational study

Regional Anesthesia for Neonates

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Intervención educativa para mejorar el diagnóstico y manejo del dolor en unidades de recién nacidos en Colombia

Objetivo: Evaluar el impacto en profesionales y pacientes de desarrollar e implementar una estrategia educativa en tres unidades neonatales en Bogotá (Colombia) para el reconocimiento y manejo del dolor. Metodología: Estudio de antes y después para evaluar el cambio en los conocimientos y aptitudes de los profesionales mediante encuestas consecutivas, y el cambio en el registro y manejo del dolor, evaluando la información consignada en las historias clínicas en ambos periodos. Resultados: Se encuestaron 70 profesionales de la salud antes y después de la implementación de la estrategia. Se encontró un cambio en sus aptitudes con respecto al uso de escalas de dolor (p = 0,03), el conocimiento de medidas no farmacológicas (p = 0,009) y el uso de medidas farmacológicas (p = 0,009). Adicionalmente, se analizaron las historias clínicas de 75 neonatos antes y 75 después de la implementación de la estrategia, lo que evidenció un incremento en el uso de escalas para evaluar el dolor asociado con procedimientos diagnósticos (1,3% vs. 20%; p < 0,01), y terapéuticos (0% vs. 56,7%; p < 0,01) y en la proporción de pacientes que recibieron manejo farmacológico (17,3% vs. 53,7%; p < 0,01). Conclusión: Los resultados sugieren que la implementación de una estrategia educativa mejora los conocimientos y aptitudes de los profesionales, así como el compromiso con las medidas dirigidas a diagnosticar y tratar adecuadamente el dolor en las unidades neonatales.

Existence and perceived application of pain management protocols in German neonatal intensive care units

We explored the existence and application of standard operating procedures (SOPs) for pain management (PM) in German neonatal intensive care units (NICUs), and identified the factors associated with their application in practice. This study was part of the Safety4NICU project, a cross-sectional survey conducted from 2015 to 2016. All 224 German NICUs were invited to participate, providing written consent from the head neonatologist and head nurse. We distributed questionnaires to the head neonatologist, the head nurse, and the NICU staff (physicians and nurses). We asked the head neonatologist whether written SOPs for PM existed, and we asked the staff whether these SOPs were applied in their daily routine. We received evaluable responses from 468 physicians and 1251 nurses from 76 NICUs. Of these 76 NICUs, the head neonatologists from 54 NICUs (71.1%) reported that written SOPs for PM exist. However, only 48.5% of the physicians and 53.7% of the nurses declared that these existing SOPs were also applied. We found various predictors for the existing SOPs as being applied, depending on the profession. For physicians, clinical training was important (OR: 2.482, p ≤ 0.05), while for nurses their working experience was a decisive predictor (OR: 1.265, p ≤ 0.05). For both, a high level of perceived cooperative norms between physicians and nurses increased the probability that SOPs for PM were applied, whereas a high bed turnover rate decreased that probability. According to the responses from head neonatologists, written SOPs for PM were common in German NICUs. However, if management strategies on pain existed, this did not mean that these were directly applied in the daily routine. Clinical training of the staff, the promotion of adequate interprofessional cooperation, as well as allowing time to deal with these SOPs might be all essential measures to strengthen the application.

Risk factors for prolonged mechanical ventilation in neonates following gastrointestinal surgery

BACKGROUND

Prolonged mechanical ventilation (MV) should be avoided in neonates. Noninvasive ventilation (NIV) can facilitate weaning from MV but has risks for patients immediately following foregut surgery due to the potential risk of anastomotic leak. We evaluated the risk factors for prolonged MV following intestinal surgery in neonates.

METHODS

We retrospectively reviewed 253 neonates undergoing intestinal surgery in 2017-2018 to identify risk factors for prolonged MV, and determine the correlation between NIV and anastomotic leak in a tertiary neonatal intensive care unit that performs the greatest number of neonatal surgeries in Ontario.

RESULTS

The most common diagnoses were necrotizing enterocolitis/spontaneous intestinal perforation (NEC/SIP) 21%, intestinal atresia 16%, esophageal atresia/tracheoesophageal fistula 14%, ano-rectal malformation 13%, malrotation/volvulus 11%, gastroschisis 9% and omphalocele 4%. The median (IQR) duration of MV post-surgery was 3 (1-8) days with 25.7 % (n=65) of neonates on MV for >7 days. Compared to infants on MV post-surgery for ≤7 days, those with MV>7 days were of lower gestational age, birth weight and weight at surgery, but a higher proportion underwent stoma creation, had a longer duration of opioid administration and higher rates of moderate to severe bronchopulmonary dysplasia (BPD) and mortality (P<0.05). Generalized linear regression analysis showed lower gestational age (GA) and longer opioid administration were associated with longer duration of MV (P<0.001), but indication for surgery, weight at surgery and stoma creation didn't correlate with longer duration of MV (P>0.05). Of the 122 patients handled by one-stage resection with primary anastomosis, 22.1% (n=27) received NIV with 74.1% (n=20) commenced on NIV after 7 days post-surgery, anastomotic leak was detected in 2.5 % (3/122) patients and didn't correlate with NIV.

CONCLUSIONS

Lower GA and longer opioid administration were risk factors for prolonged MV in neonates following intestinal surgery. Further research is needed to investigate modifiable practices around pain assessment/ventilation in these patients, and the correlation between NIV and anastomotic leak.

Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments

BACKGROUND

Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale.

PURPOSE

The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit.

METHODS

Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management.

RESULTS

There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores (P< .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.

Multimodal spatio-temporal deep learning approach for neonatal postoperative pain assessment

The current practice for assessing neonatal postoperative pain relies on bedside caregivers. This practice is subjective, inconsistent, slow, and discontinuous. To develop a reliable medical interpretation, several automated approaches have been proposed to enhance the current practice. These approaches are unimodal and focus mainly on assessing neonatal procedural (acute) pain. As pain is a multimodal emotion that is often expressed through multiple modalities, the multimodal assessment of pain is necessary especially in case of postoperative (acute prolonged) pain. Additionally, spatio-temporal analysis is more stable over time and has been proven to be highly effective at minimizing misclassification errors. In this paper, we present a novel multimodal spatio-temporal approach that integrates visual and vocal signals and uses them for assessing neonatal postoperative pain. We conduct comprehensive experiments to investigate the effectiveness of the proposed approach. We compare the performance of the multimodal and unimodal postoperative pain assessment, and measure the impact of temporal information integration. The experimental results, on a real-world dataset, show that the proposed multimodal spatio-temporal approach achieves the highest AUC (0.87) and accuracy (79%), which are on average 6.67% and 6.33% higher than unimodal approaches. The results also show that the integration of temporal information markedly improves the performance as compared to the non-temporal approach as it captures changes in the pain dynamic. These results demonstrate that the proposed approach can be used as a viable alternative to manual assessment, which would tread a path toward fully automated pain monitoring in clinical settings, point-of-care testing, and homes.

Postsurgery analgesic and sedative drug use in a French neonatal intensive care unit: A single-center retrospective cohort study

OBJECTIVE

To describe pain assessment, the pattern of analgesic and sedative drug use, and adverse drug reactions in a neonatal intensive care unit (NICU) during the postsurgery phase.

METHOD

Demographic characteristics, pain scores, and drug use were extracted and analyzed from electronic patient medical files for infants after surgery, admitted consecutively between January 2012 and June 2013.

RESULT

One hundred and sixty-eight infants were included. Acute (DAN score) and prolonged (EDIN score) pain assessment scores were used in 79% and 64% of infants, respectively, on the 1st day. This percentage decreased over the 7 days following surgery. The weekly average scores postsurgery were 2/15 (±2.2) for the EDIN score and 1.6/10 (±2.0) for the DAN score. The rates of pain control were 88% for the EDIN and 72% for the DAN. The most prescribed opiate drug was fentanyl (98 patients; 58%) with an average dose of 1.8 (±0.6) μg/kg/h. Midazolam was used in 95 patients (56%), with an average dose of 35 (±14) μg/kg/h. A bolus was administered in 7% (±7.4) of the total dose for fentanyl and 8% (±9.3) for midazolam. Similar doses were used in term and preterm neonates. Of 118 patients receiving fentanyl and/or midazolam, 40% presented urinary retention, 28% a weaning syndrome. Paracetamol (155 patients; 92%) and nalbuphine (55 patients; 33%) were the other medications most often prescribed.

CONCLUSION

The off-label use of fentanyl and midazolam was necessary to treat pain after surgery. Pain assessment should be conducted for all neonates in order to optimize their treatment. Research on analgesic and sedative medicine in vulnerable neonates seems necessary to standardize practices and reduce adverse drug reactions.

Reduced narcotic and sedative utilization in a NICU after implementation of pain management guidelines

OBJECTIVE

To assess the opioid and benzodiazepine usage in a level IV NICU after implementation of pain guidelines.

STUDY DESIGN

Guidelines were developed for infants undergoing surgical procedures and infants on mechanical ventilation. Data collected for period 1 (July to December 2013) and period 2 (March to August 2014).

RESULTS

Gestational age, birth weight and infants with hypoxic respiratory failure or requiring major procedures were comparable in two periods. Number of patients exposed to opioids decreased from 62.9% (129/205) in period 1 to 32.8% (82/250) in period 2, P=<0.001. Cumulative dose exposure decreased, opioids in morphine equivalent dose, mg kg^-1 (1.64 (0.38 to 6.94) vs 0.51 (0.04 to 2.33), P=0.002), sedatives in midazolam equivalent, mg kg^-1 (0.16 (0.03 to 7.39) vs 0.10 (0.00 to 4.00), P=0.03). Ten patients required treatment for iatrogenic opioid withdrawal versus only three in post guideline, P=0.02.

CONCLUSIONS

Evidence-based guidelines led to significant reduction in opioids and sedatives exposure, and in the number of infants requiring methadone for iatrogenic narcotic dependence.

Assessment of continuous pain in newborns admitted to NICUs in 18 European countries

AIM

Continuous pain occurs routinely, even after invasive procedures, or inflammation and surgery, but clinical practices associated with assessments of continuous pain remain unknown.

METHODS

A prospective cohort study in 243 neonatal intensive care units (NICUs) from 18 European countries recorded the frequency of pain assessments, use of mechanical ventilation, sedation, analgesia or neuromuscular blockade for each neonate for up to 28 days after NICU admission.

RESULTS

Only 2113 of 6648 (31.8%) of neonates received assessments of continuous pain, occurring variably among tracheal ventilation (TrV, 46.0%), noninvasive ventilation (NiV, 35.0%) and no ventilation (NoV, 20.1%) groups (p < 0.001). Daily assessments for continuous pain occurred in only 10.4% of all neonates (TrV: 14.0%, NiV: 10.7%, NoV: 7.6%; p < 0.001). More frequent assessments of continuous pain occurred in NICUs with pain guidelines, nursing champions and surgical admissions (all p < 0.01), and for newborns <32 weeks gestational age, those requiring ventilation, or opioids, sedatives-hypnotics, general anaesthetics (O-SH-GA) (all p < 0.001), or surgery (p = 0.028). Use of O-SH-GA drugs increased the odds for pain assessment in the TrV (OR:1.60, p < 0.001) and NiV groups (OR:1.40, p < 0.001).

CONCLUSION

Assessments of continuous pain occurred in less than one-third of NICU admissions and daily in only 10% of neonates. NICU clinical practices should consider including routine assessments of continuous pain in newborns.

Reduced Sufentanil Doses are Effective for Postoperative Analgesia After Ductal Closure in Extremely Premature Infants: A 10 Years Retrospective Cohort Study

OBJECTIVES

The objective of the study was to assess the efficacy of reduced sufentanil doses for postoperative analgesia following surgical ductal closure in extremely premature infants.

METHODS

This was a retrospective, single-center, cohort study comparing 2 sufentanil dosing regimens used between 2001 and 2010 and included all infants born at <28 weeks of gestation with surgical ductal closure. Sufentanil doses were reduced in 2007 as a standard of care. Time was divided into 3 epochs to distinguish the effects of practice changes over time from the effects of sufentanil dose change: epoch 1 (2001 to 2004), epoch 2 (May 2005 to 2007), and epoch 3 (June 2007 to 2010).

RESULTS

A total of 109 of 114 eligible infants were analyzed (mean [±SD], gestational age: 25.1 [±1.1] wk; mean [±SD], birth weight: 756 [±144] g). Median sufentanil doses were significantly higher during epochs 1 and 2 (0.1 to 0.2 µg/kg/h) than during epoch 3 (0.03 to 0.04 µg/kg/h) (P<0.0001). EDIN (Echelle de Douleur et d'Inconfort du Nouveau-né) pain scores were mostly ≤4 throughout the study period and their changes over time were not contemporaneous with the reduction in sufentanil doses; they were lower during epoch 1 versus epochs 2 and 3 (P<0.0001) and comparable between epochs 2 and 3. Midazolam doses and paracetamol use were not higher during epoch 3 as compared with epochs 1 and 2. No difference in opioid-related adverse events was observed between the 3 epochs.

CONCLUSION

Our study supports the use of low continuous intravenous sufentanil doses, consistent with morphine doses currently recommended in this population.

Sedation and analgesia practices at Italian neonatal intensive care units: results from the EUROPAIN study

BACKGROUND

We aimed to examine current bedside analgesia/sedation (A/S) and pain assessment (PA) practices in Italian neonatal intensive care units (NICUs) in relation to the findings of an epidemiological European study and recently-introduced national guidelines.

METHODS

We analyzed the Italian data from the EUROPAIN (EUROpean-Pain-Audit-In-Neonates) prospective observational study on A/S practices that involved 6680 newborns admitted to tertiary-level NICUs in 18 European countries. Demographics, type of assisted ventilation, type and mode of A/S administration and PA were analyzed. Multivariate linear regression models were used to identify factors predicting A/S and PA practices.

RESULTS

From October 1st, 2012 to June 30th, 2013, thirty Italian NICUs gathered data on 422 newborn: 131 on invasive ventilation (IV); 150 on noninvasive ventilation (NIV); and 141 on spontaneous ventilation (SV). A/S was documented for 35.3% of all infants admitted (86.3% IV; 17.3% NIV; 7.1% SV [p = 0.0001]), and varied considerably between NICUs (as reported in other European countries). Strong analgesics were used in 32.5% of cases, sedatives in 10.2%, mild analgesics in 3.8%. Fentanyl was used in 78.6% of cases, morphine in 8.4%, neuromuscular blockers in 5.3%, midazolam in 22.1%. The performance of PA was documented in 67.5% of all newborn (85.5% IV; 67.3% NIV; 51.1% SV [p = 0.001]). Illness severity, type of ventilation, bedside PA, and number of NICU beds were all factors associated with A/S use on multivariate analysis, while gestational age ≤ 32 weeks, and type of ventilation and presence of a pain team were associated with PA.

CONCLUSIONS

We documented a generally widespread, but still highly variable use of A/S and PA at Italian NICUs, despite the diffusion of national guidelines. There is an urgent need to improve routine PA to enable customized pain and stress control (and prevention) in all infants.

TRIAL REGISTRATION

Clinical Trials.gov # NCT01694745 .

Original article. Nurse-controlled analgesia for postoperative pain in pediatric patients: effects on nurses’ attitudes and patient care

Background: Because of the limited number of patient-controlled analgesia (PCA) pumps in our developing country, we proposed a technique of modified nurse-controlled analgesia (NCA) to relieve postoperative pain in pediatric patients.

Objective: We assessed efficacy, safety, compliance by nurses, and satisfaction including parent satisfaction of a modified NCA protocol compared with fixed-dose analgesia conventionally used for postoperative pain relief in pediatric patients.

Methods: A prospective study design was conducted in pediatric patients who underwent major surgery in a university hospital. In the pre-NCA phase, patients received a conventional fixed-dose opioid after surgery. In the NCA phase, nurses could initiate two additional small doses autonomously, as prescribed, if the initial bolus was inadequate. Outcome measures were the number of moderate to severe pain scores, respiratory depression, compliance by nurses, and parent satisfaction.

Results: There were 117 and 113 patients in the pre-NCA and NCA phases, respectively. Detection of moderate to severe pain ≥2 episodes in 24 h after surgery was significantly higher in the NCA phase especially in moderate to severe pain procedures. Respiratory depression was not found in either phase. The majority of nurses showed positive attitudes to routine use of a modified NCA protocol. Parent satisfaction was high in both groups.

Conclusion: The attitude of nurses toward the modified NCA protocol was positive and it significantly increased detection of episodes of moderate to severe postoperative pain, which accordingly increased patient care and pain relief without severe untoward effects.

Narcotics and Sedative Use in Preterm Neonates

OBJECTIVES

To evaluate patterns of narcotic and sedative use in neonatal intensive care units (NICUs) across Canada using data collected by the Canadian Neonatal Network.

STUDY DESIGN

We conducted a retrospective observational cohort study of preterm neonates at <33 weeks' gestation and admitted to a participating Canadian Neonatal Network NICU. The proportion of all neonates who received sedative(s), narcotic(s), or either sedative(s), narcotic(s), or both during their NICU stay was calculated for each year. Because opioids are used for premedication before intubation, only continuous infusions of a narcotic drug were included. Variation in narcotics and sedative usage between sites in 2014 was determined using logistic regression analysis, with adjustment for gestational age, surgery, and mechanical ventilation.

RESULTS

Of 20 744 neonates, 29% of neonates received a narcotic, a sedative, or both; 23% received a narcotic and 17% a sedative. Although no clinically significant changes in drug exposure were documented during the 5-year period, there were statistically significant differences in narcotic and sedative use between sites, ranging from 3% to 41% for narcotic and 2% to 48% for sedative use (aORs 0.2-5.7 and 0.1-15, respectively, P < .05).

CONCLUSIONS

Exposure to narcotic or sedative agents is highly variable in preterm neonates across Canada despite concerns of adverse outcomes associated with these drugs. The tremendous variation in practice suggests that further research on their current usage, as well as identifying optimal practice procedures is warranted.

The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse's assessment of neonates

OBJECTIVE

To determine the reliability of an objective measure of pain, agitation and sedation using the Neonatal Pain, Agitation and Sedation Scale (N-PASS) compared with nursing bedside assessment.

STUDY DESIGN

Neonates admitted in neonatal intensive care unit over a 6-month period were eligible. Pain and sedation were assessed with N-PASS, and a subjective questionnaire was administered to the bedside nurse.

RESULT

A total of 218 neonates were eligible (median: gestational age 34.6 weeks, age at assessment 7 days). N-PASS pain score correlated significantly with both nurses' pain score (Spearman coefficient (r)=0.37; P<0.001) and agitation score (r=0.56; P<0.001). N-PASS sedation score correlated with nurses' sedation score (r=-0.39; P<0.001). Adjusting for gestational age, day of life, intrauterine drug exposure and use of high frequency ventilation only slightly attenuated the correlations (r=0.36, 0.55 and -0.31, respectively).

CONCLUSION

The N-PASS captures nursing assessment of pain, agitation and sedation in this broad population and provides a quantitative assessment of subjective descriptions that often drives patient therapy.

Pain management in newborns

As a standard of care for preterm/term newborns effective pain management may improve their clinical and neurodevelopmental outcomes. Neonatal pain is assessed using context-specific, validated, and objective pain methods, despite the limitations of currently available tools. Therapeutic approaches reducing invasive procedures and using pharmacologic, behavioral, or environmental measures are used to manage neonatal pain. Nonpharmacologic approaches like kangaroo care, facilitated tucking, non-nutritive sucking, sucrose, and others can be used for procedural pain or adjunctive therapy. Local/topical anesthetics, opioids, NSAIDs/acetaminophen and other sedative/anesthetic agents can be incorporated into NICU protocols for managing moderate/severe pain or distress in all newborns.

The addition of tramadol to the standard of i.v. acetaminophen and morphine infusion for postoperative analgesia in neonates offers no clinical benefit: a randomized placebo-controlled trial

BACKGROUND

Tramadol is used following neonatal cardiac and general surgery. However, its ability to opioid-spare or facilitate earlier extubation in postoperative neonates is unquantified.

OBJECTIVE

This randomized placebo-controlled trial aimed to assess whether tramadol's addition to standard analgesia resulted in earlier extubation or reduced analgesic/sedative requirements in postsurgical neonates.

METHODS

Neonates born ≥32 weeks postmenstrual age received either tramadol [T] 2 mg·kg(-1) or placebo [P] 6-hourly for up to 5 days postthoracoabdominal surgery in addition to morphine (commenced at 20 mcg·kg(-1) ·h(-1)) and 6-hourly i.v. acetaminophen. Time to extubation, morphine and midazolam amounts, hourly pain scores, and seizure activity were compared using an intention-to-treat and per-protocol analysis.

RESULTS

Seventy-one neonates participated. Median survival time to extubation was similar between the groups (T 67 h [95% CI 51, 84] vs P 52 h [95%CI 43, 65]; P = 0.4), and similar numbers were extubated by 96 h (T 69% vs P 77%; difference -8%, 95%CI -28, 13%). Morphine and midazolam exposure was similar, with low pain scores in both groups (mean percentage of time with a pain score >5/20 during the 5 days: T 13% vs P 11%, difference in means 2.8 [95% CI -1.8, 7.6], P = 0.20). Most participants had normal cranial ultrasounds (T 86% vs P 86%); no seizures occurred clinically or electroencephalographically.

CONCLUSION

Tramadol's addition to standard analgesia in this small group of postsurgical neonates did not appear to have any positive effect on time to extubation, morphine or midazolam exposure, or pain scores. This questions the benefit of tramadol for postsurgical neonates. Importantly, no seizures occurred in these ill neonates who may potentially be at greater risk of tramadol toxicity compared with adults.

Health care professionals' pain narratives in hospitalized children's medical records. Part 2: structure and content

BACKGROUND

Although clinical narratives - described as free-text notations--have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children's medical records.

OBJECTIVES

To describe the structure and content of health care professionals' narratives related to hospitalized children's acute pain.

METHODS

All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed.

RESULTS

Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care.

CONCLUSIONS

The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children's acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives' composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals' pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.

Pain assessment and intensity in hospitalized children in Canada

Numerous acute pediatric pain assessment measures exist; however, pain assessment is not consistently performed in hospitalized children. The objective of this study was to determine the nature and frequency of acute pain assessment in Canadian pediatric hospitals and factors influencing it. Pain assessment practices and pain intensity scores documented during a 24-hour period were collected from 3,822 children aged 0 to 18 years hospitalized on 32 inpatient units in 8 Canadian pediatric hospitals. Pain assessment was documented at least once within the 24 hours for 2,615/3,822 (68.4%) children; 1,097 (28.7%) with a pain measure alone, 1,006 (26.3%) using pain narratives alone, and 512 (13.4%) with both a measure and narrative. Twenty-eight percent of assessments were conducted with validated measures. The mean standardized pain intensity score was 2.6/10 (SD 2.8); however, 33% of the children had either moderate (4-6/10) or severe (7-10/10) pain intensity recorded. Children who were older, ventilated, or hospitalized in surgical units were more likely to have a pain assessment score documented. Considerable variability in the nature and frequency of documented pain assessment in Canadian pediatric hospitals was found. These inconsistent practices and significant pain intensity in one-third of children warrant further research and practice change.

PERSPECTIVE

This article presents current pediatric pain assessment practices and data on pain intensity in children in Canadian pediatric hospitals. These results highlight the variability in pain assessment practices and the prevalence of significant pain in hospitalized children, highlighting the need to effectively manage pain in this population.

Knowledge and attitudes regarding neonatal pain among nursing staff of pediatric department: an Indian experience

Neonates receiving care in intensive care units are highly likely to experience pain due to investigations and/or treatments carried out by the health care providers. Neonates are a vulnerable population because they are unable to vocalize their pain. Unaddressed and mismanaged pain can not only affect the child's comfort, but also may alter the development and cognitive abilities of the child in a later part of his/her life. Therefore it is entirely the caregiver's responsibility to accurately assess and manage neonatal pain. We assessed and compared the knowledge and attitudes regarding neonatal pain among the nurses posted in the various units of a pediatric department [pediatric ward, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU)]. An appropriately modified Knowledge and Attitudes Survey Regarding Pain questionnaire was consensually validated, pretested, and then administered to the nursing staff of the pediatric department at a department at a hospital in Gujarat. Data were entered in Epi-Info and analyzed with the use of SPSS 14.0. The questionnaire was administered to 41 nurses working in the Department of Pediatrics, and the response rate was 97.5%. Mean age of the nurses in the study sample was 25.75 years (SD 5.513). The mean total score of the participants was 8.75 out of 17 (SD 2.549), which was unsatisfactory. The mean correct answer rate was 49.67% among the staff of NICU and 48.67% among the pediatric ward and PICU staff. The attitudes among the nurses were assessed. It was concluded that the nurses lack knowledge and that their attitudes also were hindering pain management. One of the barriers identified by the nurses was that physicians do not prescribe analgesics for managing neonatal pain. So not only the nursing staff, but all of the caregivers involved in neonatal care may be lacking in knowledge and hold perceptions and attitudes that hamper neonatal pain management.

Fatores que influenciam a prática do profissional de saúde no manejo da dor do recém-nascido

OBJETIVO: Apresentar revisão sobre as principais variáveis que podem influenciar as ações e as atitudes dos profissionais de saúde no manejo adequado da dor no período neonatal. FONTES DOS DADOS: Pesquisa bibliográfica, nas bases de dados Medline, SciELO e Lilacs, entre 1995 e 2009, restrita aos artigos escritos em inglês e português. Foram utilizados os seguintes descritores: "dor", "Terapia Intensiva Neonatal" e "profissional de Saúde". Avaliaram-se 88 artigos, sem seleção pelo desenho, sendo incluídos os 55 mais relevantes e recentes. SÍNTESE DOS DADOS: Os estudos confirmaram que o manejo da dor no neonato pelos profissionais de saúde é inadequado. Essa prática pode estar relacionada aos seguintes fatores: conhecimento insuficiente quanto à fisiopatologia da dor; não utilização de métodos de avaliação; falta de normatização sistemática ou protocolos; e falha na comunicação e incorporação da teoria na prática diária por parte da equipe multiprofissional. São acrescidos ainda os fatores subjetivos, pessoais e profissionais, que podem interferir na avaliação e no tratamento da dor no recém-nascido. CONCLUSÕES: Os obstáculos para um manejo adequado da dor são multifatoriais e o conhecimento das atitudes e crenças das equipes de saúde que trabalham com neonatos é muito importante. Há necessidade de investimentos na capacitação, formação e sensibilização dos profissionais acerca do controle e do tratamento da dor, com o intuito de proporcionar um cuidado mais humanizado ao neonato.

The analgesic properties of intraoral sucrose: an integrative review

The treatment of pain is an essential component of the clinical and ethical care of infants. Despite evidence-based practice consensus statements recommending that infants receive analgesia during minor painful procedures, numerous studies have shown that procedural pain remains poorly managed in this population. Oral sucrose administration has been associated with calming effects and reductions in observed pain behaviors with preterm and term infants aged up to 1 year. The objective of this integrative review is to synthesize findings from published randomized controlled trials evaluating the efficacy and safety of oral sucrose as a preprocedural intervention for mild to moderate procedural pain in infants. Overall, studies indicate that oral sucrose is an effective, safe, convenient, and immediate-acting analgesic for reducing crying time and significantly decreases biobehavioral pain response following painful procedures with infants.

Pain management in Swedish neonatal units--a national survey

AIM

The aim of this study was to investigate the degree to which Swedish neonatal units have adopted the national guidelines for prevention and treatment of pain in newborn infants.

METHOD

A survey was sent to all units in Sweden that provide neonatal care. For a list of potentially painful procedures, compiled from the national neonatal pain guidelines, the units were asked if they would use pharmacological and/or behavioural interventions, and in each case to specify the treatment.

RESULTS

The response rate was 80.4%. Eighty-eight percent of the units had written guidelines for pain management, and 59% of these had been updated within the last 2 years. For almost every presented case, all units reported that they used either pharmacological or behavioural treatment or both. The survey showed a wide variation in morphine and paracetamol dosing and the absence of a paracetamol loading dose in a fourth of the units.

CONCLUSIONS

This study suggests that a majority of Swedish neonatal units have adopted pain management guidelines in concordance with the Swedish national guidelines, and kept them up-to-date. For most painful situations a variety of behavioural and pharmacological interventions are used, often in combination.

Pharmacological approaches to the management of pain in the neonatal intensive care unit

Effective and consistent management of neonatal pain remains a controversial issue. Premature infants are repeatedly subjected to painful tests and procedures or suffer painful conditions when they are most vulnerable. With different mechanisms transducing various types of pain the practice of 'one-drug fits all' becomes questionable. Clinicians must use the latest non-pharmacologic and pharmacologic therapies for effective management of neonatal pain, distress, or agitation. Pharmacologic strategies for dealing with neonatal pain in the neonatal intensive care unit are described. Opioid therapy, once considered the mainstay for neonatal analgesia, may not be as effective as previously thought. Morphine infusions do not alter the neurological outcomes of preterm neonates and may not be effective against acute pain. Alternative approaches with methadone, ketamine, or local anesthetics should be considered. Clinicians must understand the contextual circumstances underlying pain in individual neonates and tailor therapy accordingly, using the most current evidence related to neonatal pain assessment and management.