Efficacy of Breast Milk Olfactory and Gustatory Interventions on Neonates’ Biobehavioral Responses to Pain during Heel Prick Procedures

The Effect of Breast Milk Odor on the Pain and Stress Levels of the Newborn During the Endotracheal Suction Procedure

Objective: The study aimed to determine the effect of the breast milk odor on the pain and stress levels of the newborn during the endotracheal suction procedure. Method: The study was conducted in the randomized-controlled experimental design at the neonatal intensive care unit of the hospital in eastern Turkey between March 2022 and December 2023. The study population included newborns at the 37th to 41st gestational weeks who were receiving mechanical ventilation treatment in the neonatal intensive care unit of a hospital in eastern Turkey. All newborns who met the inclusion criteria during the data collection phase were included in the study. The study was completed with 88 newborns (44 in the intervention group and 44 in the control group). The Newborn Introductory Information Form, ALPS-Neo Newborn Pain and Stress Assessment Scale, and follow-up form were used to collect the study data. The breast milk odor of the mothers of the newborns was used as the intervention group in the study. The mothers of the newborns were contacted to obtain breast milk, and the information was obtained from the mother on the day of the procedure. One milliliter of breast milk was taken and dropped into a sterile sponge, and it was held 10 cm away from the baby's nose from 5 minutes before to 5 minutes after endotracheal suction. A routine endotracheal suction process was performed in the control group. Ethical principles were followed in the study. Results: We found that the intervention group's pain and stress score averages were lower than the control group during and after the endotracheal suction procedure (p < 0.05). Conclusion: We found that the breast milk odor reduced the pain, stress levels, and crying duration of newborns during the endotracheal suction process.

Non-pharmacological management of infant and young child procedural pain

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.

The Effect of Gentle Touch on Cardiorespiratory Indices and Pain Behaviors Related to Venipuncture and Blood Sampling in Preterm Infants Under Intensive Care

Background

Infants undergo extremely painful procedures in a Neonatal Intensive Care Unit (NICU), which if left uncontrolled may cause complications. Therefore, this study was conducted to investigate gentle touch effect on cardiorespiratory indices and pain behaviors related to venipuncture and blood sampling in preterm infants.

Materials and Methods

A quasi-experimental study was undertaken in gentle touch and control groups in three stages. The population included premature infants in NICU of Al-Zahra Hospital, Isfahan, Iran. Using convenience sampling, 52 infants were randomly selected and assigned to two groups (n = 26). Gentle touch technique and measurement of cardiorespiratory indices were performed 5 minutes before, during, and 5 minutes after procedure, and routine care was provided for control group. Neonatal pain and cardiorespiratory indices were assessed using the Neonatal Infant Pain Scale (NIPS) and an intensive care monitor. Data was analyzed using repeated measures ANOVA, independent t-test, and Chi-square test in SPSS software.

Results

The independent t-test revealed a significant difference between mean pain score of the infants in two groups during the procedures (t50 = -3.32, p = 0.002), but no significant different was between groups before and after the procedure (p > 0.05). However, the cardiorespiratory indices were not significantly different before, during, and after the procedure (p > 0.05).

Conclusions

The results suggest that gentle touch reduced the infants' pain during venipuncture and blood sampling. Thus, it is recommended this method be applied to mitigate pain in premature infants.