Love, pain, and intensive care

Parent-led neonatal pain management-a narrative review and update of research and practices

Introduction

Research related to parent-led neonatal pain management is increasing, as is the clinical implementation. Skin-to-skin contact, breastfeeding and parents' vocalizations are examples of pain reducing methods that give parents an opportunity to protect their infant from harm while alleviating their anxiety and developing their parenting skills.

Methods

In this paper we will provide a narrative review and describe the current research about parent-led neonatal pain management. Based on this we will discuss clinical challenges, implementation strategies and implications for future research.

Results

Parents express great readiness to embrace opportunities to increase their self-efficacy in their ability to address infant pain. Parent-led pain-reducing methods are effective, feasible, cost-effective, culturally sensitive, and can be individualized and tailored to both the parent's and infant's needs. Both barriers and facilitators of parent-led pain care have been studied in research highlighting structural, organizational, educational, and intra- and interpersonal aspects. For example, health care professionals' attitudes and beliefs on parent-led methods, and their concern that parental presence during a procedure increases staff anxiety. On the other hand, the presence of a local pain champion whose duty is to facilitate the adoption of pain control measures and actively promote parent-professional collaboration, is crucial for culture change in neonatal pain management and nurses have a key role in this change. The knowledge-to-practice gap in parent-led management of infants' procedure-related pain highlight the need for broader educational applications and collaborative professional, parental and research initiatives to facilitate practice change.

Conclusion

Parent-led neonatal pain management is more than simply a humane and compassionate thing to do. The inclusion of parent-led pain care has been scientifically proven to be one of the most effective ways to reduce pain associated with repeated painful procedures in early life and parents report a desire to participate. Focus on enablers across interprofessional, organizational and structural levels and implementation of recommended pediatric pain guidelines can support the provision of optimal evidence-based family-centered neonatal pain management.

The social ecology of childhood and early life adversity

An increasing prevalence of early childhood adversity has reached epidemic proportions, creating a public health crisis. Rather than focusing only on adverse childhood experiences (ACEs) as the main lens for understanding early childhood experiences, detailed assessments of a child's social ecology are required to assess "early life adversity." These should also include the role of positive experiences, social relationships, and resilience-promoting factors. Comprehensive assessments of a child's physical and social ecology not only require parent/caregiver surveys and clinical observations, but also include measurements of the child's physiology using biomarkers. We identify cortisol as a stress biomarker and posit that hair cortisol concentrations represent a summative and chronological record of children's exposure to adverse experiences and other contextual stressors. Future research should use a social-ecological approach to investigate the robust interactions among adverse conditions, protective factors, genetic and epigenetic influences, environmental exposures, and social policy, within the context of a child's developmental stages. These contribute to their physical health, psychiatric conditions, cognitive/executive, social, and psychological functions, lifestyle choices, and socioeconomic outcomes. Such studies must inform preventive measures, therapeutic interventions, advocacy efforts, social policy changes, and public awareness campaigns to address early life adversities and their enduring effects on human potential. IMPACT: Current research does not support the practice of using ACEs as the main lens for understanding early childhood experiences. The social ecology of early childhood provides a contextual framework for evaluating the long-term health consequences of early life adversity. Comprehensive assessments reinforced with physiological measures and/or selected biomarkers, such as hair cortisol concentrations to assess early life stress, may provide critical insights into the relationships between early adversity, stress axis regulation, and subsequent health outcomes.

Parental assessment of comfort in newborns affected by life-limiting conditions treated by a standardized neonatal comfort care program

OBJECTIVE

To assess the perception of parents concerning the state of comfort maintained in their infants born with life-limiting conditions and treated by a standardized neonatal comfort care program.

STUDY DESIGN

Participants were parents (n=35 families) who elected comfort care for their newborns diagnosed with life-limiting conditions. Standardized comfort measures including family/infant bonding, warmth, nutrition/hydration and pain/discomfort management were provided to all infants. Parents consented to receive a questionnaire with quantitative response options and open-ended questions.

RESULTS

Forty-two questionnaires (26 from mothers and 16 from fathers) were collected and analyzed. Most parents reported that their child was treated with respect, in a caring, peaceful and non-invasive environment. To the question 'Do you think that overall your baby received comfort' mode response was 'always'.

CONCLUSION

Parents of infants with life-limiting conditions perceive that their babies experience comfort as a result of the care provided by the standardized Neonatal Comfort Care Program.

Defining pain in newborns: need for a uniform taxonomy?

A framework for defining pain terms such as acute, persistent, prolonged or chronic pain to newborns was derived from the scientific literature on neonatal pain assessments, previous attempts to define chronic pain and the clinical and neurophysiological features of neonatal pain. This novel framework incorporates the temporal features, localising characteristics, and secondary effects of the pain experienced, as well as the behavioural and physiological response patterns of newborns.

CONCLUSION

Although not evidence-based, this framework provides an initial starting point for defining commonly used neonatal pain terms. It will require future revision/refinement based on the accumulating evidence for non-acute pain.

Sensorial saturation and neonatal pain: a review

AIM

Sensorial saturation (SS) is an analgesic approach to babies' pain that includes three types of stimulations: oral sugar, massage and caregivers' voice. The aim of this review is to assess its efficacy.

METHODS

We performed an analysis of scientific literature from 2001 to 2017, retrieving those clinical trials where SS had been compared with other analgesic treatments during procedural pain in babies.

RESULTS

We retrieved 14 studies. Pain sources were heel-prick in nine, eye examination and intramuscular shots in two each, and endotracheal aspiration in one. SS was the most effective treatment in all cases, except in endotracheal suctioning. No drawbacks were reported in any study using SS.

CONCLUSION

SS is a safe and effective approach to neonatal pain due to heel-prick, more effective than oral sucrose or glucose in both term and preterm babies; it seems also effective in other types of acute procedural pain like eye examination or intramuscular injections, but more studies are needed to confirm these preliminary data. More studies are also needed to test SS efficacy for other procedures, and for older infants.

The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU

BACKGROUND

Vulnerable preterm infants experience repeated and prolonged pain/stress stimulation during a critical period in their development while in the neonatal intensive care unit (NICU). The contribution of cumulative pain/stressors to altered neurodevelopment remains unclear. The study purpose was to investigate the impact of early life painful/stressful experiences on neurobehavioral outcomes of preterm infants in the NICU.

METHODS

A prospective exploratory study was conducted with fifty preterm infants (28 0/7-32 6/7weeks gestational age) recruited at birth and followed for four weeks. Cumulative pain/stressors (NICU Infant Stressor Scale) were measured daily and neurodevelopmental outcomes (NICU Network Neurobehavioral Scale) were examined at 36-37weeks post-menstrual age. Data analyses were conducted on the distribution of pain/stressors experienced over time and the linkages among pain/stressors and neurobehavioral outcomes.

RESULTS

Preterm infants experienced a high degree of pain/stressors in the NICU, both in numbers of daily acute events (22.97±2.30 procedures) and cumulative times of chronic/stressful exposure (42.59±15.02h). Both acute and chronic pain/stress experienced during early life significantly contributed to the neurobehavioral outcomes, particularly in stress/abstinence (p<0.05) and habituation responses (p<0.01), meanwhile, direct breastfeeding and skin-to-skin holding were also significantly associated with habituation (p<0.01-0.05).

CONCLUSION

Understanding mechanisms by which early life experience alters neurodevelopment will assist clinicians in developing targeted neuroprotective strategies and individualized interventions to improve infant developmental outcomes.

Effect of Multisensory Stimulation on Pain of Eye Examination in Preterm Infants

Background

Eye examination as one of the painful procedures for retinopathy of prematurity screening can cause some pain-related physiological and behavioral changes in preterm infants. Multisensory stimulation is an analgesic non-pharmacological method that has analgesic effects on infants during painful procedures.

Objectives

This study aimed to determine the effect of multisensory stimulation on induced pain during eye examination for retinopathy of prematurity screening in preterm infants.

Methods

In this double-blind clinical trial, 80 preterm infants were randomly divided into two groups. In the intervention group, multisensory stimulation program was performed for 15 minutes before the beginning of examination while the control group received the routine care. Pain score for each infant was recorded by premature infant pain profile. Data were analyzed using independent t-test, Mann-Whitney, and ANOVA with repeated measures by SPSS software (version 16).

Results

The mean gestational age was 30.4 ± 1.7 weeks in the multisensory stimulation group and 30.6 ± 1.8 weeks in the control group. Based on ANOVA with repeated measures, the pain score was significantly different between two groups during the assessment process (P < 0.001). The changes in pain severity during the examination were also significant between the two groups (P < 0.001); so that the pain was more intensive in the control group than the intervention group.

Conclusions

Multisensory stimulation program as a safe and easy method can reduce pain in neonates and may be used as a way to reduce pain during eye examination in infants.

A feasibility and efficacy randomised controlled trial of swaddling for controlling procedural pain in preterm infants

AIMS AND OBJECTIVES

This study aimed to investigate the feasibility and efficacy of swaddling to control procedural pain among preterm infants.

BACKGROUND

Swaddling has been recommended for controlling neonatal pain. However, the feasibility for use is uncertain and insufficient evidence is available among preterm infants.

DESIGN

A two-arm randomised controlled trial with repeated measures.

METHOD

The study was conducted in a 21-bed neonatal intensive care unit of a regional hospital in Hong Kong. Preterm infants who required heelstick procedure were eligible. Fifty-four preterm infants between 30-37 gestational weeks were randomly assigned to swaddling (n = 27) and control (standard care, n = 27) groups. Pain assessment was performed pre, during, immediate, two, four, six and eight minutes after heelstick procedure using the Premature Infant Pain Profile.

RESULTS

The mean Premature Infant Pain Profile scores were significantly reduced in the intervention group compared to the control group during, immediate, two, four, and six minutes after the heelstick procedure. The mean changes of heart rate and oxygen saturation in the intervention group were significantly lower than that of the control group at all measured time points. Notably, the swaddled infants quickly resumed to the baseline level at two minutes whereas the control group reached the stable state at an extended period of six minutes.

CONCLUSION

The findings show that swaddling is feasible and efficacious in controlling pain for heelstick procedure among preterm infants. No adverse effects were observed.

RELEVANCE TO CLINICAL PRACTICE

This article presents the feasibility and efficacy of swaddling as a non-pharmacological and non-invasive intervention to relieve pain during the heelstick procedures among preterm infants. Swaddling can contribute to control minor procedural pain in neonates as one of the simple, safe, cost effective, humanistic and natural analgesia alternatives.

Close to me: enhancing kangaroo care practice for NICU staff and parents

PURPOSE

The benefits of kangaroo care (KC) are well supported by previously published studies, yet KC is offered inconsistently and faces obstacles in the neonatal intensive care unit (NICU). The March of Dimes designed Close to Me to facilitate and increase KC in NICUs. The program incorporates KC education for nurses and parents, as well as awareness and comfort components. The purpose of this study was to assess whether Close to Me increased favorable attitudes toward KC among nurses and parents, and changed nurse and parent behaviors to implement KC earlier, more often and for longer duration.

SUBJECTS AND DESIGN

This study took place in 5 NICUs with 48 nurse participants and 101 parent participants. It used a pre-/postprogram implementation design for nurses and a nonequivalent comparison versus intervention group design for parents.

METHODS

Nurses and parents were surveyed on knowledge, attitudes, perceived behavioral control, and behavior. Comparisons were made pre- and postprogram implementation for nurses and between intervention and comparison groups for parents. Nurse focus groups were conducted pre- and postimplementation and analyzed using a constant comparative analysis method. Parents recorded care behaviors and satisfaction in journals, which were analyzed similarly.

MAIN OUTCOME MEASURES/PRINCIPAL RESULTS

After the Close to Me intervention, nurses reported more positive attitudes toward KC (P = .04), increased transfer of ventilated babies from incubators to parents (P = .01), and more parents requesting KC. Parents who received Close to Me had greater knowledge about KC (P = .03) compared with those who did not. With the Close to Me intervention, all babies born at less than 28 weeks' gestation had KC by the age of 12 days, whereas without the intervention, some did not have KC until the age of 31 days (P < .05).

CONCLUSIONS

March of Dimes Close to Me improved knowledge and behavior regarding KC in NICUs. By offering KC education to parents, providing KC awareness and comfort components, and providing information and encouragement on the benefits and feasibility of KC to nurses, hospitals can potentially promote earlier and more frequent use of KC, particularly with infants born less than 28 weeks' gestation.

Neonatal outcomes of fetuses diagnosed with life-limiting conditions when individualized comfort measures are proposed

OBJECTIVE

To describe the neonatal outcomes of a case series of infants who were prenatally diagnosed with potential life-limiting conditions and to whom individualized comfort measures were offered.

STUDY DESIGN

This is a retrospective analysis of the postnatal outcomes of a selected population of 49 infants prenatally diagnosed with potential life-limiting conditions whose parents were prenatally referred for counseling to the comfort care team.

RESULT

The prenatal diagnosis was confirmed postnatally in 45 infants. The only four survivors had a significant discrepancy between prenatal and postnatal diagnosis. Whether they were treated with individualized comfort measures (n=28) or intensive care (n=17), all the newborns died with similar median age at death (2 days).

CONCLUSION

Diagnostic accuracy is the main determinant of outcomes. Provision of intensive care neither prevents the death of infants affected by life-limiting conditions nor prolongs life compared with that of infants treated with individualized comfort measures.

Perception of pain and distress in intubated and mechanically ventilated newborn infants by parents and health professionals

Background

An understanding of perceptions of parents and health caregivers who assist critically ill neonates is necessary to comprehend their actions and demands. Therefore this study aim to analyze the agreement among parents, nurse technicians and pediatricians regarding the presence and intensity of pain and distress in mechanically ventilated and intubated newborn infants.

Methods

Cross-sectional study comprising 52 infants and 52 trios of adults composed of one parent, one nurse technician, and one pediatrician who all observed the same infant. All infants were intubated and under mechanical ventilation and were not handled during the observations. Each newborn was simultaneously observed by the trio of adults for 1 minute to evaluate the presence of pain and distress. The intensity of pain and distress that the adults believed was felt by the infants was marked in a visual analogical scale. Adults’ agreement about the simultaneous presence of pain and distress in each infant was analyzed by marginal homogeneity and Cochran tests. The agreement about the intensity of pain and distress in each infant was studied by Bland-Altman plot and intraclass correlation coefficient (ICC).

Results

The assessments of pain and distress were heterogeneous in all three investigated groups of adults as determined by the results of a Bland-Altman plot. The presence of distress was more frequently reported compared with pain (marginal heterogeneity, p < 0.01). The pain and distress scores in each adult group were not correlated as shown by ICC [parents, 0.36 (95% CI: 0.01-0.63); nurses 0.47 (0.23-0.66); pediatricians, 0.46 (0.22-0.65)].

Conclusions

Adults systematically underscore pain in comparison to distress in mechanically ventilated newborns, without recognizing the association between them.

[Developmental centered care. Situation in Spanish neonatal units]

INTRODUCTION

Developmental centered care (DC) is focused on sensorineural and emotional development of the newborns. In Spain we have had information on the application of DC since 1999, but the extent of actual implementation is unknown.

OBJETIVE

To determine the level of implementation of DC in Spanish neonatal units where more than 50 infants weighing under 1500g were cared for in 2012. A comparison was made with previous data published in 2006.

MATERIAL AND METHODS

A descriptive observational cross-sectional study was performed using a survey with seven questions as in the 2006 questionnaire.

RESULTS

The survey was sent to 27 units. The response rate was 81% in 2012 versus 96% in 2006. Noise control measures were introduced in 73% of units in 2012 versus 11% in 2006 (P<.01). The use of saccharose was 50% in 2012 versus 46% in 2006 (P=.6). Parents free entry was 82% in 2012 versus 11% in 2006 (P<.01). Kangaroo care was used without restriction by 82% in 2012 compared to 31% in 2006 (P<.01).

CONCLUSIONS

The implementation of the DC in Spain has improved. There is still room for improvement in areas, such as the use of saccharose or noise control. However, it is important to highlight the positive change that has occurred in relation to unrestricted parental visits.

Effects of skin-to-skin contact on autonomic pain responses in preterm infants

The purpose of this randomized crossover trial was to determine the effects on autonomic responses in preterm infants of longer Kangaroo Care (30 minutes, KC30) and shorter KC (15 minutes, KC15) before and throughout heel stick compared with incubator care (IC). Beat-to-beat heart rate (HR) and spectral power analysis of heart rate variability, low frequency power (LF), high frequency power (HF), and LF/HF ratio were measured in 26 infants. HR changes from Baseline to Heel Stick were significantly less in KC30 and KC15 than in IC, and more infants had HR decrease in IC than in 2 KC conditions. In IC, LF and HF significantly increased from Baseline to Heel Stick and dropped from Heel Stick to Recovery; in 2 KC conditions, no changes across study phases were found. During Heel Stick, LF and HF were significantly higher in IC than in KC30. In all 3 conditions, LF/HF ratio decreased from Baseline to Heel Stick and increased to Recovery; no differences were found between IC and two KC conditions. Both longer and shorter KC before and throughout heel stick can stabilize HR response in preterm infants, and longer KC significantly affected infants' sympathetic and parasympathetic responses during heel stick compared with incubator care.

PERSPECTIVE

This study showed that KC has a significant effect on reducing autonomic pain responses in preterm infants. The findings support that KC is a safe and effective pain intervention in the neonatal intensive care unit.

Sensorial saturation for infants' pain

INTRODUCTION

Sensorial saturation (SS) is a multisensorial stimulation consisting of delicate tactile, gustative, auditory and visual stimuli. This procedure consists of simultaneously: attracting the infant's attention by massaging the infant's face; speaking to the infant gently, but firmly, and instilling a sweet solution on the infant's tongue.

METHODS

We performed a systematic Medline search of for articles focusing on human neonatal studies related to SS. The search was performed within the last 10 years and was current as of January 2012.

RESULTS

We retrieved 8 articles that used a complete form of SS and 2 articles with an incomplete SS. Data show that the use of SS is effective in relieving newborns' pain. Oral solution alone are less effective than SS, but the stimuli without oral sweet solution are ineffective. the partial forms of SS have some effectiveness, but minor than the complete SS. Only one article showed lack of SS as analgesic method, after endotracheal suctioning.

CONCLUSIONS

SS can be used for all newborns undergoing blood samples or other minor painful procedures. It is more effective than oral sugar alone. SS also promotes interaction between nurse and infant and is a simple effective form of analgesia for the neonatal intensive care unit.

Anesthesia and analgesia in the NICU

Painful procedures in the neonatal intensive care unit are common, undertreated, and lead to adverse consequences. A stepwise approach to treatment should include pain recognition, assessment, and treatment, starting with nonpharmacologic and progressing to pharmacologic methods for increasing pain. The most common nonpharmacologic techniques include nonnutritive sucking with and without sucrose, kangaroo care, swaddling, and massage therapy. Drugs used to treat neonatal pain include the opiates, benzodiazepines, barbiturates, ketamine, propofol, acetaminophen, and local and topical anesthetics. The indications, advantages, and disadvantages of the commonly used analgesic drugs are discussed. Guidance and references for drugs and dosing for specific neonatal procedures are provided.

Kangaroo care and behavioral and physiologic pain responses in very-low-birth-weight twins: a case study

The purpose of this case study was to describe pain responses in three study conditions: longer (30 minutes) kangaroo care (KC) before and throughout heel stick (KC30), shorter (15 minutes) KC before and throughout heel stick (KC15), and incubator care throughout heel stick (IC) in 28-week gestational age twins. Pain responses were measured by crying time, Preterm Infant Pain Profile (PIPP), and heart rate variability indexes, including low-frequency power (LF, representing sympathetic activity), high-frequency power (HF, parasympathetic activity), and LF/HF ratio (sympathetic-parasympathetic balance). Both twins cried more and had higher PIPP pain scores and tachycardia during heel stick in the IC condition. Infant B had an incident of apnea and tachycardia by the end of the heel stick and a bradycardia episode during recovery in the IC condition. The twins had lower LF/HF ratios (better autonomic nervous system balance) during recovery in both longer and shorter KC conditions compared with the IC condition. Infant B had difficulty returning to LF/HF ratio baseline level after the painful procedure in the IC condition. These data suggest that both longer and shorter KC before and throughout painful procedures can be helpful in reducing behavioral and physiologic pain responses in preterm infants.

Facilitated tucking as a non-pharmacological intervention for neonatal pain relief: is it clinically feasible?

There is an impressive body of knowledge on pain management in infants hospitalized in neonatal intensive care units. However, deficits in the clinical management of pain in these infants remain. One reason is the gap between research evidence and translation of this knowledge into the clinical setting. This is particularly true for non-pharmacological pain-relieving methods. Effective performance of some of these methods requires additional staffing and time. This viewpoint articles describes the clinical challenges associated with implementing 'facilitated tucking'. Although 'facilitated tucking' is described as an efficient method for acute pain relief, the clinical facilitators required to successfully implement such a resource consuming-intervention remain unclear.

CONCLUSION

  Translational research on the feasibility of using 'facilitated tucking' in the management of neonatal pain is warranted, including the economic impact of this intervention. Increased manpower costs need to be weighed against the possible long-term economical consequences of pain exposure in infants.

Evaluation of transcutaneous bilirubinometry in preterm neonates

OBJECTIVE

To determine the accuracy and precision of transcutaneous bilirubin (TcB) measurements in preterm neonates.

STUDY DESIGN

Neonates were stratified into three groups on the basis of gestational age: 24 to 28 weeks (Group 1, n=30), 29 to 31 weeks (Group 2, n=29) and 32 to 34 weeks (Group 3, n=31). TcB was measured using the Draeger Air Shields JM-103, and when possible, measurements were made by two observers. TcB and total serum bilirubin (TSB) measurements were compared, and interobserver precision for TcB measurements was assessed.

RESULT

Correlations between TcB and TSB ranged from 0.79 to 0.92. Most of the differences between TcB and TSB were +/-2 mg per 100 ml, and there was no trend for the difference to increase with increasing bilirubin values. Sensitivity, specificity and negative predictive values ranged from 0.67 to 1.0, 0.29 to 0.81 and 0.60 to 1.0, respectively. Intraclass correlations were 0.87 to 0.92.

CONCLUSION

TcB correlates significantly with TSB in preterm neonates, and interobserver precision is significant. Routine measurement of TcB in preterm neonates may provide enhanced clinical monitoring for hyperbilirubinemia.