Culturally Based Practice in Neonatal Procedural Pain Management: A Mini Review

The effectiveness of massage interventions on procedural pain in neonates: A systematic review and meta-analysis

BACKGROUND

The painful procedures experienced by neonates during hospitalization have short-term or long-term effects on neonates. While the limitations of previous interventions make it imperative to explore effective interventions that are readily available. This systematic review and meta-analysis was conducted to evaluate the safety and effectiveness of massage for pain management in neonates.

METHODS

This systematic review was registered in PROSPER. PubMed, Embase, Cochrane Library, and the Clinical Trials Registry were searched to December 2021. Two reviewers independently carried out study selection, data extraction, bias risk assessment. Continuous data were analyzed by mean differences (MD). Dichotomous data were reported using relative risk. If at least two studies reported identical results by the same pain assessment tool, a meta-analysis was conducted using random effect model and inverse variance.

RESULTS

Total 11 included studies involving 755 neonates investigated the effects of massage on neonatal pain response compared to standard care. The meta-analysis showed that massage could effectively improve pain response in neonates compared to standard care no matter whether neonatal infant pain scale (NIPS) or premature infant pain profile (PIPP) was used as an assessment tool. Besides, massage was also effective for crying duration, blood oxygen saturation both during and after the procedure, but non-effective for the variation of respiratory rate after the procedure, and heart rate both during and after the procedure.

CONCLUSIONS

Massage may have a positive effect on pain relief of neonate, and rigorous trials are needed in the future to determine the most effective massage method.

Efficacy and safety of non-pharmacological interventions for neonatal pain: an overview of systematic reviews

OBJECTIVES

To synthesise current evidence from systematic reviews (SRs) regarding the efficacy and safety of non-pharmacological interventions to prevent and treat pain in newborn infants.

DESIGN

Overview of SRs.

DATA SOURCES

We searched PubMed, Embase, Cochrane Library, Web of Science, CINAHL, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, Chinese Science and Technology Periodical Database (VIP) and Google Scholar to identify all relevant SRs published in the last 5 years.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included SRs that evaluated the efficacy and safety of non-pharmacological interventions for neonatal pain.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data, assessed the methodological quality using a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 and graded the evidence quality with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 29 SRs were included in this overview, of which 28 focused on procedural pain and only 1 focused on postoperative pain. Based on AMSTAR 2, seven reviews were found to be of 'high quality', eight of 'moderate quality', five of 'low quality' and nine of 'critically low quality'. The GRADE results suggested that facilitated tucking, kangaroo care, sweet solutions, familiar odour or combined non-pharmacological interventions, such as a combination of sucrose and non-nutritive sucking, were effective and safe in reducing pain from medical procedures in neonates. However, sucrose alone was less effective than local anaesthesia or a combination of the two during circumcision.

CONCLUSIONS

Facilitated tucking, small volumes of sweet solutions, kangaroo care and familiar odour were recommended. Scientific implementation strategies should be developed to promote the clinical use of these effective non-pharmacological interventions. Meanwhile, further rigorous trials and SRs are needed to identify the best non-pharmacological approaches for pain from common surgery and illnesses in neonates.

PROSPERO REGISTRATION NUMBER

CRD42021292583.

Comparison of the analgesic effect of inhaled lavender vs vanilla essential oil for neonatal frenotomy: a randomized clinical trial (NCT04867824)

It is necessary to treat neonatal pain because it may have short- and long-term adverse effects. Frenotomy is a painful procedure where sucking, a common strategy to relieve pain, cannot be used because the technique is performed on the tongue. In a previous randomized clinical trial, we demonstrated that inhaled lavender essential oil (LEO) reduced the signs of pain during neonatal frenotomy. We aimed to find out whether inhaled vanilla essential oil (VEO) is more effective in reducing pain during frenotomy than LEO. Randomized clinical trial with neonates who underwent a frenotomy for type 3 tongue-ties between May and October 2021. Pain was assessed using pre and post-procedure heart rate (HR) and oxygen saturation (SatO2), crying time, and NIPS score. Neonates were randomized into "experimental" and "control" group. In both groups, we performed swaddling, administered oral sucrose, and let the newborn suck for 2 min. We placed a gauze pad with one drop of LEO (control group) or of VEO (experimental group) under the neonate's nose for 2 min prior to and during the frenotomy. We enrolled 142 neonates (71 per group). Both groups showed similar NIPS scores (2.02 vs 2.38) and crying times (15.3 vs 18.7 s). We observed no differences in HR increase or in SatO2 decrease between both groups. We observed no side effects in either of the groups.

CONCLUSIONS

We observed no appreciable difference between LEO and VEO; therefore, we cannot conclude which of them was more effective in treating pain in neonates who underwent a frenotomy.

TRIAL REGISTRATION

 This clinical trial is registered with www.

CLINICALTRIALS

gov with NCT04867824.

WHAT IS KNOWN

• Pain management is one of the most important goals of neonatal care as it can have long-term neurodevelopmental effects. • Lavender essential oil can help relieve pain due to its sedative, antispasmodic, and anticolic properties.

WHAT IS NEW

• Lavender and vanilla essential oils are safe, beneficial, easy to use, and cheap in relieving pain in neonates who undergo a frenotomy for type 3 tongue-ties.

Analgesic effect of inhaled lavender essential oil for frenotomy in healthy neonates: a randomized clinical trial

BACKGROUND

Neonatal pain may affect long-term neurodevelopment and must be treated. Frenotomy is a painful procedure wherein a common strategy to relieve pain (sucking) cannot be used because the technique is performed on the tongue. Lavender essential oil (LEO) has sedative and antispasmodic properties and has been successfully used to treat pain during heel puncture and vaccination. Our aim was to demonstrate if the use of inhaled LEO is effective in reducing pain during frenotomy in healthy, full-term neonates.

METHODS

We conducted a randomized clinical trial in neonates who underwent a frenotomy between August 2020 and April 2021. We assessed pain using pre and post-procedure heart rate and oxygen saturation, crying time and Neonatal Infant Pain Scale (NIPS) score. Patients with type 3 tongue tie were randomized into the "experimental group" and "control group". In both groups, we performed swaddling, administered oral sucrose, and let the newborn suck for two minutes. In the experimental group, we also placed a gauze pad with one drop of LEO under the neonate's nose for two minutes prior to and during the frenotomy.

RESULTS

We enrolled 142 patients (71 per group). The experimental group showed significantly lower NIPS scores (1.88 vs 2.92) and cried almost half the amount of time (14.8 vs. 24.6 seconds, P = 0.006). Comparing with the control group, we observed no side effects in either of the groups.

CONCLUSIONS

We observed a significant decrease in crying time and lower NIPS scores in the neonates who received inhaled LEO and underwent a frenotomy for type 3 tongue-ties. Thus, we recommend using inhaled LEO during neonatal frenotomies.

Changes in Physicians' Perceptions and Practices on Neonatal Pain Management Over the Past 20 Years. A Survey Conducted at Two Time-Points

Intense research for more than three decades expelled the view that neonates do not experience pain. The aim of this survey was to investigate whether the Greek physicians involved in neonatal intensive care have changed their perceptions regarding neonatal pain, adapting their management practices to the knowledge that have emerged in the past 20-years. This study is a survey conducted at two time-points, 20 years apart. Anonymous questionnaires were distributed to 117 and 145 physicians working in neonatal intensive care units (NICUs) all over Greece in years 2000 and 2019, respectively. The response rate was 90.6 and 80.7% in 2000 and 2019, respectively. All respondents, at both time-points, believed that neonates experience pain, which has serious acute and long-term consequences, while the vast majority considered analgesia-sedation (A-S) during painful interventions as obligatory. Utilization of NICU protocols and pain assessment tools remained low although increased significantly between 2000 and 2019. The use of systemic A-S postoperatively was high at both time-points, while its implementation in infants subjected to prolonged pain, specifically mechanical ventilation, increased significantly by 2019. Systemic or local analgesia for acute procedural pain was used by lower proportions of physicians in 2019, except for the tracheal intubation. In contrast, the use of sweet solutions and non-pharmacological measures prior to or during bedside procedures significantly increased over time. Opioid administration significantly increased, while a shift from morphine to fentanyl was observed. International literature and perinatal-neonatal congresses were stated as the main sources of updating physicians' knowledge and improving management practice on neonatal pain prevention and treatment. In conclusion, Greek NICU-physicians' perceptions that neonates can experience pain with potentially serious acute and long-term consequences remained strong over the past 20 years. Although physicians' practices on neonatal pain management improved, they are still suboptimal, while significant differences exist among centers. Continuing education, globally accepted management protocols, and readily applied pain assessment tools would further improve the management of procedural pain and stress in neonates.