Evaluation and development of potentially better practices to improve pain management of neonates

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.

Practices of Procedural Pain Management in Neonates through Continuous Quality Improvement Measures

Objective

Although the benefits of pain control measures in neonates are well known, the actual usage was not optimal in our unit. Therefore, we implemented a quality improvement project to improve pain management practices through multiple Plan-Do-Study-Act (PDSA) cycles.

Method

Our project included hemodynamically stable newborns weighing ≥1300 g. We identified four common procedures: intravenous cannulation, venous sampling, heel prick, and nasogastric tube insertion. The selected pain control measures were skin-to-skin contact, breastfeeding, expressed breast milk orally, and oral sucrose. Between April 2019 and September 2019, we intervened multiple times and reassessed shortcomings. We encouraged evidence-based practices and gave solutions for shortcomings. Data were interpreted weekly to assess the compliance to pain control interventions.

Results

Minimal pain control measures (3-4%) were utilized for identified procedures before the project began. We could improve the use of pain control measures steadily and achieve the target of 80% of procedures after seven different interventions over five months. There was a retention of the effect on reassessing twice at second and fourth months of stopping further intervention once the target got achieved.

Conclusion

Quality Improvement science can identify the shortcomings and help to improve the compliance for pain control practices in neonates, as demonstrated in this neonatal unit.

Knowledge and Practice of Nurses and Associated Factors in Managing Neonatal Pain at Selected Public Hospitals in Addis Ababa, Ethiopia, 2020

Introduction

Hospitalized neonates experience moderate to severe, acute or chronic pain. Recent study indicates that health care providers especially in developing countries have a knowledge and skills gap related to neonatal pain management.

Objective

The aim of this study was to assess the neonatal ICU nurses’ knowledge and practice and factors associated with neonatal pain management at selected public hospital of Addis Ababa, Ethiopia.

Methods

Facility-based cross-sectional study design was employed at four selected public hospitals in Addis Ababa, from April to May 2020. A simple random sampling method was used to recruit study participants using a semi-structured and self-administered questionnaire. The logistic regression model was used to identify the association, and odds ratio was used to test the strength of the associations between outcome and predictor variables.

Results

This study was conducted with 119 nursing staffs working in the neonatal intensive care unit with a 96.6% response rate. The study reveals that 68.7% of nurses had adequate knowledge and only 32.2% of them had good practice of neonatal pain management. There was a significant relationship between nurses’ knowledge scores and receiving in-service training on neonatal pain management. Having an infant pain management policy in place, getting training on neonatal pain management and knowledge category were factors significantly associated with practice of nurses in neonatal pain management.

Discussion

According to the results of the current research, the majority (85.2%) of participants knew that the vital signs of new-borns can be affected by pain. However, only 60.9% of nurses considered pain as one of the vital signs in new-borns. This indicates that neonatal pain may not be assessed as frequently as a vital sign. And the finding reveals that nurses had poor practice but had adequate knowledge in managing neonatal pain. The respective hospitals and Ethiopian Ministry of Health should provide gap-filling training on neonatal pain management to the nurses.

A Comparison of Pain Scores in Neonatal Circumcision with or without Local Anesthesia in Jos, Nigeria

Introduction:

Neonatal circumcisions are commonly performed in Nigeria, most often without anesthesia. The aim of this study was to determine whether anesthesia was required for neonatal circumcision.

Materials and Methods:

All new-born male neonates presenting for routine circumcision were considered for inclusion in the study. This was a randomized control study, comparing pain scores during circumcision with local anesthesia or without local anesthesia. A total of 72 neonates were randomly assigned to the two groups using computer-generated random numbers, with 36 in each group. The neonates were not matched for age or weight. All the anesthetic procedures and circumcisions were performed in identical manner by the principal investigators using the plastic bell technique. Approval for the study was obtained from the Research Ethics Committee of the hospital. Written voluntary informed consent was obtained from the parents of the neonates.

Results:

The mean age and weight of the neonates in the study were 17 ± 2 days and 3.2 ± 0.68 kg, respectively. The mean Neonatal/Infant pain score was 4.8 in the local anesthesia group and 6.0 in those without anesthesia. The mean transcutaneous PO₂ was 90.47 ± 7.53 in those with anesthesia compared to 85.83 ± 5.61 in those without anesthesia. The mean heart rate was 133.88 ± 35.00 beats/min in the anesthesia group compared to 152.11 ± 79.80 in those without anesthesia. Neonates circumcised without local anesthesia had higher respiratory rate compared to those circumcised with local anesthesia.

Conclusion:

Neonates circumcised without local anesthesia had higher mean pain scores, heart rate, lower oxygen saturation and increased mean respiratory rate than those that had local anesthesia. Local anesthesia should be routinely used during neonatal circumcision.

Perceived maternal information on premature infant's pain during hospitalization: the French EPIPAGE-2 national cohort study

BACKGROUND

Parents of preterm neonates wish greater involvement in pain management; little is known about factors associated with this involvement. We aim to describe perceived maternal information on infants' pain during hospitalization (PMIP), to study associations between PMIP and mothers' attitudes during painful procedures, and to identify individual and contextual factors associated with PMIP.

METHODS

Analyses of questionnaires from the French national cohort study of preterm neonates, EPIPAGE-2. PMIP was derived from mothers' answers to questions about information perceived on both pain assessment and management.

RESULTS

Among 3056 eligible neonates born before 32 weeks, 1974, with available maternal reports, were included in the study. PMIP was classified as "sufficient," "little, not sufficient," or "insufficient, or none" for 22.7, 45.9, and 31.3% of neonates, respectively. Mothers reporting PMIP as "sufficient" were more frequently present and more likely comforting their child during painful procedures. Factors independently associated with "sufficient" PMIP were high maternal education, gestational age <29 weeks, daily maternal visits, perception of high team support, and implementation of the neonatal and individualized developmental care and assessment program.

CONCLUSION

Perceived maternal information on premature infants' pain reported as sufficient increased maternal involvement during painful procedures and was associated with some units' policies.

Promoting developmental supportive care in preterm infants and families in a level III neonatal intensive care unit (NICU) setting in India

Despite evidence of short- and long-term benefits of developmental care, several studies have documented nurses' lack of knowledge and skills related to developmental care concepts. This study aims to enhance neonatal nurses' abilities to acquire care practices (knowledge and skills) regarding Developmental Supportive Care (DSC). A nonrandomized before and after intervention design was adopted to improve the knowledge and skills of staff nurses in DSC practices for preterm infants in Level III B NICU. The study included 50 level III B NICU nurses (25 in interventional group, 25 in control group) located within a tertiary care hospital in India. A significant increase in the mean knowledge score was seen among participants in the intervention group (pre-test: 16.6 ± 3.1, post-test: 29.9 ± 4.1, p = 0.01) but not in the control group (pre: 16.4 ± 2.2, post: 18.6 ± 3.6, p = 0.98). The improvement in the skills of providing DSC among neonatal nurses was also higher in the intervention group (106.4 ± 7.4) relative to the control group (65.8 ± 3.6), p < 0.01, at 0.05 level of significance. The Developmental Supportive Care Program (DSCP) had a significant impact in improving the knowledge and skills of nurses in providing care and preventing complications in preterm infants.

Neuroprotective Care of Extremely Preterm Infants in the First 72 Hours After Birth

Birth at extremely low gestational ages presents a significant threat to infants' survival, health, development, and future well-being. After birth, a critical period of brain development must continue outside the womb. Neuro-supportive and neuroprotective family centered developmental care for and standardized care practices for extremely preterm infants have been shown to improve outcomes. Neuroprotective interventions must include a focus on the emotional connections of infants and their families. Being in skin-to-skin contact with the mother is the developmentally expected environment for all mammals and is especially important for supporting physiologic stability and neurodevelopment of preterm infants.

Quality pharmacy services and key performance indicators in Polish NICUs: a Delphi approach

Background Currently, there is no literature describing what a quality level of practice entails in Polish neonatal intensive care units (NICUs), nor are there any means of currently measuring the quality of pharmaceutical care provided to NICU patients. Objective To identify a set of essential pharmacist roles and pharmacy-relevant key performance indicators (KPI's) suitable for Polish neonatal intensive units (NICUs). Setting Polish hospital pharmacies and NICUs. Method Using a modified Delphi technique, potential KPI's structured along Donabedian's domains as well as pharmacy services were presented to an expert panel of stakeholders. Two online, consecutive Delphi rounds, were completed by panellists between August and September 2017. Main outcome measure To identify the minimum level of pharmacy services that should be consistently provided to NICU patients. Results A total of 16 panellists contributed to the expert panel. Overall, consensus of 75% was reached for 23 indicators and for 28 roles. When considering pharmacy services for the NICU, the experts were found to highly value traditional pharmacy roles, such as dispensing and extemporaneous compounding, however, they were still eager for roles in the other domains, such as educational and clinical services, to be listed as essential for NICU practice. Panellists were found to positively value the list of indicators presented, and excluded only 9 out of the total list. Conclusion There is a need for future research to establish a minimum standard of practice for Polish pharmacists to encourage the progression and standardisation of hospital pharmacy services to meet the level of practice seen in NICUs worldwide.

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.

A Quality Improvement Collaborative Program for Neonatal Pain Management in Japan

BACKGROUND

Neonatal pain management guidelines have been released; however, there is insufficient systematic institutional support for the adoption of evidence-based pain management in Japan.

PURPOSE

To evaluate the impact of a collaborative quality improvement program on the implementation of pain management improvements in Japanese neonatal intensive care units (NICUs).

METHODS

Seven Japanese level III NICUs participated in a neonatal pain management quality improvement program based on an Institute for Healthcare Improvement collaborative model. The NICUs developed evidence-based practice points for pain management and implemented these over a 12-month period. Changes were introduced through a series of Plan-Do-Study-Act cycles, and throughout the process, pain management quality indicators were tracked as performance measures. Jonckheere's trend test and the Cochran-Armitage test for trend were used to examine the changes in quality indicator implementations over time (baseline, 3 months, 6 months, and 12 months).

FINDINGS

Baseline pain management data from the 7 sites revealed substantial opportunities for improvement of pain management, and testing changes in the NICU setting resulted in measurable improvements in pain management. During the intervention phase, all participating sites introduced new pain assessment tools, and all sites developed electronic medical record forms to capture pain score, interventions, and infant responses to interventions.

IMPLICATIONS FOR PRACTICE

The use of collaborative quality improvement techniques played a key role in improving pain management in the NICUs.

IMPLICATIONS FOR RESEARCH

Collaborative improvement programs provide an attractive strategy for solving evidence-practice gaps in the NICU setting.

Neurobiological Consequences of Early Painful Experience: Basic Science Findings and Implications for Evidence-Based Practice

As healthcare teams have worked to improve infant survival rates, the management of painful events experienced by these hospitalized neonates has increased and yet pain management remains highly variable between healthcare institutions. At the same time, emerging evidence suggests that these early painful experiences may alter the trajectory of development for pain-processing pathways both peripherally and centrally. This concise review highlights findings from both the basic and clinical science literature supporting the hypothesis that early painful experiences can have long-lasting negative effects on biological, psychological, and socioemotional functions. Implications for pain management in neonates and considerations for evidence-based practice change are discussed.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

Administration of oral sucrose with and without non-nutritive sucking is the most frequently studied non-pharmacological intervention for procedural pain relief in neonates.

OBJECTIVES

To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin - TcpO2, TcpCO2), near infrared spectroscopy (NIRS), electroencephalogram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long-term neurodevelopmental outcomes.

SEARCH METHODS

We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016). We did not impose language restrictions.

SELECTION CRITERIA

RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture.

DATA COLLECTION AND ANALYSIS

Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I(2) test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system.

MAIN RESULTS

Seventy-four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta-analyses and for most analyses the GRADE assessments indicated low- or moderate-quality evidence. There was high-quality evidence for the beneficial effect of sucrose (24%) with non-nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD -1.70 (95% CI -2.13 to -1.26; I(2) = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD -2.14 (95% CI -3.34 to -0.94; I(2) = 0% (no heterogeneity; 2 studies, n = 164). There was high-quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD -2.79 (95% CI -3.76 to -1.83; I(2) = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD -1.05 (95% CI -1.98 to -0.12; I(2) = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan-analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long-term neurodevelopmental outcomes are unknown.

AUTHORS' CONCLUSIONS

Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate-quality evidence that sucrose in combination with other non-pharmacological interventions such as non-nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long-term (neurodevelopmental) outcomes.

A Guide to Pain Assessment and Management in the Neonate

Newborn infants experience acute pain with various medical procedures. Evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes. Multiple validated scoring systems exist to assess pain in a neonate; however, there is no standardized or universal approach for pain management. Healthcare facilities should establish a neonatal pain control program. The first step is to minimize the total number of painful iatrogenic events when possible. If a procedure cannot be avoided, a tiered approach to manage pain using environmental, non-pharmacologic, and pharmacologic modalities is recommended. This systematic approach should decrease acute neonatal pain, poor outcomes, and provider and parent dissatisfaction.

Standardizing morphine use for ventilated preterm neonates with a nursing-driven comfort protocol

OBJECTIVE

To test whether implementing a nursing-driven comfort protocol standardizes morphine use in one neonatal intensive care unit (NICU) and to examine how non-standard morphine (N-SM) relates to days of ventilation, days of total parenteral nutrition (TPN) and length of stay (LOS).

STUDY DESIGN

This was a retrospective/prospective observational study using pharmacy records, medical records, and an outcomes database. Comfort protocol implementation began February 2011 and was applied to preterm, ventilated neonates <1500 grams. Pre- and post-implementation proportions of N-SM days were compared using the binomial test. A percent 'P'-chart spanning 30 quarters was constructed with statistical-process control analysis. Multivariable linear regression adjusting for acuity assessed the relationship between N-SM use and days of ventilation, TPN and LOS.

RESULT

Hundred and thirty-four patients met inclusion criteria, 116 prior to and 18 after implementation. The proportion of patients given N-SM for one or more days decreased from 59 to 35% after protocol implementation (P = 0.017). A 9-month period of decreased N-SM days was observed after protocol implementation. Controlling for acuity, each additional day of N-SM use was associated with 0.47 more days of ventilation (95% confidence interval (CI): 0.26-0.69, P < 0.001) and 0.52 more days of TPN (95% CI: 0.35-0.68, P < 0.001). Exposure to N-SM was associated with 17 additional days of hospitalization (P = 0.009, 95% CI: 4.5-30).

CONCLUSION

Implementing a nursing-driven comfort protocol significantly reduced N-SM use. N-SM in the NICU is negatively associated with key clinical outcomes. Testing similar protocols in other settings is warranted.

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.

Knowledge, attitudes and practices of neonatal staff concerning neonatal pain management

BACKGROUND

Neonatal pain management has received increasing attention over the past four decades. Research into the effects of neonatal pain emphasises the professional, ethical and moral obligations of staff to manage pain for positive patient outcomes. However, evaluation studies continuously report evidence of inadequate neonate pain management and a gap between theory and practice.

OBJECTIVE

This study reviewed current practice in neonatal pain management to describe the knowledge, attitudes and practices of nurses and doctors regarding pain management for neonates in two academic hospitals.

METHOD

A non-experimental, prospective quantitative survey, the modified Infant Pain Questionnaire, was used to collect data from 150 nurses and doctors working in the neonatal wards of two academic hospitals in central Gauteng.

RESULTS

The response rate was 35.33% (n=53), most respondents being professional nurses (88.68%; n=47) working in neonatal intensive care units (80.77%; n=42); 24 (45.28%) had less than 5 years' and 29 respondents 6 or more years' working experience in neonatal care. A review of pain management in the study setting indicated a preference for pharmacological interventions to relieve moderate to severe pain. An association (p<0.05) was found between pain ratings on 5 procedures and frequency of administration of pharmacological pain management. Two-thirds of respondents (64%) reported that there were no pain management guidelines in the neonatal wards in which they worked.

CONCLUSION

The interventions to manage moderate neonatal pain are in line with international guidelines. However, neonatal pain management may not occur systematically based on prior assessment of neonatal pain, choice of most appropriate intervention and evaluation. This study recommends implementation of a guideline to standardise practice and ensure consistent and adequate pain management in neonates.

Pain in the neonate: focus on nonpharmacologic interventions

The assessment and treatment of pain in the neonate, especially preterm neonates, has been a challenge in the NICU for many years. Nurses caring for these vulnerable patients are in a key position to not only recognize when the neonate is experiencing pain but to also work collaboratively with other health care providers in determining the best method to treat and help prevent pain associated with procedures and routine caregiving activities. The American Academy of Pediatrics along with parent groups has recognized the importance of pain-prevention programs in treating pain in the neonate. Nurses, by anticipating and reducing both painful procedures and bedside interruptions, along with innovative nonpharmacologic interventions, can dramatically decrease the neonate's exposure to pain and the potential for long-term effects. An overview of nonpharmacologic interventions in the treatment of neonatal pain is provided for NICU nurses to help them effectively reduce their patient's pain and discomfort.

The case for quality improvement in the Neonatal Intensive Care Unit

Quality improvement (QI) is now a central part of the work of clinicians throughout healthcare. It is based on clear scientific principles, a valid way of measuring change and has theories of reliability and human factors that underpin the interventions. The Neonatal Intensive Care Unit (NICU) is a highly complex adaptive system that lends itself to the application of QI principles. This will require the development of a safety culture that continually seeks to improve. Clinicians and all those who work in NICU will require training in the methodologies of QI and patient safety to effect change. Working together in collaborative networks can accelerate change. In this paper we discuss some of the key concepts and provide some examples of improvement in the NICU.

Improving pain assessment in the NICU: a quality improvement project

Pain assessment documentation was inadequate because of the use of a subjective pain assessment strategy in a tertiary level IV neonatal intensive care unit (NICU). The aim of this study was to improve consistency of pain assessment documentation through implementation of a multidimensional neonatal pain and sedation assessment tool. The study was set in a 60-bed level IV NICU within an urban children's hospital. Participants included NICU staff, including registered nurses, neonatal nurse practitioners, clinical nurse specialists, pharmacists, neonatal fellows, and neonatologists. The Plan Do Study Act method of quality improvement was used for this project. Baseline assessment included review of patient medical records 6 months before the intervention. Documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment were reviewed. Literature review and listserv query were conducted to identify neonatal pain tools. Survey of staff was conducted to evaluate knowledge of neonatal pain and also to determine current healthcare providers' practice as related to identification and treatment of neonatal pain. A multidimensional neonatal pain tool, the Neonatal Pain, Agitation, and Sedation Scale (N-PASS), was chosen by the staff for implementation. Six months and 2 years following education on the use of the N-PASS and implementation in the NICU, a chart review of all hospitalized patients was conducted to evaluate documentation of pain assessment on admission, routine pain assessment, reassessment of pain after an elevated pain score, discussion of pain in multidisciplinary rounds, and documentation of pain assessment in the medical progress note. Documentation of pain scores improved from 60% to 100% at 6 months and remained at 99% 2 years following implementation of the N-PASS. Pain score documentation with ongoing nursing assessment improved from 55% to greater than 90% at 6 months and 2 years following the intervention. Pain assessment documentation following intervention of an elevated pain score was 0% before implementation of the N-PASS and improved slightly to 30% 6 months and 47% 2 years following implementation. Identification and implementation of a multidimensional neonatal pain assessment tool, the N-PASS, improved documentation of pain in our unit. Although improvement in all quality improvement monitors was noted, additional work is needed in several key areas, specifically documentation of reassessment of pain following an intervention for an elevated pain score.

[Analgesia and sedation during placement of peripherally inserted central catheters in neonates]

This study aimed to characterize the analgesia and sedation strategies in neonates having a peripherally inserted central catheter (PICC) placed, and to relate it to the number of venipunctures, duration of procedure and catheter tip position. This was a cross-sectional study with prospective data collection, conducted in a neonatal intensive care unit of a private hospital in the city of São Paulo, during the period from August 31, 2010 to July 1, 2011, which evaluated 254 PICC insertions. The adoption of analgesic or sedative strategies occurred in 88 (34.6%) catheter placements and was not related to the number of venipunctures, duration of procedure or catheter tip position. Intravenous administration of midazolam, in 47 (18.5%), and fentanyl, in 19 (7.3%), catheter insertions were the most frequent strategies. Wider adoption of analgesic strategies is recommended before, during and after the procedure.

Premedication for neonatal endotracheal intubation: results from the epidemiology of procedural pain in neonates study

OBJECTIVES

To describe the frequency and nature of premedications used prior to neonatal endotracheal intubation; to confront observed practice with current recommendations; and to identify risk factors for the absence of premedication.

DESIGN, SETTING, AND PATIENTS

Data concerning intubations were collected prospectively at the bedside as part of an observational study collecting around-the-clock data on all painful or stressful procedures performed in neonates during the first 14 days of their admission to 13 tertiary care units in the region of Paris, France, between 2005 and 2006.

INTERVENTION

Observational study.

MEASUREMENTS AND MAIN RESULTS

Specific premedication prior to endotracheal intubation was assessed. Ninety one intubations carried out on the same number of patients were analyzed. The specific premedication rate was 56% and included mostly opioids (67%) and midazolam (53%). Compared with recent guidance from the American Academy of Pediatrics, used premedications could be classified as "preferred" (12%), "acceptable" (18%), "not recommended" (27%), and "not described" (43%). In univariate analysis, infants without a specific premedication compared with others were younger at the time of intubation (median age: 0.7 vs. 2.0 days), displayed significantly more frequent spontaneous breathing at the time of intubation (31% vs. 12%) and a higher percentage of analgesia for all other painful procedures (median values: 16% vs. 6%). In multivariate analysis, no factor remained statistically significant.

CONCLUSIONS

Premedication use prior to neonatal intubation was not systematically used and when used it was most frequently inconsistent with recent recommendations. No patient- or center-related independent risk factor for the absence of premedication was identified in this study.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

Administration of oral sucrose with and without non-nutritive sucking is the most frequently studied non-pharmacological intervention for procedural pain relief in neonates.

OBJECTIVES

To determine the efficacy, effect of dose and safety of oral sucrose for relieving procedural pain in neonates.

SEARCH METHODS

We used the standard methods of the Cochrane Neonatal Review Group. Electronic and manual searches were performed in November 2011 for published randomised controlled trials (RCTs) in MEDLINE (1950 to November 2011), EMBASE (1980 to 2011), CINAHL (1982 to November 2011) and the Cochrane Central Register of Controlled Trials (The Cochrane Library). We did not impose language restrictions.

SELECTION CRITERIA

RCTs in which term, preterm, or both term and preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age) received sucrose for procedural pain. Control conditions included no treatment, water, pacifier, positioning/containing or breastfeeding.

DATA COLLECTION AND ANALYSIS

Main outcome measures were physiological, behavioural, or both pain indicators with or without composite pain scores. A mean difference (MD) with 95% confidence intervals (CI) using the fixed-effect model was reported for continuous outcome measures. Trial quality was assessed as per The Cochrane Collaboration

MAIN RESULTS

Fifty-seven studies enrolling 4730 infants were included. Results from only a few studies could be combined in meta-analyses. When Premature Infant Pain Profile (PIPP) scores were pooled, sucrose groups had significantly lower scores at 30 seconds (weighted mean difference (WMD) -1.76; 95% CI -2.54 to - 0.97; 4 trials; 264 neonates] and 60 seconds (WMD -2.05; 95% CI -3.08 to -1.02; 3 trials' 195 neonates) post-heel lance. For retinopathy of prematurity (ROP) examinations, sucrose did not significantly reduce PIPP scores (WMD -0.65; 95% CI -1.88 to 0.59; 3 trials; 82 neonates). There were no differences in adverse effects between sucrose and control groups. Sucrose significantly reduced duration of total crying time (WMD -39 seconds; 95% CI -44 to -34; 2 trials; 88 neonates), but did not reduce duration of first cry during heel lance (WMD -9 seconds; 95% CI -20 to 2; 3 trials; 192 neonates). Oxygen saturation (%) was significantly lower in infants given sucrose during ROP examination compared to controls (WMD -2.6; 95% CI -4.9 to - 0.2; 2 trials; 62 neonates). Results of individual trials that could not be incorporated in meta-analyses supported these findings. The effects of sucrose on long-term neurodevelopmental outcomes are unknown.

AUTHORS' CONCLUSIONS

Sucrose is safe and effective for reducing procedural pain from single events. An optimal dose could not be identified due to inconsistency in effective sucrose dosage among studies. Further investigation on repeated administration of sucrose in neonates and the use of sucrose in combination with other non-pharmacological and pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long-term (neurodevelopmental) outcomes.

Implementation of a neonatal pain management module in the computerized physician order entry system

BACKGROUND

Despite the recommended guidelines, the neonatal management of pain and discomfort often remains inadequate. The purpose of the present study was to determine whether adding a pain and discomfort module to a computerized physician order entry (CPOE) system would improve pain and discomfort evaluation in premature newborns under invasive ventilation.

METHODS

All newborns <37 weeks gestational age (GA) and requiring invasive ventilation were included in a prospective study during two 6-month periods: before and after the inclusion of the pain and discomfort evaluation module. The main outcome measure was the percentage of patients having at least one assessment of pain and discomfort per day of invasive ventilation using the COMFORT scale.

RESULTS

A total of 122 patients were included: 53 before and 69 after the incorporation of the module. The mean age was 30 (3) weeks GA. After the module was included, the percentage of patients who benefited from at least one pain and discomfort assessment per day increased from 64% to 88% (p < 0.01), and the mean number (SD) of scores recorded per day increased from 1 (1) to 3 (1) (p < 0.01). When the score was not within the established range, the nursing staff adapted analgesia/sedation doses more frequently after module inclusion (53% vs. 34%, p < 0.001). Despite higher mean doses of midazolam after module introduction [47 (45) vs. 31 (18) μg/kg/hr, p < 0.05], the durations of invasive ventilation and hospital stay, and the number of nosocomial infections, were not significantly modified.

CONCLUSIONS

Adding a pain and discomfort tool to the CPOE system was a simple and effective way to improve the systematic evaluation of premature newborns who required ventilatory assistance.

Participation in medical research; a systematic review of the understanding and experience of children and adolescents

OBJECTIVE

To systematically review the state of knowledge regarding the understanding and experience of psychological burden and risk of children and adolescents who participate in medical research. Further to provide recommendations to maximize understanding and minimize the burden and risk.

METHODS

Studies were selected that focus on children and adolescents as source of information via PubMed and PsycINFO; search terms were medical research or trial or experiment, child or adolescent, non-therapeutic, therapeutic, psychology, consent or understanding, risk, burden or stress.

RESULTS

Of 413 abstracts identified, ten studies on understanding and eight on the experience of burden and risk met our selection criteria. Overall, understanding of the study purpose was reasonable, but low for the procedure. Understanding increased with age and appeared to be overestimated by the young participants. Research on experience of burden was scarce, but identified invasive procedures and procedures related to sexual development as the most burdensome. Only one study assessed psychological risks.

CONCLUSION

Systematic evidence should be collected on the various aspects of medical procedures related to the experienced burden and risk. This will be useful in informing children and adolescents, parents and medical ethical committees.

Effect of liposomal lidocaine and sucrose alone and in combination for venipuncture pain in newborns

OBJECTIVE

To determine the relative effectiveness of liposomal lidocaine, sucrose, and their combination for reducing pain in term newborns.

METHODS

Ours was a double-blind, randomized, controlled, double-dummy trial of 330 healthy term newborns. Before venipuncture for the newborn screening test, neonates received (1) 1 g of liposomal lidocaine cream topically, (2) 2 mL of 24% sucrose solution orally, or (3) sucrose and liposomal lidocaine. The facial grimacing score (0-100) was used to assess pain. Adverse events and lidocaine levels were used to assess safety.

RESULTS

Infant characteristics did not differ among groups. Facial grimacing scores were lower in the sucrose group compared with those in the liposomal lidocaine group (mean difference: -27 [95% confidence interval (CI): -36 to -19; P < .001) and for the sucrose plus liposomal lidocaine group compared with those in the liposomal lidocaine group (mean difference: -23 [95% CI: -31 to -14]; P < .001). The sucrose and sucrose plus liposomal lidocaine groups did not differ (mean difference: -5 [95% CI: -13 to 4]; P = .3). Local skin reactions were not observed, and the incidence of spitting up did not differ between sucrose-exposed and non-sucrose-exposed infants (1.4% vs 2.7%, respectively; P = .22). The mean (SD) plasma lidocaine level was 44.6 (55.3) ng/mL.

CONCLUSIONS

Sucrose was more effective than liposomal lidocaine for reducing pain during venipuncture in newborns. The addition of liposomal lidocaine to sucrose did not confer any additional benefit to sucrose alone. There was no evidence of harm from liposomal lidocaine or sucrose.

Closing the evidence-practice gap for newborn pain using clinical networks

AIM

The Australian New Zealand Neonatal Network undertook a project to close the evidence practice gap for the management of newborn pain in neonatal units within Australia. The aim was to establish a process for using evidence to support practice change and in doing so close the existing practice evidence gap for newborn pain.

METHOD

An implementation model using a clinical network with state facilitators, local champions and project teams was used in 24 tertiary units and six district hospitals throughout Australia. The process included audit and feedback, benchmarking, educational workshops on critical appraisal and audit of family awareness of pain. Multiple types of data were collected to enable changes in practices for pain management to be evaluated.

RESULTS

There was a 21% overall improvement in the number of infants receiving breastfeeding or sucrose for procedural pain, however, breastfeeding rates remain poorly utilised. The use of a pain assessment tool increased from 14% to 22%, with 56% of units introducing the use of an assessment tool into their practice. Families became more aware that their infant can experience pain and strategies to manage the pain (from 19% to 57%) project through distribution of information.

CONCLUSION

The networks for the uptake of evidence program have enabled the topic of procedure pain in neonates to be evaluated. We have shown that through a well planned program of coordination, facilitation and using local champions and project teams a change in practice can occur.

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

Title

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice.

Aim

This paper is a discussion of evidence-based core measures for developmental care in neonatal intensive care units.

Background

Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease- and procedure-independent measures based on the Universe of Developmental Care model.

Data sources

Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue.

Discussion

Five core measure sets for evidence-based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family-centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant-family dyads.

Conclusion

Standardized disease-independent core measures for developmental care establish minimum evidence-based practice expectations and offer an objective basis for cross-institutional comparison of developmental care programmes.

NICU practices and outcomes associated with 9 years of quality improvement collaboratives

OBJECTIVE

Quality improvement collaboratives (QICs) can improve short-term outcomes, but few have examined their long-term results. This study evaluated the changes in treatment practices and outcomes associated with participation in multiple sequential QICs.

DESIGN AND METHODS

This retrospective, 9-year, pre-post study of very low birth weight infants, we assessed treatment and outcomes from the 8 NICUs of the Reduce Lung Injury (ReLI) group of a QIC sponsored by the Vermont Oxford Network (VON). We analyzed data from 1998 (pre-ReLI), 2001 (last ReLI year), and 2006 (5 years after ReLI) by using univariate and multiple regression.

RESULTS

A total of 4065 very low birth weight infants were treated in ReLI NICUs in 1998, 2001, and 2006. From 1998 to 2006, the ReLI group decreased delivery room intubation (70% vs 52%; adjusted odds ratio [aOR]: 0.2 [95% confidence interval (CI): 0.2-0.3]; P < .001), conventional ventilation (75% vs 62%; aOR: 0.3 [95% CI: 0.2-0.4]; P < .001), and postnatal steroids for BPD (35% vs 10%; aOR: 0.09 [95% CI: 0.07-0.1]; P < .001). They increased the use of nasal continuous positive airway pressure (57% vs 78%; aOR: 3.3 [95% CI: 2.7-3.9]; P < .001). BPD-free survival remained unchanged (68% vs 66%; aOR: 0.9 [95% CI: 0.7-1.1]; P = .16), the BPD rate increased (25% vs 29%; aOR: 1.3 [95% CI: 1.1-1.6]; P = .017), survival to discharge increased (90% vs 93%; aOR: 1.5 [95% CI: 1.1-2.2]; P < .001), and nosocomial infections decreased (18% vs 15%; aOR: 0.8 [95% CI: 0.6-0.99]; P = .045).

CONCLUSIONS

Participation in VON-sponsored QICs was associated with sustained implementation of potentially better respiratory practices, increased survival, and reduced nosocomial infections. The BPD-free survival rate did not change, and the BPD rate increased. Implemented changes endured for at least 5 years after the QIC.

Implementation of a multidisciplinary guideline-driven approach to the care of the extremely premature infant improved hospital outcomes

AIM

To test the hypothesis that implementing guidelines for the standardized care of the extremely premature infant (<27 weeks) in the first week of life would improve patient outcomes in an all referral NICU.

METHODS

Data were collected on all infants <27 weeks gestational age and <7 days of age on admission cared for using these small baby guidelines (SBG), as well as on all age-matched infants admitted the year prior (comparison).

RESULTS

Thirty-seven patients were cared for utilizing the SBG and 40 patients were in the comparison group. There were no differences between the groups in gestational age, birthweight or age on admission. There was no difference in survival to discharge (73% SBG, 70% comparison). The mean length of stay for survivors was 112 +/- 38 days SBG and 145 +/- 76 days (p < 0.05) comparison group. Survival without BPD was greater in the SBG group (24%) than in the comparison group (9%; p < 0.05), and survival without severe IVH was greater in the SBG group (65%) than in the comparison group (38%; p < 0.01).

CONCLUSIONS

These data demonstrate that applying a unified approach to the care of the extremely premature infant in the first week of life resulted in a decrease in the length of hospitalization and improved patient outcomes.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

Administration of oral sucrose with and without non-nutritive sucking is frequently used as a non-pharmacological intervention for procedural pain relief in neonates.

OBJECTIVES

To determine the efficacy, effect of dose and safety of oral sucrose for relieving procedural pain in neonates.

SEARCH STRATEGY

The standard methods of the Cochrane Neonatal Collaborative Review Group were used.

SELECTION CRITERIA

Randomized controlled trials in which term and/or preterm neonates (postnatal age maximum of 28 days corrected for postmenstrual age) received sucrose for procedural pain. Control conditions included water, pacifier, positioning/containing or breastfeeding.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological and/or behavioural pain indicators and/or composite pain scores. A weighted mean difference (WMD) with 95% confidence intervals (CI) using the fixed effects model was reported for continuous outcome measures.

MAIN RESULTS

Forty-four studies enrolling 3,496 infants were included. Results from only a few studies could be combined in meta-analyses. Sucrose significantly reduced duration of total crying time (seconds) [WMD -39.26 (95% CI -44.29, -34.24), 88 neonates], but did not reduce duration of first cry (seconds) during heel lance [WMD -8.99 (95% CI -20.07, 2.10), 192 neonates]. No significant differences were found for percent change in heart rate from baseline at one minute [WMD 0.90 (95% CI -5.81, 7.61), 86 neonates] and three minutes [WMD -6.20 (95% CI -15.27, 2.88), 86 neonates] post-heel lance, or for mean heart rate at three minutes post-heel lance [WMD -0.98 (95% CI -8.29, 6.32), 154 neonates]. Oxygen saturation (%) was significantly lower in infants given sucrose during ROP examination compared to controls [WMD -2.58 (95% CI -4.94, - 0.23), 62 neonates]. Infants given sucrose post-heel lance had significantly lower PIPP scores at 30 seconds [WMD -1.64 (95% CI -2.47, - 0.81), 220 neonates] and 60 seconds [WMD -2.05 (95% CI -3.08, -1.02), 195 neonates]. For ROP exams, sucrose did not significantly reduce PIPP scores [WMD -0.65 (95% CI -1.88, 0.59), 82 neonates]. There were no differences in adverse effects between sucrose and control groups.

AUTHORS' CONCLUSIONS

Sucrose is safe and effective for reducing procedural pain from single events. An optimal dose could not be identified due to inconsistency in effective sucrose dosage among studies.Further investigation on repeated administration of sucrose in neonates and the use of sucrose in combination with other non-pharmacological (e.g. behavioural, physical) and pharmacologic interventions is needed. Sucrose use in extremely low birth-weight and unstable and/or ventilated neonates needs to be addressed.

Exploring barriers to pain management in newborn intensive care units: a pilot survey of NICU nurses

PURPOSE

To explore barriers that NICU nurses face when attempting to optimally manage newborn pain.

SUBJECTS

Ninety California NICU nurses with current membership in the National Association of Neonatal Nurses (NANN) voluntarily participated.

DESIGN

A descriptive survey study.

METHODS

A researcher-developed survey consisting of 37 questions was mailed to 300 NICU nurses; 102 were returned and 90 were usable. Probability sampling from a listing of California registered nurses with current membership in the NANN was used to obtain the study's sampling frame.

PRINCIPAL RESULTS

Less than half of the nurses felt that newborn pain is well managed within the NICUs where they are employed. Barriers identified related to physicians' pain management practices, lack of evidence-based pain management protocols, nurses' and physicians' resistance to change practice, infant pain assessment tools, and inadequate staff training regarding pain assessment and management.

CONCLUSION

A knowledge-practice gap still exists within newborn pain management. Increased caregiver education remains a necessity, but strategies that address resistance to change practice within healthcare settings must also be considered.

Clinical practice: analgesia in neonates

Effective management of pain remains an important indicator of the quality of care provided to neonates. Since the review of McIntosh in this journal over a decade ago, an extensive number of papers on assessment, prevention, and treatment of pain have been reported. In addition, preclinical insights into neurodevelopmental aspects of pain processing and the neuro-apoptotic effects of analgesics and sedatives were unveiled. Based on the newly collected evidence, the practice of "one-drug, one dose and one treatment fits all" became obsolete, necessitating a more individualized analgesia, based on non-pharmacological and pharmacological therapies and preventive strategies for effective management of neonatal pain. The progress made is impressive, but the current major challenge is to implement the available knowledge in clinical care. Future research should therefore focus on the evaluation of the effectiveness of non-opioid and moderately potent opioids compared to morphine and should also describe the methods to facilitate effective implementation. Finally, there is an extensive field of procedural techniques that need to be evaluated on their pain related response.

Anaesthesia and analgesia: contribution to surgery, present and future

Anaesthetists provide comprehensive perioperative medical care to patients undergoing surgical and diagnostic procedures, including postoperative intensive care when needed. They are involved in the management of perioperative acute pain as well as chronic pain. This manuscript considers some of the recent advances in modern anaesthesia and their contribution to surgery, from the basic mechanisms of action, to the delivery systems for general and regional anaesthesia, to the use of new drugs and new methods of monitoring. It assesses the resulting progress in acute and chronic pain services and looks at patient safety and risk management. It speculates on directions that may shape its future contributions to the management of the patient undergoing surgery.

Non-pharmacological techniques for pain management in neonates

Significant progress in understanding the physiology, clinical correlates, and consequences of neonatal pain have resulted in greater attention to pain management during neonatal intensive care. A number of nonpharmacological therapies have been investigated, including nonnutritive sucking, with and without sucrose use, swaddling or facilitated tucking, kangaroo care, music therapy, and multi-sensorial stimulation. Although the efficacy of these approaches is clearly evident, they cannot provide analgesia for moderate or severe pain in the neonate. Further, some of these therapies cannot be effectively applied to all populations of critically ill neonates. Acupuncture, an ancient practice in Chinese medicine, has gained increasing popularity for symptom control among adults and older children. Acupuncture may provide an effective nonpharmacological approach for the treatment of pain in neonates, even moderate or severe pain, and should be considered for inclusion in a graduated multidisciplinary algorithm for neonatal pain management.

Implementation and case-study results of potentially better practices to improve pain management of neonates

OBJECTIVE

Collaborative quality improvement techniques were used to facilitate local quality improvement in the management of pain in infants. Several case studies are presented to highlight this process.

METHODS

Twelve NICUs in the Neonatal Intensive Care Quality Improvement Collaborative 2002 focused on improving neonatal pain management and sedation practices. These centers developed and implemented evidence-based potentially better practices for pain management and sedation in neonates. The group introduced changes through plan-do-study-act cycles and tracked performance measures throughout the process.

RESULTS

Strategies for implementing potentially better practices varied between centers on the basis of local characteristics. Individual centers identified barriers to implementation, developed tools for improvement, and shared their experience with the collaborative. Baseline data from the 12 sites revealed substantial opportunities for improved pain management, and local potentially better practice implementation resulted in measurable improvements in pain management at participating centers.

CONCLUSIONS

The use of collaborative quality improvement techniques enhanced local quality improvement efforts and resulted in effective implementation of potentially better practices at participating centers.

Summary proceedings from the neonatal pain-control group

Recent advances in neurobiology and clinical medicine have established that the fetus and newborn may experience acute, established, and chronic pain. They respond to such noxious stimuli by a series of complex biochemical, physiologic, and behavioral alterations. Studies have concluded that controlling pain experience is beneficial with respect to short-term and perhaps long-term outcomes. Yet, pain-control measures are adopted infrequently because of unresolved scientific issues and lack of appreciation for the need for control of pain and its long-term sequelae during the critical phases of neurologic maturation in the preterm and term newborn. The neonatal pain-control group, as part of the Newborn Drug Development Initiative (NDDI) Workshop I, addressed these concerns. The specific issues addressed were (1) management of pain associated with invasive procedures, (2) provision of sedation and analgesia during mechanical ventilation, and (3) mitigation of pain and stress responses during and after surgery in the newborn infant. The cross-cutting themes addressed within each category included (1) clinical-trial designs, (2) drug prioritization, (3) ethical constraints, (4) gaps in our knowledge, and (5) future research needs. This article provides a summary of the discussions and deliberations. Full-length articles on procedural pain, sedation and analgesia for ventilated infants, perioperative pain, and study designs for neonatal pain research were published in Clinical Therapeutics (June 2005).

Analgesia and anesthesia for neonates: Study design and ethical issues

OBJECTIVE

The purpose of this article is to summarize the clinical, methodologic, and ethical considerations for researchers interested in designing future trials in neonatal analgesia and anesthesia, hopefully stimulating additional research in this field.

METHODS

The MEDLINE, PubMed, EMBASE, and Cochrane register databases were searched using subject headings related to infant, newborn, neonate, analgesia, anesthesia, ethics, and study design. Cross-references and personal files were searched manually. Studies reporting original data or review articles related to these topics were assessed and critically evaluated by experts for each topical area. Data on population demographics, study characteristics, and cognitive and behavioral outcomes were abstracted and synthesized in a systematic manner and refined by group members. Data synthesis and results were reviewed by a panel of independent experts and presented to a wider audience including clinicians, scientists, regulatory personnel, and industry representatives at the Newborn Drug Development Initiative workshop. Recommendations were revised after extensive discussions at the workshop and between committee members.

RESULTS

Designing clinical trials to investigate novel or currently available approaches for analgesia and anesthesia in neonates requires consideration of salient study designs and ethical issues. Conditions requiring treatment include pain/stress resulting from invasive procedures, surgical operations, inflammatory conditions, and routine neonatal intensive care. Study design considerations must define the inclusion and exclusion criteria, a rationale for stratification, the confounding effects of comorbid conditions, and other clinical factors. Significant ethical issues include the constraints of studying neonates, obtaining informed consent, making risk-benefit assessments, defining compensation or rewards for participation, safety considerations, the use of placebo controls, and the variability among institutional review boards in interpreting federal guidelines on human research. For optimal study design, investigators must formulate well-defined study questions, choose appropriate trial designs, estimate drug efficacy, calculate sample size, determine the duration of the studies, identify pharmacokinetic and pharmacodynamic parameters, and avoid drug-drug interactions. Specific outcome measures may include scoring on pain assessment scales, various biomarkers and their patterns of response, process outcomes (eg, length of stay, time to extubation), intermediate or long-term outcomes, and safety parameters.

CONCLUSIONS

Much more research is needed in this field to formulate a scientifically sound, evidence-based, and clinically useful framework for management of anesthesia and analgesia in neonates. Newer study designs and additional ethical dilemmas may be defined with accumulating data in this field.