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Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S, DiLorenzo-Klas M, Racine NM, Ahola Kohut S, Lisi D, Turcotte K, Stevens B, Uman LS. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 2023; 6:CD006275. [PMID: 37314064 PMCID: PMC10265939 DOI: 10.1002/14651858.cd006275.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title. OBJECTIVES To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update. We also searched reference lists and contacted researchers via electronic list-serves. We incorporated 76 new studies into the review. SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis. DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes. MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence. In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements. AUTHORS' CONCLUSIONS Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.
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Affiliation(s)
| | - Oana Bucsea
- Department of Psychology, York University, Toronto, Canada
| | - Ilana Shiff
- Department of Psychology, York University, Toronto, Canada
| | - Cheryl Chow
- Department of Psychology, York University, Toronto, Canada
| | | | | | | | - Nicole M Racine
- Department of Psychology, University of Calgary, Calgary, Canada
| | - Sara Ahola Kohut
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Diana Lisi
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Kara Turcotte
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Bonnie Stevens
- Nursing Research, The Hospital for Sick Children, Toronto, Canada
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Integrative Review of Cobedding of Infant Twins. J Obstet Gynecol Neonatal Nurs 2023; 52:128-138. [PMID: 36702163 DOI: 10.1016/j.jogn.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To synthesize the evidence on the benefits and risks of cobedding for infant twins and to assess the perceptions and practices of parents and health care workers regarding this practice. DATA SOURCES We searched the following databases for articles published between 1997 and 2022: CINAHL, Cochrane, Ovid MEDLINE, PubMed, Scopus, and Google Scholar. STUDY SELECTION We included full-text articles published in English in which the authors addressed twin cobedding in hospital or home settings. We reviewed the abstracts of 106 articles and retained 54 for full-text review. Of these, 18 met eligibility criteria and were included in the review. DATA EXTRACTION We extracted the following data: author(s), year of publication, setting, purpose, study design, sample characteristics, methodologic details, outcomes and findings, and limitations. We appraised the quality of each study. DATA SYNTHESIS In the included articles, researchers identified no differences in apnea, heart rate, or oxygen saturation between cobedded and separately bedded infants. Compared to separately bedded infants, cobedded infants had greater weight gain and synchronization of sleep-wake states. Researchers found benefits for procedural pain relief and recovery after heel lance among cobedded infants. Researchers report that many parents are choosing to cobed their twins, but we found limited qualitative data exploring parents' perceptions or practices. In the included articles, nurses had positive perceptions of twin cobedding. Overall, the quality of evidence was low because of inconsistencies in study methods and small sample sizes that resulted in imprecise results. CONCLUSION We found potential benefits and no evidence of harm related to cobedding of twin infants. However, the evidence was insufficient to provide recommendations for practice, and additional research is warranted.
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Cobo MM, Moultrie F, Hauck AGV, Crankshaw D, Monk V, Hartley C, Evans Fry R, Robinson S, van der Vaart M, Baxter L, Adams E, Poorun R, Bhatt A, Slater R. Multicentre, randomised controlled trial to investigate the effects of parental touch on relieving acute procedural pain in neonates (Petal). BMJ Open 2022; 12:e061841. [PMID: 36250332 PMCID: PMC9301810 DOI: 10.1136/bmjopen-2022-061841] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Newborn infants routinely undergo minor painful procedures as part of postnatal care, with infants born sick or premature requiring a greater number of procedures. As pain in early life can have long-term neurodevelopmental consequences and lead to parental anxiety and future avoidance of interventions, effective pain management is essential. Non-pharmacological comfort measures such as breastfeeding, swaddling and sweet solutions are inconsistently implemented and are not always practical or effective in reducing the transmission of noxious input to the brain. Stroking of the skin can activate C-tactile fibres and reduce pain, and therefore could provide a simple and safe parent-led intervention for the management of pain. The trial aim is to determine whether parental touch prior to a painful clinical procedure provides effective pain relief in neonates. METHODS AND ANALYSIS This is a multicentre randomised controlled trial. A total of 112 neonates born at 35 weeks' gestation or more requiring a blood test in the first week of life will be recruited and randomised to receive parental stroking either preprocedure or postprocedure. We will record brain activity (EEG), cardiac and respiratory dynamics, oxygen saturation and facial expression to provide proxy pain outcome measures. The primary outcome will be the reduction of noxious-evoked brain activity in response to a heel lance. Secondary outcomes will be a reduction in clinical pain scores (Premature Infant Pain Profile-Revised), postprocedural tachycardia and parental anxiety. ETHICS AND DISSEMINATION The study has been approved by the London-South East Research Ethics Committee (ref: 21/LO/0523). The results will be widely disseminated through peer-reviewed publications, international conferences and via our partner neonatal charities Bliss and Supporting the Sick Newborn And their Parents (SSNAP). If the parental tactile intervention is effective, recommendations will be submitted via the National Health Service clinical guideline adoption process. STUDY STATUS Commenced September 2021. TRIAL REGISTRATION NUMBER NCT04901611; 14 135 962.
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Affiliation(s)
- Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, UK
- Colegio de Ciencias Biologicas y Ambientales, Universidad San Francisco de Quito USFQ, Quito, Ecuador
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ravi Poorun
- Children's Services, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- College of Medicine & Health, University of Exeter, Exeter, UK
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
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Campbell-Yeo M, Benoit B, Newman A, Johnston C, Bardouille T, Stevens B, Jiang A. The influence of skin-to-skin contact on Cortical Activity during Painful procedures in preterm infants in the neonatal intensive care unit (iCAP mini): study protocol for a randomized control trial. Trials 2022; 23:512. [PMID: 35725632 PMCID: PMC9208173 DOI: 10.1186/s13063-022-06424-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/24/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Strong evidence suggests that maternal-infant skin-to-skin contact (SSC) is effective in reducing behavioural responses to pain. Given the multi-sensory benefits of SSC, it is highly likely that SSC provided during pain in early life may reduce pain-induced brain activity. The aim of this study is to examine the effect of SSC compared to 24% sucrose on pain-induced activity in the preterm infant brain during a medically required heel lance. Secondary objectives include determining (a) differences between behavioural pain response and noxious-related brain activity during heel lance and (b) rate of adverse events across groups. METHODS We will randomly assign 126 babies (32 to 36 completed weeks gestational age) admitted to the neonatal intensive care unit, and their mothers within the first seven days of age to receive (i) SSC plus sterile water and (ii) 24% oral sucrose. Each baby will receive a medically indicated heel lance, following a no treatment baseline period. The primary outcome is noxious-related brain activity measured using an electroencephalogram (EEG) pain-specific event-related potential. Secondary outcomes include pain intensity measured using a bio-behavioural infant pain assessment tool (Premature Infant Pain Profile-Revised) and rate of adverse events. DISCUSSION This will be the first clinical trial to compare the effect of SSC and 24% sucrose on pain-induced brain activity in the preterm infant brain during a clinical noxious stimulus, measured using EEG. Given the negative neurodevelopmental outcomes associated with unmanaged pain, it is imperative that preterm babies receive the most effective pain-reducing treatments to improve their health outcomes. Our findings will have important implications in informing optimal pain assessment and management in preterm infants. TRIAL REGISTRATION ClinicalTrials.gov NCT03745963 . Registered on November 19, 2018.
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Affiliation(s)
- Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Dalhousie University and IWK Health, Halifax, NS Canada
| | - Britney Benoit
- Rankin School of Nursing, St. Francis Xavier University, Antigonish, NS Canada
| | - Aaron Newman
- Faculty of Science, Department of Psychology & Neuroscience, Dalhousie University, Halifax, NS Canada
| | | | - Tim Bardouille
- Department of Physics & Atmospheric Science, Dalhousie University, Halifax, NS Canada
| | - Bonnie Stevens
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto and Child Health Evaluative Sciences Program, Research Institute, The Hospital for Sick Children (SickKids), Toronto, ON Canada
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Shiff I, Bucsea O, Pillai Riddell R. Psychosocial and Neurobiological Vulnerabilities of the Hospitalized Preterm Infant and Relevant Non-pharmacological Pain Mitigation Strategies. Front Pediatr 2021; 9:568755. [PMID: 34760849 PMCID: PMC8573383 DOI: 10.3389/fped.2021.568755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/23/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Preterm pain is common in the Neonatal Intensive Care Unit (NICU), with multiple invasive procedures occurring daily. Objective: To review the psychosocial and neurobiological vulnerabilities of preterm infants and to provide an updated overview of non-pharmacological strategies for acute procedural pain in hospitalized preterm infants. Methods: We utilized a narrative review methodology, which also included a synthesis of key pieces of published systematic reviews that are relevant to the current work. Results and Conclusions: Preterm infants are uniquely susceptible to the impact of painful procedures and prolonged separation from caregivers that are often inherent in a NICU stay. Non-pharmacological interventions can be efficacious for mitigating procedural pain for preterm infants. Interventions should continue to be evaluated with high quality randomized controlled trials, and should endeavor to take into account the neurobiological and psychosocial aspects of preterm vulnerability for pain prevention and management strategies.
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Affiliation(s)
- Ilana Shiff
- Department of Psychology, York University, Toronto, ON, Canada
| | - Oana Bucsea
- Department of Psychology, York University, Toronto, ON, Canada
| | - Rebecca Pillai Riddell
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Psychiatry Research, Hospital for Sick Children, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive care unit hospitalization: a single-blind randomized controlled trial. Pain 2020; 160:2580-2588. [PMID: 31356452 DOI: 10.1097/j.pain.0000000000001646] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Preterm neonates hospitalized in the neonatal intensive care unit undergo frequent painful procedures daily, often without pain treatment, with associated long-term adverse effects. Maternal-infant skin-to-skin contact, or kangaroo care (KC), and sweet-tasting solutions such as sucrose are effective strategies to reduce pain during a single procedure; however, evidence of sustained efficacy over repeated procedures is limited. We aimed to determine the relative sustained efficacy of maternal KC, administered alone or in combination with 24% sucrose, to reduce behavioral pain intensity associated with routine neonatal procedures, compared with 24% sucrose alone. Stable preterm infants (n = 242) were randomized to receive KC and water, KC and 24% sucrose, or 24% sucrose before all routine painful procedures throughout their neonatal intensive care unit stay. Pain intensity, determined using the Premature Infant Pain Profile, was measured during 3 medically indicated heel lances distributed across hospitalization. Maternal and neonatal baseline characteristics, Premature Infant Pain Profile scores at 30, 60, or 90 seconds after heel lance, the distribution of infants with pain scores suggesting mild, moderate, or severe pain, Neurobehavioral Assessment of the Preterm Infant scores, and incidence of adverse outcomes were not statistically significantly different between groups. Maternal KC, as a pain-relieving intervention, remained efficacious over time and repeated painful procedures without evidence of any harm or neurological impact. It seemed to be equally effective as 24% oral sucrose, and the combination of maternal KC and sucrose did not seem to provide additional benefit, challenging the existing recommendation of using sucrose as the primary standard of care.
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Johnston C. Neonatal pain: A journey spanning three decades. PAEDIATRIC AND NEONATAL PAIN 2020; 2:33-39. [PMID: 35548592 PMCID: PMC8975195 DOI: 10.1002/pne2.12020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/22/2020] [Accepted: 04/07/2020] [Indexed: 11/21/2022]
Abstract
From 1980 into present day, 2020, the evolution of neonatal pain research is told as a journey by one researcher, Celeste Johnston. At the beginning of her work, there was essentially no interest or work in the area. She was fortunate to be led into the area by a clinical problem: how to determine the amount of pain babies in the NICU were experiencing. That question resulted in over three decades of work with neonates. Measuring pain was the first challenge and is one that remains a focus of current research. Initially, the only choices for treating pain in neonates were either opioids or anesthetics, each with problems. Research on sweet taste and more recently on skin‐to‐skin contact has offered effective and safe options for procedural pain. Although progress has been made in the incidence of pain management in infants, it still is far less than it could be. Steps along the way of measurement, treatment, and knowledge utilization are chronicled by this researcher.
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Affiliation(s)
- Céleste Johnston
- McGill University Hunts Point NS Canada
- IWK Health Centre Halifax NS Canada
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Gimenez IL, Rodrigues RF, Oliveira MCDF, Santos BAR, Arakaki VDSNM, Santos RSD, Peres RT, Sant'Anna CC, Ferreira HC. Temporal assessment of neonatal pain after airway aspiration. Rev Bras Ter Intensiva 2020; 32:66-71. [PMID: 32401971 PMCID: PMC7206953 DOI: 10.5935/0103-507x.20200011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/29/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To temporally assess a painful stimulus in premature infants using 3 neonatal pain scales. METHODS A total of 83 premature infants were observed during airway aspiration by 3 evaluators (E1, E2 and E3) using 3 pain assessment scales (Neonatal Facial Coding System - NFCS; Neonatal Infant Pain Scale - NIPS; and Premature Infant Pain Profile - PIPP) at 5 time points: T1 (before airway aspiration), T2 (during airway aspiration), T3 (1 minute after airway aspiration), T4 (3 minutes after airway aspiration), and T5 (5 minutes after airway aspiration). Light's Kappa (agreement among examiners and among scales at each time point) and the McNemar test (comparison among time points) were used considering p < 0.05. RESULTS There was a significant difference between the 3 examiners for T1 and T2 using the 3 scales. In T3, pain was observed in 22.9%/E1, 28.9%/E2, and 24.1%/E3 according to the NFCS; 22.9%/E1, 21.7%/E2, and 16.9%/E3 according to the NIPS; and 49.4%/E1, 53.9%/E2, and 47%/E3 according to the PIPP. There was a difference between T1 and T3 using the 3 scales, except for 2 examiners for the PIPP (E2: p = 0.15/E3: p = 0.17). Comparing T4 and T5 to T1, there was no difference in the 3 scales. CONCLUSION Premature infants required at least 3 minutes to return to their initial state of rest (no pain).
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Affiliation(s)
| | | | | | | | | | - Rosana Silva Dos Santos
- Departamento de Fisioterapia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Tosta Peres
- Departamento de Matemática, Centro Federal de Educação Tecnológica Celso Suckow da Fonseca, Rio de Janeiro, RJ, Brasil
| | - Clemax Couto Sant'Anna
- Departamento de Pediatria, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Halina Cidrini Ferreira
- Departamento de Fisioterapia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Effectiveness of Sucrose Used Routinely for Pain Relief and Neonatal Clinical Risk in Preterm Infants: A Nonrandomized Study. Clin J Pain 2019; 34:713-722. [PMID: 29300197 DOI: 10.1097/ajp.0000000000000584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preterm infants (PI) requiring the neonatal intensive care unit are exposed to early repetitive pain/distress. Little is known about how pain relief strategies interact with infants' clinical health status, such as severity of illness with pain responses. This study aimed to examine main and interactive effects of routine sucrose intervention and neonatal clinical risk (NCR) on biobehavioral pain reactivity-recovery in PI during painful blood collection procedures. METHODS Very low birth weight PI (<1500 g; n=104) were assigned to low and high clinical risk groups, according to the Clinical Risk Index for Babies. Sucrose group (n=52) received sucrose solution (25%; 0.5 mL/kg) 2 minutes before the procedures and control group received standard care. Biobehavioral pain reactivity-recovery was assessed according to the Neonatal Facial Coding System, sleep-wake state scale, crying time, and heart rate at 5 phases (baseline, antisepsis, puncture (P), recovery-dressing, and recovery-resting [R]). Repeated measure ANOVA with mixed-design was performed considering pain assessment phases, intervention group, and NCR. RESULTS Independent of NCR, sucrose presented main effect in decreasing neonates' facial activity pain responses and crying time, during P and R. Independent of NCR level or routine sucrose intervention, all neonates displayed activated state in P and decreased biobehavioral responses in R phase. Although no sucrose or NCR effects were observed on physiological reactivity, all neonates exhibited physiological recovery 10 minutes after P, reaching the same heart rate patterns as the baseline. CONCLUSIONS Independent of NCR level, sucrose intervention for pain relief during acute painful procedures was effective to reduce pain intensity and increase biobehavioral regulation.
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Perroteau A, Nanquette MC, Rousseau A, Renolleau S, Bérard L, Mitanchez D, Leblanc J. Efficacy of facilitated tucking combined with non-nutritive sucking on very preterm infants' pain during the heel-stick procedure: A randomized controlled trial. Int J Nurs Stud 2018; 86:29-35. [PMID: 29960105 DOI: 10.1016/j.ijnurstu.2018.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Reducing acute pain in premature infants during neonatal care improves their neurophysiological development. The use of pharmacological and non-pharmacological analgesia, such as sucrose, is limited per day, particularly for very preterm infants. Thus, the usual practice of non-nutritive sucking is often used alone. Facilitated tucking could be an additional strategy to non-nutritive sucking for reducing pain. To the best of our knowledge, no randomized trial has compared the combination of facilitated tucking and non-nutritive sucking to non-nutritive sucking alone. OBJECTIVES To compare the efficacy of facilitated tucking in combination with non-nutritive sucking (intervention group) to non-nutritive sucking alone (control group) in reducing pain during the heel-stick procedure in very preterm infants. DESIGN Prospective, randomized controlled trial. SETTINGS Level III and II neonatal care units, including the neurosensory care management program. METHODS Very preterm infants (gestational age between 28 and 32 weeks) were randomly assigned by a computer programme to the intervention or control group during a heel-stick procedure within the first 48 h of life. In both groups, infants were placed in an asymmetric position on a cushion; noise and light were limited following routine care. A heel-stick was performed first in the care sequence. In the intervention group, facilitated tucking was performed by a nurse or nursing assistant. The procedure was video recorded from 15 s (T-15 s) before the procedure until three minutes (T + 3 min) after the end of the procedure. Pain was blindly assessed by two independent specialist nurses. The primary outcome was the pain score evaluated 15 s before the procedure and 30 s immediately after by the premature infant pain profile (PIPP) scale. The secondary outcome was the pain score evaluated between T-15 s and T + 3 min by the DAN scale (a French acronym for the acute pain of a newborn). RESULTS Sixty infants were included (30 in each group). The PIPP pain scores did not differ between the intervention group (median: 8.0; interquartile range (IQR): 6.0-12.0) and the control group (median: 9.5; IQR: 7.0-13.0, p = 0.32). Pain assessed by the DAN scale at T + 3 min was lower in the intervention group than in the control group (median: 0.3; IQR: 0.0-1.0 and 2.0; IQR: 0.5-3.0, respectively, p = 0.001). CONCLUSIONS The combined use of facilitated tucking and non-nutritive sucking did not significantly alleviate pain during the heel-stick procedure. However, the addition of facilitated tucking facilitated faster pain recovery following the heel-stick procedure.
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Affiliation(s)
- Anne Perroteau
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Armand Trousseau, Department of Perinatology, F75012, Paris, France.
| | - Marie-Christine Nanquette
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Armand Trousseau, Department of Perinatology, F75012, Paris, France.
| | - Alexandra Rousseau
- Assistance Publique - Hôpitaux de Paris (AP-HP), Groupe Hospitalier des Hôpitaux Universitaires Est Parisien (HUEP), Clinical Research Unit of East of Paris (URC-Est), F75012, Paris, France.
| | - Sylvain Renolleau
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Necker Enfants Malades, Department of Resuscitative Medicine and Surgical, F75015, Paris, France.
| | - Laurence Bérard
- Assistance Publique - Hôpitaux de Paris (AP-HP), Groupe Hospitalier des Hôpitaux Universitaires Est Parisien (HUEP), Clinical Research Platform of East of Paris (URC-Est/CRC-Est), F75012, Paris, France.
| | - Delphine Mitanchez
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Armand Trousseau, Department of Perinatology, F75012, Paris, France.
| | - Judith Leblanc
- Assistance Publique - Hôpitaux de Paris (AP-HP), Groupe Hospitalier des Hôpitaux Universitaires Est Parisien (HUEP), Clinical Research Center of East of Paris (CRC-Est), F75012, Paris, France.
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The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial. BMC Pediatr 2018; 18:85. [PMID: 29475433 PMCID: PMC5824554 DOI: 10.1186/s12887-018-1026-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 01/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Orally administered sucrose is effective and safe in reducing pain intensity during single, tissue-damaging procedures in neonates, and is commonly recommended in neonatal pain guidelines. However, there is wide variability in sucrose doses examined in research, and more than a 20-fold variation across neonatal care settings. The aim of this study was to determine the minimally effective dose of 24% sucrose for reducing pain in hospitalized neonates undergoing a single skin-breaking heel lance procedure. Methods A total of 245 neonates from 4 Canadian tertiary neonatal intensive care units (NICUs), born between 24 and 42 weeks gestational age (GA), were prospectively randomized to receive one of three doses of 24% sucrose, plus non-nutritive sucking/pacifier, 2 min before a routine heel lance: 0.1 ml (Group 1; n = 81), 0.5 ml (Group 2; n = 81), or 1.0 ml (Group 3; n = 83). The primary outcome was pain intensity measured at 30 and 60 s following the heel lance, using the Premature Infant Pain Profile-Revised (PIPP-R). The secondary outcome was the incidence of adverse events. Analysis of covariance models, adjusting for GA and study site examined between group differences in pain intensity across intervention groups. Results There was no difference in mean pain intensity PIPP-R scores between treatment groups at 30 s (P = .97) and 60 s (P = .93); however, pain was not fully eliminated during the heel lance procedure. There were 5 reported adverse events among 5/245 (2.0%) neonates, with no significant differences in the proportion of events by sucrose dose (P = .62). All events resolved spontaneously without medical intervention. Conclusions The minimally effective dose of 24% sucrose required to treat pain associated with a single heel lance in neonates was 0.1 ml. Further evaluation regarding the sustained effectiveness of this dose in reducing pain intensity in neonates for repeated painful procedures is warranted. Trial registration ClinicalTrials.gov: NCT02134873. Date: May 5, 2014 (retrospectively registered).
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12
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Schinkel MG, Chambers CT, Hayden JA, Jordan A, Dol J, Higgins KS. A scoping review on the study of siblings in pediatric pain. Can J Pain 2017; 1:199-215. [PMID: 35005355 PMCID: PMC8730589 DOI: 10.1080/24740527.2017.1399053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Sibling relationships are longstanding across an individual’s life and are influential in children’s development. The study of siblings in pediatric pain is, although in early stages, a growing field. Aims: This scoping review sought to summarize and map the type of research available examining siblings and pediatric pain to identify gaps and directions for future research. Methods: Studies were identified based on a search of PubMed, CINAHL, PsycInfo, Embase, and Web of Science (up to November 2016). We extracted data about study methods, the sample, outcome assessment, and the influence/relationships investigated. Results: Thirty-five studies were included. Most studies used quantitative methods (n = 28), and participants typically included children (i.e., aged 6–12; n = 24) and adolescents (i.e., aged 13–18; n = 18). The majority of studies examined siblings in the context of chronic and disease-related pain (n = 30). Though quantitative studies primarily focused on the genetic influence of pain conditions (n = 18), qualitative and mixed-methods studies typically focused on exploring the impact of siblings with and without pain on one another (n = 2) and the impact of pain on the broader dyadic relationship/functioning (n = 4). Conclusions: Sibling research in pediatric pain has been primarily focused on the biological/physical components of pain, using quantitative approaches. Conducting more studies using qualitative or mixed-methods designs, incorporating multiple assessment measures (e.g., observational, self-report) and multiple perspectives (e.g., siblings, health professionals), may provide an opportunity to gain richer and more comprehensive information regarding the experience of siblings.
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Affiliation(s)
- Meghan G Schinkel
- Departments of Psychology and Neuroscience, Dalhousie University, Halifax, Canada.,Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada
| | - Christine T Chambers
- Departments of Psychology and Neuroscience, Dalhousie University, Halifax, Canada.,Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada.,Pediatrics, Dalhousie University, Halifax, Canada
| | - Jill A Hayden
- Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Abbie Jordan
- Department of Psychology, University of Bath, Bath, UK.,Centre for Pain Research, University of Bath, Bath, UK
| | - Justine Dol
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada.,Faculty of Health, Dalhousie University, Halifax, Canada
| | - Kristen S Higgins
- Departments of Psychology and Neuroscience, Dalhousie University, Halifax, Canada.,Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada
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Legrand A, Frondas A, Aubret F, Corre A, Flamant C, Simon L, Desrobert C, Rozé JC. Randomised controlled trial shows that co-bedding twins may reduce birthweight recovery delay, parenteral nutrition weaning time and hospitalisation. Acta Paediatr 2017; 106:2055-2059. [PMID: 28436200 DOI: 10.1111/apa.13885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 03/06/2017] [Accepted: 04/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Arnaud Legrand
- Women's and Children's Clinical Investigation Center (CIC FEA 1413); Nantes University Hospital; Nantes France
| | - Anne Frondas
- Department of Neonatal Medicine; Nantes University Hospital; Nantes France
| | - Fabien Aubret
- Department of Evolutive Ecology USR 2936; CNRS USR 2936; France
| | - Anne Corre
- Department of Neonatal Medicine; Nantes University Hospital; Nantes France
| | - Cyril Flamant
- Department of Neonatal Medicine; Nantes University Hospital; Nantes France
| | - Laure Simon
- Department of Neonatal Medicine; Nantes University Hospital; Nantes France
| | - Clothilde Desrobert
- Department of Neonatal Medicine; Marseille University Hospital; Marseille France
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Validation of the Persian Version of Premature Infant Pain Profile-Revised in Hospitalized Infants at the Neonatal Intensive Care Units. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.10056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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15
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LINHARES MBM, GASPARDO CM. Non-pharmacological management of neonatal pain: Research and clinical practice in the Neonatal Intensive Care Unit. ESTUDOS DE PSICOLOGIA (CAMPINAS) 2017. [DOI: 10.1590/1982-02752017000300003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract According to the World Health Organization and the International Association for the Study of Pain, pain is a relevant worldwide problem in the healthcare field. The present study aimed to describe the definition of pediatric pain and the main characteristics, and to examine the findings regarding the impact of pain on the development of the child. The best clinical practices in Neonatal Intensive Care Units should include developmental care and specifically implement pain management, aiming to protect the health and development of the infants. The efficacious non-pharmacological management of neonatal pain includes breastfeeding, skin-to-skin, non-nutritive sucking, facilitated-tucking and swaddling. Sweet solutions also have pain relief effects. Psychologists could actively participate in the implementation of non-pharmacological interventions and in the whole process to sensitize and train the professional teams, to alert parents to protection against pain and to support policymakers in the implementation of pain guidelines in the hospital.
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Johnston C, Campbell‐Yeo M, Disher T, Benoit B, Fernandes A, Streiner D, Inglis D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst Rev 2017; 2:CD008435. [PMID: 28205208 PMCID: PMC6464258 DOI: 10.1002/14651858.cd008435.pub3] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants. OBJECTIVES The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonatesThe secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants. SEARCH METHODS For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. SELECTION CRITERIA Studies with randomisation or quasi-randomisation, double- or single-blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals. DATA COLLECTION AND ANALYSIS The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC. MAIN RESULTS Twenty-five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes.Seventeen studies (n = 810) compared SSC to a no-treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of -10.78 beats per minute (95% CI -13.63 to -7.93) favouring SSC. Meta-analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI -4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta-analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta-analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = -34.16, 95% CI -42.86 to -25.45), and two (n = 100) following IM injection (MD = -8.83, 95% CI -14.63 to -3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD -3.21, 95% CI -3.94 to -2.47), at 60 seconds (3 studies; n = 156) (MD -1.64, 95% CI -2.86 to -0.43), and at 90 seconds (n = 156) (MD -1.28, 95% CI -2.53 to -0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI -1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta-analysis findings.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. AUTHORS' CONCLUSIONS SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother-providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions.
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Affiliation(s)
| | - Marsha Campbell‐Yeo
- IWK Health CentreNeonatal Intensive Care Unit5850/5980 University AvenuePO Box 9700HalifaxNSCanadaB3K 6R8
| | | | | | - Ananda Fernandes
- Coimbra College of NursingDepartment of Child HealthAv. BissayaBarretoAp. 55CoimbraPortugal3001‐901
| | - David Streiner
- McMaster UniversityDepartment of Psychiatry and Behavioural Neurociences100 West 5th StreetRoom B‐366HamiltonONCanadaL8N 3K7
| | - Darlene Inglis
- IWK Health CentreNeonatal Intensive Care Unit5850/5980 University AvenuePO Box 9700HalifaxNSCanadaB3K 6R8
| | - Rebekah Zee
- IWK Health CentreNeonatal Intensive Care Unit5850/5980 University AvenuePO Box 9700HalifaxNSCanadaB3K 6R8
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Cardoso MVLML, Farias LM, de Melo GM. Music and 25% glucose pain relief for the premature infant: a randomized clinical trial. Rev Lat Am Enfermagem 2016; 22:810-8. [PMID: 25493677 PMCID: PMC4292669 DOI: 10.1590/0104-1169.0029.2484] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 09/02/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: to analyze the total Premature Infant Pain Profile scores of premature infants
undergoing arterial puncture during music and 25% glucose interventions, and to
assess their association with neonatal and therapeutic variables. METHOD: a randomized clinical trial with 80 premature infants; 24 in the Experimental
Group 1 (music), 33 in the Experimental Group 2 (music and 25% glucose), 23 in the
Positive Control Group (25% glucose). All premature infants were videotaped and a
lullaby was played for ten minutes before puncture in Experimental Groups 1 and 2;
25% glucose administered in Experimental Group 2 and the Positive Control Group
two minutes before puncture. RESULTS: 60.0% of premature infants had moderate or maximum pain; pain scores and
intervention groups were not statistically significant. Statistically significant
variables: Experimental Group 1: head and chest circumference, Apgar scores,
corrected gestational age; Experimental Group 2: chest circumference, Apgar
scores, oxygen therapy; Positive Control group: birth weight, head circumference.
CONCLUSION: neonatal variables are associated with pain in premature infants. Brazilian
Registry of Clinical Trials: UTN: U1111-1123-4821.
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18
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016; 1:7. [PMID: 28066825 PMCID: PMC5218543 DOI: 10.12688/wellcomeopenres.10005.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016. [PMID: 28066825 DOI: 10.12688/wellcomeopenres.10005.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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Lai NM, Foong SC, Foong WC, Tan K. Co-bedding in neonatal nursery for promoting growth and neurodevelopment in stable preterm twins. Cochrane Database Syst Rev 2016; 4:CD008313. [PMID: 27075527 PMCID: PMC6464533 DOI: 10.1002/14651858.cd008313.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The increased birth rate of twins during recent decades and the improved prognosis of preterm infants have resulted in the need to explore measures that could optimize their growth and neurodevelopmental outcomes. It has been postulated that co-bedding simulates twins' intrauterine experiences in which co-regulatory behaviors between them are observed. These behaviors are proposed to benefit twins by reducing their stress, which may promote growth and development. However, in practice, uncertainty surrounds the benefit-risk profile of co-bedding. OBJECTIVES We aimed to assess the effectiveness of co-bedding compared with separate (individual) care for stable preterm twins in the neonatal nursery in promoting growth and neurodevelopment and reducing short- and long-term morbidities, and to determine whether co-bedding is associated with significant adverse effects.As secondary objectives, we sought to evaluate effects of co-bedding via the following subgroup analyses: twin pairs with different weight ranges (very low birth weight [VLBW] < 1500 grams vs non-VLBW), twins with versus without significant growth discordance at birth, preterm versus borderline preterm twins, twins co-bedded in incubator versus cot at study entry, and twins randomized by twin pair versus neonatal unit. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). We used keywords and medical subject headings (MeSH) to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (via PubMed), EMBASE (hosted by EBSCOHOST), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and references cited in our short-listed articles, up to February 29, 2016. SELECTION CRITERIA We included randomized controlled trials with randomization by twin pair and/or by neonatal unit. We excluded cross-over studies. DATA COLLECTION AND ANALYSIS We extracted data using standard methods of the CNRG. Two review authors independently assessed the relevance and risk of bias of retrieved records. We contacted the authors of included studies to request important information missing from their published papers. We expressed our results using risk ratios (RRs) and mean differences (MDs) when appropriate, along with 95% confidence intervals (95% CIs). We adjusted the unit of analysis from individual infants to twin pairs by averaging measurements for each twin pair (continuous outcomes) or by counting outcomes as positive if developed by either twin (dichotomous outcomes). MAIN RESULTS Six studies met the inclusion criteria; however, only five studies provided data for analysis. Four of the six included studies were small and had significant limitations in design. As each study reported outcomes differently, data for most outcomes were effectively contributed by a single study. Study authors reported no differences between co-bedded twins and twins receiving separate care in terms of rate of weight gain (MD 0.20 grams/kg/d, 95% CI -1.60 to 2.00; one study; 18 pairs of twins; evidence of low quality); apnea, bradycardia, and desaturation (A/B/D) episodes (RR 0.85, 95% CI 0.18 to 4.05; one study; 62 pairs of twins; evidence of low quality); episodes in co-regulated states (MD 0.96, 95% CI -3.44 to 5.36; one study; three pairs of twins; evidence of very low quality); suspected or proven infection (RR 0.84, 95% CI 0.30 to 2.31; three studies; 65 pairs of twins; evidence of very low quality); length of hospital stay (MD -4.90 days, 95% CI -35.23 to 25.43; one study; three pairs of twins; evidence of very low quality); and parental satisfaction measured on a scale of 0 to 55 (MD -0.38, 95% CI -4.49 to 3.73; one study; nine pairs of twins; evidence of moderate quality). Although co-bedded twins appeared to have lower pain scores 30 seconds after heel lance on a scale of 0 to 21 (MD -0.96, 95% CI -1.68 to -0.23; two studies; 117 pairs of twins; I(2) = 75%; evidence of low quality), they had higher pain scores 90 seconds after the procedure (MD 1.00, 95% CI 0.14 to 1.86; one study; 62 pairs of twins). Substantial heterogeneity in the outcome of infant pain response after heel prick at 30 seconds post procedure and conflicting results at 30 and 90 seconds post procedure precluded clear conclusions. AUTHORS' CONCLUSIONS Evidence on the benefits and harms of co-bedding for stable preterm twins was insufficient to permit recommendations for practice. Future studies must be adequately powered to detect clinically important differences in growth and neurodevelopment. Researchers should assess harms such as infection, along with medication errors and caregiver satisfaction.
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Affiliation(s)
- Nai Ming Lai
- Taylor's UniversitySchool of MedicineSubang JayaMalaysia
| | - Siew Cheng Foong
- Penang Medical CollegeDepartment of PaediatricsNo 4 Sepoy LinesPenangMalaysia10450
| | - Wai Cheng Foong
- Penang Medical CollegeDepartment of PaediatricsNo 4 Sepoy LinesPenangMalaysia10450
| | - Kenneth Tan
- Monash UniversityDepartment of Paediatrics246 Clayton RoadClaytonMelbourneVictoriaAustraliaVIC 3168
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Pillai Riddell RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, Ahola Kohut S, Hillgrove Stuart J, Stevens B, Lisi DM. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 2015; 2015:CD006275. [PMID: 26630545 PMCID: PMC6483553 DOI: 10.1002/14651858.cd006275.pub3] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan. This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'. OBJECTIVES To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added. SELECTION CRITERIA Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update. DATA COLLECTION AND ANALYSIS Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method. MAIN RESULTS Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence. AUTHORS' CONCLUSIONS There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.
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Affiliation(s)
- Rebecca R Pillai Riddell
- York UniversityDepartment of Psychology4700 Keele StreetOUCH Laboratory, 2004/6 Sherman Health Sciences BuildingTorontoONCanadaM3J 1P3
| | - Nicole M Racine
- York UniversityDepartment of Psychology4700 Keele StreetOUCH Laboratory, 2004/6 Sherman Health Sciences BuildingTorontoONCanadaM3J 1P3
| | - Hannah G Gennis
- York UniversityDepartment of Psychology4700 Keele StreetOUCH Laboratory, 2004/6 Sherman Health Sciences BuildingTorontoONCanadaM3J 1P3
| | - Kara Turcotte
- University of British Columbia OkanaganDepartment of PsychologyKelownaBCCanada
| | | | - Rachel E Horton
- The Child and Adolescent Psychology CentrePrivate PracticeAuroraONCanada
| | | | - Jessica Hillgrove Stuart
- York UniversityDepartment of Psychology4700 Keele StreetOUCH Laboratory, 2004/6 Sherman Health Sciences BuildingTorontoONCanadaM3J 1P3
| | - Bonnie Stevens
- The Hospital for Sick ChildrenNursing Research555 University AvenueTorontoONCanadaM5G 1X8
| | - Diana M Lisi
- University of British Columbia OkanaganDepartment of PsychologyKelownaBCCanada
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Campbell-Yeo ML, Disher TC, Benoit BL, Johnston CC. Understanding kangaroo care and its benefits to preterm infants. Pediatric Health Med Ther 2015; 6:15-32. [PMID: 29388613 PMCID: PMC5683265 DOI: 10.2147/phmt.s51869] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The holding of an infant with ventral skin-to-skin contact typically in an upright position with the swaddled infant on the chest of the parent, is commonly referred to as kangaroo care (KC), due to its simulation of marsupial care. It is recommended that KC, as a feasible, natural, and cost-effective intervention, should be standard of care in the delivery of quality health care for all infants, regardless of geographic location or economic status. Numerous benefits of its use have been reported related to mortality, physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breastfeeding duration, and degree of exclusivity) domains, as an effective therapy to relieve procedural pain, and improved neurodevelopment. Yet despite these recommendations and a lack of negative research findings, adoption of KC as a routine clinical practice remains variable and underutilized. Furthermore, uncertainty remains as to whether continuous KC should be recommended in all settings or if there is a critical period of initiation, dose, or duration that is optimal. This review synthesizes current knowledge about the benefits of KC for infants born preterm, highlighting differences and similarities across low and higher resource countries and in a non-pain and pain context. Additionally, implementation considerations and unanswered questions for future research are addressed.
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Affiliation(s)
- Marsha L Campbell-Yeo
- School of Nursing, Dalhousie University
- Department of Pediatrics, IWK Health Centre
- Department of Psychology and Neuroscience, Dalhousie University
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS
| | | | | | - C Celeste Johnston
- Department of Pediatrics, IWK Health Centre
- Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS
- Ingram School of Nursing, McGill University, Montréal, QC, Canada
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Hayward KM, Johnston CC, Campbell-Yeo ML, Price SL, Houk SL, Whyte RK, White SD, Caddell KE. Effect of cobedding twins on coregulation, infant state, and twin safety. J Obstet Gynecol Neonatal Nurs 2015; 44:193-202. [PMID: 25712585 DOI: 10.1111/1552-6909.12557] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of cobedding on twin coregulation and twin safety. DESIGN Randomized controlled trial (RCT). SETTING Two university affiliated Level III neonatal intensive care units (NICUs). PARTICIPANTS One hundred and seventeen sets (N = 234) of stable preterm twins (<37 weeks gestational age at birth) admitted to the NICU. METHODS Sets of twins were randomly assigned to be cared for in a single cot (cobedded) or in separate cots (standard care). State response was obtained from videotaped and physiologic data measured and recorded for three, 3-hour sessions over a one-week study period. Tapes were coded for infant state by an assessor blind to the purpose of the study. RESULTS Twins who were cobedded spent more time in the same state (p < .01), less time in opposite states (p < .01), were more often in quiet sleep (p < .01) and cried less (p < .01) than twins who were cared for in separate cots. There was no difference in physiological parameters between groups (p = .85). There was no difference in patient safety between groups (incidence of sepsis, p = .95), incidence of caregiver error (p = .31), and incidence of apnea (p = .70). CONCLUSIONS Cobedding promotes self-regulation and sleep and decreases crying without apparent increased risk.
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Badiee Z, Nassiri Z, Armanian A. Cobedding of twin premature infants: calming effects on pain responses. Pediatr Neonatol 2014; 55:262-8. [PMID: 24694748 DOI: 10.1016/j.pedneo.2013.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 11/14/2013] [Accepted: 11/26/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The purpose of this trial was to determine whether cobedding of preterm twins has analgesic effects during heel lancing or not. METHODS One hundred premature twins (50 sets) born between 26 weeks' and 34 weeks' gestation undergoing heel blood sampling were randomly assigned into two groups: the cobedding group (receiving care in the same incubator) and the standard care group (receiving care in separate incubators). Pain was assessed using the premature infant pain profile score. Duration of crying was measured after heel blood sampling, and salivary cortisol was measured prior to and after heel blood sampling. RESULTS Infants in the standard care group cried for a longer time during heel lancing than those in the cobedding group (42.6 ± 19.8 seconds vs. 36.4 ± 21.7 seconds, p = 0.03). The mean premature infant pain profile score after heel lancing was significantly higher in the standard care group (9.8 ± 2.6 vs. 8.06 ± 2.8, p = 0.002). The mean salivary cortisol after heel lancing was also significantly higher in the standard care group (24.3 ± 7.4 nmol/L vs. 20.8 ± 7.4 nmol/L, p = 0.02). No significant adverse effects were seen with cobedding. CONCLUSION Cobedding is a comforting measure for twin premature infants during heel lancing, which can be performed without any significant adverse effects.
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Affiliation(s)
- Zohreh Badiee
- Department of Pediatrics, School of Medicine, and Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Zohreh Nassiri
- Department of Pediatrics, School of Medicine, and Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirmohammad Armanian
- Department of Pediatrics, School of Medicine, and Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst Rev 2014:CD008435. [PMID: 24459000 DOI: 10.1002/14651858.cd008435.pub2] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC), otherwise known as Kangaroo Care (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants. OBJECTIVES The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates undergoing painful procedures compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and the effects of the amount of SSC (duration in minutes) and the method of administration (who provided the SSC, positioning of caregiver and neonate pair).The secondary objectives were to determine the incidence of untoward effects of SSC and to compare the SSC effect in different postmenstrual age subgroups of infants. SEARCH METHODS The standard methods of the Cochrane Neonatal Collaborative Review Group were used. Databases searched in August 2011: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library); Evidence-Based Medicine Reviews; MEDLINE (1950 onwards); PubMed (1975 onwards); EMBASE (1974 onwards); CINAHL (1982 onwards); Web of Science (1980 onwards); LILACS database (1982 onwards); SCIELO database (1982 onwards); PsycInfo (1980 onwards); AMED (1985 onwards); Dissertation-Abstracts International (1980 onwards). Searches were conducted throughout September 2012. SELECTION CRITERIA Studies with randomisation or quasi-randomisation, double or single-blinded, involving term infants (> 37 completed weeks postmenstrual age (PMA)) to a maximum of 44 weeks PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by doctors, nurses, or other healthcare professionals. DATA COLLECTION AND ANALYSIS The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A weighted mean difference (WMD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC. MAIN RESULTS Nineteen studies (n = 1594 infants) were included. Fifteen studies (n = 744) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), two used intramuscular injection, and one used 'vaccination' (n = 80). The studies that were included were generally strong and free from bias.Eleven studies (n = 1363) compared SSC alone to a no-treatment control. Although 11 studies measured heart rate during painful procedures, data from only four studies (n = 121) could be combined to give a mean difference (MD) of 0.35 beats per minute (95% CI -6.01 to 6.71). Three other studies that were not included in meta-analyses also reported no difference in heart rate after the painful procedure. Two studies reported heart rate variability outcomes and found no significant differences. Five studies used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (n = 268) (MD -3.21, 95% CI -3.94 to -2.48), 60 seconds (n = 164) (MD -1.85, 95% CI -3.03 to -0.68), and 90 seconds (n = 163) (MD -1.34, 95% CI -2.56 to -0.13), but at 120 seconds (n = 157) there was no difference. No studies provided findings on return of heart rate to baseline level, oxygen saturation, cortisol levels, duration of crying, and facial actions that could be combined for analysis.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate but not oxygen saturation. SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but was not different to breastfeeding. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. AUTHORS' CONCLUSIONS SSC appears to be effective, as measured by composite pain indicators and including both physiological and behavioural indicators, and safe for a single painful procedure such as a heel lance. Purely behavioural indicators tended to favour SSC but there remains questionable bias regarding behavioural indicators. Physiological indicators were typically not different between conditions. Only two studies compared mother providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. New studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed.
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Affiliation(s)
- Celeste Johnston
- Ingram School of Nursing, McGill University, Quebec, Canada, H3A 2T5
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Lai NM, Foong SC, Foong WC, Tan K. Co-bedding in neonatal nursery for promoting growth and neurodevelopment in stable preterm twins. Cochrane Database Syst Rev 2012; 12:CD008313. [PMID: 23235658 DOI: 10.1002/14651858.cd008313.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND With the increased birth rate of twins during the recent decades and improved prognosis of preterm infants, there is a need to explore measures that could optimise their growth and neurodevelopmental outcomes. It has been postulated that co-bedding simulates the twins' intrauterine experiences in which co-regulatory behaviours between the twins are observed. These behaviours are proposed to benefit the twins by reducing their stress, which may promote growth and development. However, uncertainties exist on the benefit-risk profile of co-bedding in practice. OBJECTIVES We aimed to assess the effects of co-bedding on growth, and other clinically relevant physiological and neurodevelopmental outcomes for stable preterm twins. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 7), MEDLINE (via PubMed), EMBASE (hosted by EBCHOST), CINAHL and references cited in our shortlisted articles using keywords and MesH headings, up to July 2012. SELECTION CRITERIA We included randomised controlled trials with randomisation either at the level of each twin pair and/or at the level of neonatal unit. We excluded cross-over studies. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the CNRG. Two review authors independently assessed the relevance and risk of bias of the retrieved records. We contacted the authors of the included studies if important information was missing from their published papers. We expressed our results using risk ratio (RR) and mean difference (MD) where appropriate with their 95% confidence intervals (CIs). We adjusted the unit of analysis from individual infants to twin pairs by averaging the measurement for each twin pair (continuous outcome) or by counting the outcome as positive if any of the twins developed the outcome (dichotomous outcome). MAIN RESULTS Five studies met the inclusion criteria; however, data were only available for analysis in four studies. Four of the five included studies were small and had significant limitations in design. As each study reported the outcomes differently, data for most of the outcomes were effectively contributed by a single study. There were no differences between co-bedded twins and twins that received separate care in the rate of weight gain (MD 0.20 grams/kg/day, 95% CI: -1.60 to 2.00), apnoea, bradycardia and desaturation (A/B/D) episodes (RR: 0.85, 95% CI: 0.18 to 4.05; 1 study), length of hospital stay (MD -4.90 days, 95% CI: -35.23 to 25.43) and infection rates (typical RR: 0.84, 95% CI: 0.30 to 2.31; 3 studies). There were also no differences in parental perceptions of care. Co-bedded twins appeared to spend more time crying, but they also seemed to spend more time in quiet sleep. There was low or very low quality of evidence across all the outcomes. AUTHORS' CONCLUSIONS There was insufficient evidence on the benefits and harms of co-bedding stable preterm twins to make any recommendation in practice. There is a need for future studies that are adequately powered to detect clinically important differences in growth and neurodevelopment. Such studies should also assess harms including infections and medication errors, and caregiver satisfaction.
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Affiliation(s)
- Nai Ming Lai
- Department of Paediatrics, Paediatric and Child Health Research Group, University of Malaya Medical Center, Kuala Lumpur,Malaysia.
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