Bernese Pain Scale For Neonates Research Articles

Pain responses in preterm infants and parental stress over repeated painful procedures: a randomized pilot trial

Objectives In this pilot study, the aims were to determine the feasibility of whether pain behavior in extremely and very preterm infants and perceived parental stress change when parents are involved in pain reducing measures, either actively, performing facilitated tucking or passively, observing the intervention, in comparison to the involvement of nurses only. In addition, the infant’s pain reactivity and parental stress over three time points of measurement was of interest. Methods Extremely and very preterm infants in need of subcutaneous erythropoietin were randomly assigned to the two intervention groups. The intervention encompassed that one parent of each infant was involved during the painful procedure: Either parents executed facilitated tucking themselves or stood by, observing the procedure. Usual care involved that nurse executed facilitated tucking. All infants received 0.5 ml of 30% oral glucose solution via cotton swab before the painful procedure. Infant pain was observed with the Bernese Pain Scale for Neonates (BPSN) and measured with the MedStorm skin conductance algesimeter (SCA) before, during, and after the procedure. Parents’ stress levels were measured before and after the painful procedure on the infant, using the Current Strain Short Questionnaire (CSSQ). Feasibility of a subsequent trial was determined by assessing recruitment, measurement and active parental involvement. Quantitative data collection methods (i.e. questionnaires, algesimeter) were employed to determine the number of participants for a larger trial and measurement adequacy. Qualitative data (interviews) was employed to determine parents’ perspectives of their involvement. Results A total of 13 infants (98% participation rate) were included along with their mothers. Median gestational age was 27 weeks (IQR 26-28 weeks), 62% were female. Two infants (12.5%) dropped out of the study as they were transferred to another hospital. Facilitated tucking turned out to be a good method to actively involve parents in pain reducing measures. No significant differences between the two intervention and control groups were found concerning parental stress and infant pain (p = .927). Power analysis indicated that at least N = 741 infants (power of 81%, α = .05) would be needed to obtain statistically significant results in a larger trial, as effect sizes were smaller than expected. Two of the three measurement tools – i.e. the BPSN and CSSQ) – proved easy to implement and were well accepted. owever, the SCA was challenging in this context. Measurements were also found to be time-consuming and resource-intense (i.e. health professionals as assistants). Conclusions Although the intervention was feasible and was readily accepted by parents, the study design was found to be challenging along with the SCA. In preparation of the larger trial, the study design needs to be revisited and adjusted. Thus, issues of time and resources may be resolved. In addition, national and international collaboration with similar neonatal intensive care units (NICU) needs to be considered. Thus, it will be possible to conduct an appropriately powered larger trial, which will yield important results to improve pain management in extremely and preterm infants in NICU.

Avoiding use of lid speculum and indentation reduced infantile stress during retinopathy of prematurity examinations.

To study the safety and efficacy of indirect ophthalmoscopy with (Sp) or without (speculum free, SpF) the use of lid speculum and scleral indentation for retinopathy of prematurity (ROP) screening. In this crossover randomized controlled trial, preterm infants received either the Sp on their first and the SpF technique on their second examination a week later or vice versa. Video recordings of the infants' reactions were assessed by two observers, using Premature Infant Pain Profile-Revised score and the crying score of the Bernese Pain Scale for Neonates. Fundoscopy adequacy, its duration and adverse events within the first 24 hr postscreening were also recorded. Thirty-seven infants with median (interquartile range) gestational age of 28.7 (28.0, 30.2) weeks and mean (standard deviation, SD) birth weight 1225 (377) grams were enrolled. The mydriasis-induced stress was similar between the Sp and SpF exam (mean difference [MD]: 0.78, 95% confidence interval [CI]: -0.83, 2.38; p = 0.33). The stress induced by fundoscopy (MD: 4.98, 95% CI: 3.58, 6.37; p < 0.001) and examination overall (MD: 2.32, 95% CI: 0.96, 3.67; p = 0.001) were higher in the Sp than in the SpF exam, and so was the crying score during fundoscopy (MD: 1.31, 95% CI: 1.06, 1.56; p < 0.001). Adverse events in the two groups were similar (p = 0.13). Fundoscopy was adequate in identifying the absence of treatment-requiring ROP in all cases, and lasted longer in the Sp than in the SpF exam (p < 0.001). Our study suggests that the use of speculum and indentation should be reserved for the few cases where fundus visualization is insufficient for excluding the presence of severe ROP.

Implementierung eines neonatalen Schmerzassessmentinstruments auf einer neonatologischen Intensivstation - Ein Qualitätsentwicklungsprojekt.

Implementation of a Neonatal Pain Assessment Instrument at a Neonatal Intensive Care Unit - A Quality Improvement Project Abstract. Background: Optimal pain management is necessary in order to not jeopardize the development of preterm neonates. Aim: Implementation and evaluation of systematic and best possible pain assessment with the Bernese Pain Scale for Neonates for all preterm and sick neonates of a neonatal intensive care unit by nursing staff. Methods: The educational concept is based on three key strategies: knowledge translation (group- and one-on-one training), reflection (case conferences) and clinical training. The frequency of the use of the Pain Score was recorded before (T0) and after implementation (T1) and six months after completion of the project (T2). Results: Before the implementation (T0) the use of the Bernese Pain Scale was regulated by an internal guideline but its application could not be verified during the baseline period (fulfillment rate of 0 %). After implementation (T1) at least one assessment per shift per neonate could be achieved in 99.1 % of the cases. Nurses conducted 210 assessments on 38 neonates in T1. In follow-up (T2) six months after implementation fulfillment rate of 100 % in 34 neonates was achieved with 188 pain assessments. Conclusions: This implementation strategy was successful in establishing the assessment instrument in clinical practice.

Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors.

Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered. We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN. We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models. Premature birth (b=-0.721), caffeine (b=-0.302), and the behavioural states quiet and awake (b=-0.283), active and asleep (b=-0.158), and quiet and asleep (b=-0.498) were associated with changes in behavioural pain scores. Premature birth (b=-0.232), mechanical ventilation (b=-0.196), and duration of the heel stick procedure (b=0.0004) were associated with changes in physiological pain scores. Premature birth (b=-0.907), Caffeine (b=-0.402), the behavioural states quiet and awake (b=-0.274), and quiet and asleep (b=-0.459), and duration of the heel stick procedure (b=0.001) were associated with changes in the modified BPSN total scores. Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs. We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.

Prophylactic low-dose paracetamol administration associated with lowered rate of patent ductus arteriosus in preterm infants – Impact on outcome and pain perception

To determine the rate of patent ductus arteriosus after prophylactic low-dose paracetamol administration, the impact on outcome parameters, possible treatment side-effects and the influence on pain perception. We report retrospective single-centre outcome data of premature infants ≤ 32 weeks of gestation (n = 476). The intervention group received intravenous paracetamol, the control group obtained no preventive therapy. Ductal closure rate and outcome parameters were compared between the two groups. Adverse effects were determined by laboratory parameters. For the assessment of pain the Bernese Pain Scale for Neonates was used. The rate of patent ductus arteriosus was significantly lower in the paracetamol-treated group compared to the control group (13.6% vs. 38.2%, p < 0.001). With regard to secondary outcome parameters, severe and moderate bronchopulmonary dysplasia (2.7% vs. 7.4%, p = 0.023), severe retinopathy of prematurity (0% vs. 4.4%, p = 0.002) and late onset sepsis (2.7% vs. 8.3%, p = 0.009) were significantly less frequent in the paracetamol group. Except for a 1.5-fold increased risk for hyperbilirubinemia (86.0% vs. 77.6%, p = 0.035) in the paracetamol group following treatment, no significant differences in laboratory parameters were found. Relating to pain, the administration of Glucose 33% was significantly more often necessary in the control group compared to the paracetamol-treated group (mean 13.48 vs. 8.71, p < 0.001), just as the need for additional treatment with systemic analgesics, which was more frequent in the control group (mean 0.72 vs. 0.57, p = 0.361). In our study we were able to show a significantly lower rate of patent ductus arteriosus after prophylactic paracetamol administration without serious adverse effect, but a beneficial influence of this regime on the patient's pain perception.

The influence of gestational age in the psychometric testing of the Bernese Pain Scale for Neonates

BackgroundAssessing pain in neonates is challenging because full-term and preterm neonates of different gestational ages (GAs) have widely varied reactions to pain. We validated the Bernese Pain Scale for Neonates (BPSN) by testing its use among a large sample of neonates that represented all GAs.MethodsIn this prospective multisite validation study, we assessed 154 neonates between 24 2/7 and 41 4/7 weeks GA, based on the results of 1–5 capillary heel sticks in their first 14 days of life. From each heel stick, we produced three video sequences: baseline; heel stick; and, recovery. Five blinded nurses rated neonates’ pain responses according to the BPSN. The underlying factor structure of the BPSN, interrater reliability, concurrent validity with the Premature Infant Pain Profile-Revised (PIPP-R), construct validity, sensitivity and specificity, and the relationship between behavioural and physiological indicators were explored. We considered GA and gender as individual contextual factors.ResultsThe factor analyses resulted in a model where the following behaviours best fit the data: crying; facial expression; and, posture. Pain scores for these behavioural items increased on average more than 1 point during the heel stick phases compared to the baseline and recovery phases (p < 0.001). Among physiological items, heart rate was more sensitive to pain than oxygen saturation. Heart rate averaged 0.646 points higher during the heel stick than the recovery phases (p < 0.001). GA increased along with pain scores: for every additional week of gestation, the average increase of behavioural pain score was 0.063 points (SE = 0.01, t = 5.49); average heart rate increased 0.042 points (SE = 0.01, t = 6.15). Sensitivity and specificity analyses indicated that the cut-off should increase with GA. Modified BPSN showed good concurrent validity with the PIPP-R (r = 0.600–0.758, p < 0.001). Correlations between the modified behavioural subscale and the item heart rate were low (r = 0.102–0.379).ConclusionsThe modified BPSN that includes facial expression, crying, posture, and heart rate is a reliable and valid tool for assessing acute pain in full-term and preterm neonates, but our results suggest that adding different cut-off points for different GA-groups will improve the BPSN’s clinical usefulness.Trial registrationThe study was retrospectively registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461. Registration date: 12 April 2016.

Individual contextual factors in the validation of the Bernese pain scale for neonates: protocol for a prospective observational study

BackgroundThe Bernese Pain Scale for Neonates (BPSN) is a multidimensional pain assessment tool that is already widely used in clinical settings in the German speaking areas of Europe. Recent findings indicate that pain responses in preterm neonates are influenced by individual contextual factors, such as gestational age (GA), gender and the number of painful procedures experienced. Currently, the BPSN does not consider individual contextual factors. Therefore, the aim of this study is the validation of the BPSN using a large sample of neonates with different GAs. Furthermore, the influence of individual contextual factors on the variability in pain reactions across GA groups will be explored. The results will be used for a modification of the BPSN to account for individual contextual factors in future clinical pain assessment in neonates.Methods and designThis prospective multisite validation study with a repeated measures design will take place in three university hospital neonatal intensive care units (NICUs) in Switzerland (Bern, Basel and Zurich). To examine the impact of GA on pain responses and their variability, the infants will be stratified into six GA groups ranging from 24 0/7 to 42 0/7. Among preterm infants, 2–5 routine capillary heel sticks within the first 14 days of life, and among full-term infants, two heel sticks during the first days of life will be documented. For each heel stick, measurements will be video recorded for each of three phases: baseline, heel stick, and recovery. The infants’ pain responses will be rated according to the BPSN by five nurses who are blinded as to the number of each heel stick and as to the measurement phases. Individual contextual factors of interest will be extracted from patient charts.DiscussionUnderstanding and considering the influence of individual contextual factors on pain responses in a revised version of the BPSN will help the clinical staff to more appropriately assess pain in neonates, particularly preterm neonates hospitalized in NICUs. Pain assessment is a first step toward appropriate and efficient pain management, which itself is an important factor in later motor and cognitive development in this vulnerable patient population.Trial registrationThe study is registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461. Registration date: 12 April 2016.

Comparison of Two Different Doses of Sucrose in Pain Relief by Using Bernese Pain Scale for Neonates

Comparison of Two Different Doses of Sucrose in Pain Relief by Using Bernese Pain Scale for Neonates

Rectal Paracetamol in Newborn Infants after Assisted Vaginal Delivery May Increase Pain Response

To assess the efficacy of paracetamol (acetaminophen) for neonatal pain relief. Randomized, double-blind placebo-controlled trial in 3 Swiss university hospitals. Term and near-term infants (n = 123) delivered by forceps or vacuum were randomized to receive 2 suppositories with paracetamol (60/80/100 mg in infants <3000 g/3000-4000 g/>4000 g birth weight) or placebo at 2 and 8 hours of life. Pain and discomfort during the first 24 hours was assessed by the échelle de douleur et d'inconfort du nouveau né [neonatal pain and discomfort scale] score. The response to the subsequent heel prick for metabolic screening at days 2-3 of life was investigated by the Bernese Pain Scale for Neonates (BPSN). The échelle de douleur et d'inconfort du nouveau né [neonatal pain and discomfort scale] pain scale ratings after assisted vaginal delivery were low and declined within 4 hours of life (P < .01) irrespective of paracetamol administration. At 2-3 days of life, BPSN scores after heel prick were significantly higher in infants who had received paracetamol, compared with controls, both when BPSN were scored by nurses at the bedside (median [IQR] 4 [2-7] vs 2 [0-5], P = .017) or off-site from videos (4 [2-8] vs 2 [1-7], P = .04). Thirty-five of 62 (57%) infants treated with paracetamol cried after heel prick, compared with 25 of 61 (41%) controls (P = .086). Infants born by assisted vaginal delivery have low pain scores in the immediate period after birth. Paracetamol given to newborns soon after birth may aggravate a subsequent stress response.

Contextual factors associated with pain response of preterm infants to heel‐stick procedures

Evidence indicates that medical and demographic contextual factors (cFs) impact pain responses in preterm neonates, but the existing evidence is very heterogeneous. To explore the effect of cFs on pain responses to heel-stick procedures of preterm infants. This study was a secondary analysis of data collected during a randomized controlled trial examining pain response to non-pharmacological interventions across repeated heel sticks. Five heel sticks across the first 14 days of life were videotaped. Pain response was rated with the Bernese Pain Scale for Neonates (BPSN) by four raters blinded to the heel-stick phases (baseline, heel stick, recovery). Demographic and medical cFs were extracted from medical charts. Mixed single and multiple regression analyses were performed controlling for the intervention group, site and heel-stick phase. Apgar scores at 1 min were negatively associated with behavioural (p = 0.002) BPSN scores, while Apgar scores at 5 min after birth were positively associated with behavioural (p = 0.006) scores. Accumulated number of painful procedures (p = 0.002) and gender (p = 0.02) were positively associated with physiological scores while continuous positive airway pressure CPAP (p = 0.009) and mechanical ventilation (p = 0.005) were negatively associated. Higher exposure to painful procedures, male infants and having CPAP or mechanical ventilation were cFs associated with physiological response. The only variables significantly associated with behavioural BPSN scores were Apgar scores but these relationships were inconsistent.

Oral Sucrose and “Facilitated Tucking” for Repeated Pain Relief in Preterms: A Randomized Controlled Trial

To test the comparative effectiveness of 2 nonpharmacologic pain-relieving interventions administered alone or in combination across time for repeated heel sticks in preterm infants. A multicenter randomized controlled trial in 3 NICUs in Switzerland compared the effectiveness of oral sucrose, facilitated tucking (FT), and a combination of both interventions in preterm infants between 24 and 32 weeks of gestation. Data were collected during the first 14 days of their NICU stay. Three phases (baseline, heel stick, recovery) of 5 heel stick procedures were videotaped for each infant. Four independent experienced nurses blinded to the heel stick phase rated 1055 video sequences presented in random order by using the Bernese Pain Scale for Neonates, a validated pain tool. Seventy-one infants were included in the study. Interrater reliability was high for the total Bernese Pain Scale for Neonates score (Cronbach's α: 0.90-0.95). FT alone was significantly less effective in relieving repeated procedural pain (P < .002) than sucrose (0.2 mL/kg). FT in combination with sucrose seemed to have added value in the recovery phase with lower pain scores (P = .003) compared with both the single-treatment groups. There were no significant differences in pain responses across gestational ages. Sucrose with and without FT had pain-relieving effects even in preterm infants of <32 weeks of gestation having repeated pain exposures. These interventions remained effective during repeated heel sticks across time. FT was not as effective and cannot be recommended as a nonpharmacologic pain relief intervention for repeated pain exposure.

Endogenous Stress Response on Pentatonic Music in Very Low Birthweight Infants

Background: Music exposition of prematures has previously been reported to reduce pain, improve vital signs and result in overall non-specific “well-being”. Valid data on endogenous stress hormone response to music, determined by salivary cortisol levels, are scarce. Objective: The aim of this study was to test the effect of live pentatonic music on the ambient stress level of very low birthweight infants. Methods: Stable infants (birthweight 500 - 1500 g, mean age: 22 days, n=16) were exposed to 15 minutes of live harp music on 3 consecutive days, at the same time of the day. Music was identically played on a kantele. Saliva was collected prior to music exposition and at defined time points after music. Salivary cortisol and cortisone levels were measured by liquid-chromatography-tandem-mass-spectrometry and salivary cortisol additionally by ELISA (n=10). Stress levels were additionally assessed by recordings of heart rate, respiratory rate and oxygen saturation. Pain level was determined by Bernese-Pain-Scale-for-Neonates (BSN). Results: Salivary cortisol decreased from baseline to 25 minutes and 4 hours after intervention on all 3 days (p < 0.05 on day 1 and 3). Apneas, the number of desaturations as well as BSN levels improved significantly on all 3 days (p< 0.05). Conclusion: Our findings indicate that pentatonic music exposition can decrease stress hormone levels of preterm neonates in a NICU environment. These are the first data regarding the effect of music exposition on stress hormone levels in a sufficient cohort of VLBW infants supporting a positive effect of music on these infants.

Variability in pain response to a non‐pharmacological intervention across repeated routine pain exposure in preterm infants: a feasibility study

To explore the variability in pain response in preterm infants across time who received sucrose during routine heel stick. Single group, exploratory repeated measures design. Two tertiary level neonatal intensive care units (NICU) in Switzerland. Nine preterm infants born between 28 2/7 and 31 4/7 weeks of gestation during their first 14 days of life. Pain was assessed by the Bernese Pain Scale for Neonates (BPSN), the Premature Infant Pain Profile (PIPP) and the Visual Analogue Scale (VAS). Salivary cortisol was analysed. 72-94% of the variability was within-subject variability, indicating inconsistency of pain responses across the 5 heel sticks. Interrater agreement was highest during heel sticks 1-3 and decreased during heel stick 4 and 5, indicating a possible alteration of pain patterns. No significant differences in the amount of cortisol could be detected before and after the heel sticks (p = 0.55), indicating no stress-induced peak after the painful intervention. However, a general gradual decrease of cortisol levels across time could be detected. A high variability in pain response among preterm neonates across time could be described. Consistency of cortisol levels before and after the heel sticks could indicate the effectiveness of sucrose across time.

Pain assessment in the neonate using the Bernese Pain Scale for Neonates

Background: Neonates who require treatment in the neonatal intensive care unit (NICU) are subjected to many invasive painful procedures. Aims: Assessment of pain in preterm and term neonates with or without ventilation on continuous positive airway pressure using the Bernese Pain-Scale for Neonates (BPSN). The validity and the reliability of the BPSN was established. Study design and subjects: Pain assessments ( n=288) were performed by 6 health care workers in different situations of term and preterm neonates. Each neonate ( n=12) was observed in four given situations (after feeding, while a foot was being warmed, while a routine capillary blood sample was taken and 15 min after the blood sample was taken). Pain assessments were made by two nurses at the bedside using the BPSN, the Visual-Analogue Scale (VAS) and the Premature Infant Pain Profile (PIPP). At the same time, a video sequence was made which was shown later to four different nurses to assess pain using the BPSN, the PIPP, and the VAS. Results: The construct validity of the BPSN was very good ( F=41.3, p<0.0001). Moreover, concurrent and convergent validity of the BPSN compared to VAS and PIPP was r=0.86, and r=0.91, p<0.0001, respectively. Finally, the study demonstrated high coefficients for interrater ( r=0.86–0.97) and intrarater reliability ( r=0.98–0.99). Conclusion: The BPSN was shown to be a valid and reliable tool for assessing pain in term and preterm neonates with and without ventilation.

Pain assessment in the neonate using the Bernese Pain Scale for Neonates

Background : Neonates who require treatment in the neonatal intensive care unit (NICU) are subjected to many invasive painful procedures. Aims : Assessment of pain in preterm and term neonates with or without ventilation on continuous positive airway pressure using the Bernese Pain-Scale for Neonates (BPSN). The validity and the reliability of the BPSN was established. Study design and subjects : Pain assessments ( n =288) were performed by 6 health care workers in different situations of term and preterm neonates. Each neonate ( n =12) was observed in four given situations (after feeding, while a foot was being warmed, while a routine capillary blood sample was taken and 15 min after the blood sample was taken). Pain assessments were made by two nurses at the bedside using the BPSN, the Visual-Analogue Scale (VAS) and the Premature Infant Pain Profile (PIPP). At the same time, a video sequence was made which was shown later to four different nurses to assess pain using the BPSN, the PIPP, and the VAS. Results : The construct validity of the BPSN was very good ( F =41.3, p <0.0001). Moreover, concurrent and convergent validity of the BPSN compared to VAS and PIPP was r =0.86, and r =0.91, p <0.0001, respectively. Finally, the study demonstrated high coefficients for interrater ( r =0.86–0.97) and intrarater reliability ( r =0.98–0.99). Conclusion : The BPSN was shown to be a valid and reliable tool for assessing pain in term and preterm neonates with and without ventilation.