Heel Lance Research Articles

Adaptation and Initial Validation of the Premature Infant Pain Profile–Revised (PIPP-R) in Brazil

BackgroundThe use of reliable pain assessment measures is essential for scoring and managing pain in infants. The Premature Infant Pain Profile (PIPP) is reliable and valid and has been recently revised. To adapt and validate the PIPP-R into Portuguese and to evaluate its psychometric properties are required to ensure maintenance of meaning and content. AimsThe aim of this study was to culturally adapt to Brazilian Portuguese and explore content validity and construct validity of the Premature Infant Pain Profile–Revised. DesignThis is a methodological study. Participants/SettingsTwo existing data sets of randomized clinical trials previously conducted were used to examine initial construct validity of the prefinal version of the Premature Infant Pain Profile–Revised. MethodsCross-cultural adaptation and validation occurred in four steps. Independent versions of the Premature Infant Pain Profile–Revised were produced, followed by the preparation of a synthetic version. Two back-translated versions were realized by professional translators. An expert committee evaluated idiomatic and semantic equivalence and clarity and relevance of the items. A content validity index was calculated. Finally, a consolidated prefinal version in Portuguese was then produced. ResultsNo difficulties in producing the material were reported. Semantic and idiomatic aspects were considered adequate, and content validity index was 1.0. Premature Infant Pain Profile and Premature Infant Pain Profile–Revised scores were highly correlated for pain after heel lancing and venipuncture (R2 = 0.986, p < .001) and for pain associated with analgesic strategies (R2 = 0.966-1.00, p < .001). ConclusionsThe Premature Infant Pain Profile–Revised was culturally adapted into Brazilian Portuguese. Appropriate content validity index was determined. Evidence of construct validity was also found. Future studies are warranted to explore the feasibility and other psychometric properties of using the Premature Infant Pain Profile–Revised translated and adapted into Brazilian Portuguese in the clinical setting.

Effects of Acupressure and Foot Massage on Pain During Heel Lancing in Neonates

Effects of Acupressure and Foot Massage on Pain During Heel Lancing in Neonates

Comparison of pain response to vein puncture versus heel lance among preterm infants undergoing blood sampling

Background Pain in neonates is largely underestimated and neglected. Accurate pain assessment is the first step toward effective pain management. Skin-breaking procedures such as heel lances, vein punctures, and arterial punctures are the most frequently performed painful procedures in neonatal ICUs. Few studies have been done to compare preterm infants’ pain response to heel lance vs venipuncture. Aim The aim was to compare pain response to venipuncture vs heel lance among preterm infants undergoing blood sampling. Materials and methods A comparative descriptive research design was used on a convenient sample of 60 preterm infants less than 37 weeks of gestation who were undergoing blood sampling for complete blood count, blood chemistry, or glucose estimation. Neonatal assessment sheet, blood sampling assessment sheet, and premature infant pain profile scale were used to collect data from two neonatal ICUs of both Cairo University Children Hospital (El Monira) and El Manial University Hospital (Kaser El Aini). After a written consent from parents, the same preterm infant pain response was continuously monitored 30 s before procedure and up to 6 min during the procedure over 2 days (one for venipuncture and one for heel lance). Results The total mean premature infant pain profile score significantly increased during venipuncture than heel lance. Behavioral state was significantly more unstable during vein puncture than heel lance. Venipuncture procedure significantly increased heart rate and decreased oxygen saturation more than heel lance. Conclusion Preterm infants perceive pain as demonstrated by premature infant pain profile scale and vein puncture is the more painful procedure than heel lancing for blood sampling in preterm infants. Recommendations Premature infant pain profile scale should be included in the routine assessment for preterm infants.

Erratum: Effect of music (Brahms lullaby) and non-nutritive sucking on heel lance in preterm infants: A randomized controlled crossover trial.

[This corrects the article DOI: 10.1093/pch/pxy072.].

Use of morphine before retinopathy of prematurity examinations

Use of morphine before retinopathy of prematurity examinations

Analgesic efficacy and safety of morphine in the Procedural Pain in Premature Infants (Poppi) study: randomised placebo-controlled trial

SummaryBackgroundInfant pain has immediate and long-term effects but is undertreated because of a paucity of evidence-based analgesics. Although morphine is often used to sedate ventilated infants, its analgesic efficacy is unclear. We aimed to establish whether oral morphine could provide effective and safe analgesia in non-ventilated premature infants for acute procedural pain.MethodsIn this single-centre masked trial, 31 infants at the John Radcliffe Hospital, Oxford, UK, were randomly allocated using a web-based facility with a minimisation algorithm to either 100 μg/kg oral morphine sulphate or placebo 1 h before a clinically required heel lance and retinopathy of prematurity screening examination, on the same occasion. Eligible infants were born prematurely at less than 32 weeks' gestation or with a birthweight lower than 1501 g and had a gestational age of 34–42 weeks at the time of the study. The co-primary outcome measures were the Premature Infant Pain Profile–Revised (PIPP-R) score after retinopathy of prematurity screening and the magnitude of noxious-evoked brain activity after heel lancing. Secondary outcome measures assessed physiological stability and safety. This trial is registered with the European Clinical Trials Database (number 2014-003237-25).FindingsBetween Oct 30, 2016, and Nov 17, 2017, 15 infants were randomly allocated to morphine and 16 to placebo; one infant assigned placebo was withdrawn from the study before monitoring began. The predefined stopping boundary was crossed, and trial recruitment stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. None of the co-primary outcome measures differed significantly between groups. PIPP-R score after retinopathy of prematurity screening was mean 11·1 (SD 3·2) with morphine and 10·5 (3·4) with placebo (mean difference 0·5, 95% CI −2·0 to 3·0; p=0·66). Noxious-evoked brain activity after heel lancing was median 0·99 (IQR 0·40–1·56) with morphine and 0·75 (0·33–1·22) with placebo (median difference 0·25, 95% CI −0·16 to 0·80; p=0·25).InterpretationAdministration of oral morphine (100 μg/kg) to non-ventilated premature infants has the potential for harm without analgesic efficacy. We do not recommend oral morphine for retinopathy of prematurity screening and strongly advise caution if considering its use for other acute painful procedures in non-ventilated premature infants.FundingWellcome Trust and National Institute for Health Research.

EEG, behavioural and physiological recordings following a painful procedure in human neonates

We present a dataset of cortical, behavioural, and physiological responses following a single, clinically required noxious stimulus in a neonatal sample. Cortical activity was recorded from 112 neonates (29–47 weeks gestational age at study) using a 20-channel electroencephalogram (EEG), which was time-locked to a heel lance. This data is linked to pain-related behaviour (facial expression), physiology (heart rate, oxygenation) and a composite clinical score (Premature Infant Pain Profile, PIPP). The dataset includes responses to non-noxious sham and auditory controls. The infants’ relevant medical and pain history was collected up to the day of the study and recorded in an extensive database of variables including clinical condition at birth, diagnoses, medications, previous painful procedures, injuries, and selected maternal information. This dataset can be used to investigate the cortical, physiological, and behavioural pain-related processing in human infants and to evaluate the impact of medical conditions and experiences upon the infant response to noxious stimuli. Furthermore, it provides information on the formation of individual pain phenotypes.

Twenty-Five Percent Dextrose and EBM in Pain Relief During Heel Lance in Late Preterm Babies Using the PIPP Score: A Randomized Controlled Trial

Objective: To compare the analgesic effect of 25% dextrose and expressed breast milk (EBM) in pain relief during heel lance in late preterm babies using the premature infant pain profile (PIPP) score. Study Design: Prospective, double blind, randomized controlled trial. Setting: The neonatal intensive care unit of Jaipur Golden Hospital, Rohini, Delhi. Participants: One-hundred eleven late preterm babies who required heel lancing for glycemic control and who were on oral feeds and were hemodynamically stable. Methodology: The babies were randomized into 2 intervention groups (25% dextrose and EBM) and control group (sterile water). The test solution of 2mL was given to baby 2 minutes before heel lancing. The facial response to pain (brow bulge, eye squeeze, and nasolabial furrow) was analyzed from the video. Maximum heart rate (HR) and minimum blood oxygen saturation (SpO2) were also recorded at 30 seconds, 1 minute, 1.5 minutes, and 2.5 minutes after heel lancing by another camera. Outcome Variable: PIPP score, HR, SpO2 at 30 seconds, 1 minute, 1.5 minutes, and 2.5 minutes after heel lancing. Results: A total of 63 babies were considered for final analysis with 21 each in the 25% dextrose, EBM, and sterile water groups. The mean PIPP score in the 25% dextrose, EBM, and control groups at 30 seconds were 4.52, 6.86, and 10.14, respectively ( P &lt; .001). At 1 minute, the PIPP scores were 3.24, 5.14, and 8.24, respectively, for the 25% dextrose, EBM, and control groups ( P &lt; .001). Twenty-five percent dextrose gave better pain relief than EBM. Mean difference between the PIPP score in the 25% dextrose and EBM groups was –2.34 and –1.9 at 30 seconds and 1 minute, respectively, after the painful procedure ( P = .001). Babies in intervention groups had less increase in HR and less decrease in SpO2. Conclusions: Twenty-five percent dextrose and EBM significantly reduced procedural pain in neonates, though pain relief was better in the 25% dextrose group as compared to the EBM group.

Asymmetric detrended fluctuation analysis in neonatal stress

Objective: To detect stress in newborns by observing heart rate (HR) variability utilizing an asymmetric detrended fluctuation analysis (ADFA), we sought to determine the fractal structure of the series of inter-beat intervals, so as to distinguish the periods of acceleration of the HR from decelerations. Thus, two scaling exponents, α+ and α−, representing decelerations and accelerations respectively, are obtained. Approach: Forty healthy term newborns were included in this study, undergoing two different types of stress stimuli: routine heel lance blood sampling for metabolic screening purposes, and its simulation by applying dull pressure on the heel. Main results: It appears that when newborns face stress, the scaling exponent related to accelerations significantly increases and becomes higher than the deceleration scaling exponent. To test the diagnostic properties of the scaling exponents, an ROC curve analysis was applied; α− showed good diagnostic performance with an AUC between 0.626 and 0.826, depending on the length of the time series. The joint use of α+ and α− further increased the diagnostic performance, in particular for shorter series of RR intervals, with an AUC between 0.691 and 0.833. Significance: ADFA, particularly of the acceleration scaling exponent, may be a useful clinical diagnostic tool for monitoring neonatal stress.

Laser Acupuncture on LI 4 Compared with Oral Glucose Administration for Pain Prevention in Healthy Term Neonates Undergoing Routine Heel Lance

Laser Acupuncture on LI 4 Compared with Oral Glucose Administration for Pain Prevention in Healthy Term Neonates Undergoing Routine Heel Lance

Effect of music (Brahms lullaby) and non-nutritive sucking on heel lance in preterm infants: A randomized controlled crossover trial.

ObjectivesThis study examined a more effective pain management method, without sucrose, on heel lance in preterm infants using the Premature Infant Pain Profile (PIPP).DesignIn a nonblinded, randomized controlled, two-period, two-sequence crossover trial, 25 infants were randomly allocated to intervention (a Brahms lullaby with non-nutritive sucking, facilitated tucking and holding) or standard care (facilitated tucking and holding).SettingLocal Perinatal Medical Centre’s NICU in Japan, July 2014 until June 2015.Outcome measuresThe primary outcome variable was PIPP, and secondary outcomes were heart rate (HR), oxygen saturation, and abnormal HR (> baseline mean plus 2 SDs, or <120 minus 2 SDs).ResultsThe infants were 33.8 weeks gestational age at birth, 1,983.7 g birth weight, and 32 to 35 weeks postconceptual age. At all 10 measurement points, constructed of every 30 seconds postheel lance, mean PIPP of infants during the intervention (3.6 to 2.4) was significantly lower than during the standard care (8.0 to 4.6) (range, P=0.0039 to P<0.0001). All PIPP reduction rates from the 30 seconds point were similar between the two groups. The HR of preterm infants at the 120 seconds points were significantly lower (P=0.0151), and the HRs of 6 points were considerably lower during the intervention than during the standard care (range, P≤0.0879 to P≥0.049). The abnormal HR total number was significantly lower during the intervention (2) than the standard care (23) (frequency ratio=0.087, P<0.0001).ConclusionThis method demonstrated stronger analgesia, early pain relief, and maintenance of homeostasis on heel lance in preterm infants.

The distribution of pain activity across the human neonatal brain is sex dependent

In adults, there are differences between male and female structural and functional brain connectivity, specifically for those regions involved in pain processing. This may partly explain the observed sex differences in pain sensitivity, tolerance, and inhibitory control, and in the development of chronic pain. However, it is not known if these differences exist from birth. Cortical activity in response to a painful stimulus can be observed in the human neonatal brain, but this nociceptive activity continues to develop in the postnatal period and is qualitatively different from that of adults, partly due to the considerable cortical maturation during this time. This research aimed to investigate the effects of sex and prematurity on the magnitude and spatial distribution pattern of the long-latency nociceptive event-related potential (nERP) using electroencephalography (EEG). We measured the cortical response time-locked to a clinically required heel lance in 81 neonates born between 29 and 42 weeks gestational age (median postnatal age 4 days). The results show that heel lance results in a spatially widespread nERP response in the majority of newborns. Importantly, a widespread pattern is significantly more likely to occur in females, irrespective of gestational age at birth. This effect is not observed for the short latency somatosensory waveform in the same infants, indicating that it is selective for the nociceptive component of the response. These results suggest the early onset of a greater anatomical and functional connectivity reported in the adult female brain, and indicate the presence of pain-related sex differences from birth.

The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial

BackgroundOrally 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.MethodsA 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.ResultsThere 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.ConclusionsThe 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 registrationClinicalTrials.gov: NCT02134873. Date: May 5, 2014 (retrospectively registered).

Laser Acupuncture at Large Intestine 4 Compared with Oral Glucose Administration for Pain Prevention in Healthy Term Neonates Undergoing Routine Heel Lance: Study Protocol for an Observer-Blinded, Randomised Controlled Clinical Trial.

Background Nonpharmacological strategies have actually become more important in neonatal pain management during routinely applied minor painful procedures. However, commonly used nonpharmacological strategies are inferior to orally administered sweet solutions. Therefore, we will compare laser acupuncture, as a recent nonpharmacological method, with the standard care of oral glucose solution for pain prevention. Methods Ninety-five healthy term neonates will be allocated into one of two groups. Before routine heel lance for metabolic screening, one group will receive laser acupuncture at acupuncture point Large Intestine 4 (LI 4) bilaterally for 60 seconds per point (acupuncture group) and the other will receive the standard care with orally administered glucose solution (glucose group). The complete procedure of blood sampling will be recorded on video, excluding the intervention before heel lance. A paediatric nurse, blinded with respect to the allocation, will evaluate these video recordings and determine the Premature Infant Pain Profile (PIPP) for each neonate. Primary outcome will be the mean difference in PIPP scores between groups. Discussion This observer-blinded randomised controlled trial has been designed to explore potential advantages of laser acupuncture in the management of neonatal pain because more data are required to provide information about its efficacy and safety. Trial Registration This trial is registered with DRKS00010122.

A study to assess the effectiveness of swaddling on pain among neonates undergoing heel lancing procedure in neonatal intensive care units

Neonates, infants and children often require examinations and investigations for admissions in the hospital. Even after admission frequent examinations and procedures will be carried out for further management. Pain during such investigations, treatments and procedures are called as procedural pain.1Appropriate pain relief can be achieved through administration of analgesics. But analgesics can cause different side effects and reaction to the newborns.2 Swaddling is the procedure of wrapping a baby in a blanket for warmth and security.3 swaddling provides stimulation across the proprioceptive, thermal, and tactile sensory systems that may reduce pain through gate control mechanisms.4

National Newborn Screening Tests Carried Out with Heel Lance and Their Importance

National Newborn Screening Tests Carried Out with Heel Lance and Their Importance

Assessing Neonatal Pain, Duration of Crying and Procedure Time following Use of Automatic or Manual Heel Lances: A Randomized Controlled Study.

The objective of this study was to compare neonatal pain, duration of crying and procedure time following use of automatic or manual heel lancets. This randomized trial was conducted with neonates undergoing heel prick procedures in a neonatal intensive care unit for routine blood bilirubin monitoring. An information form, an observation form and the Neonatal Infant Pain Scale (NIPS) were used. Pain before, during and after (1 and 3 min) was assessed using NIPS scoring. Seventy neonates were included (automatic lancet, n = 35; manual lancet, n = 35); there was no difference between the groups (p > 0.01). Pain scores were significantly lower, with automatic lancets compared with manual lancets (p = 0.001). The duration of crying after the procedure (p = 0.001) and procedure time (p = 0.001) was significantly shorter with automatic lancets compared with manual lancets. Automatic heel lancets in neonates are more effective than manual lancets at reducing pain, and shorten the procedure time and duration of post-procedural crying.

Nociceptive Cortical Activity Is Dissociated from Nociceptive Behavior in Newborn Human Infants under Stress

SummaryNewborn infants display strong nociceptive behavior in response to tissue damaging stimuli, and this is accompanied by nociceptive activity generated in subcortical and cortical areas of the brain [1, 2]. In the absence of verbal report, these nociceptive responses are used as measures of pain sensation in newborn humans, as they are in animals [3, 4]. However, many infants are raised in a physiologically stressful environment, and little is known about the effect of background levels of stress upon their pain responses. In adults, acute physiological stress causes hyperalgesia [5, 6, 7], and increased background stress increases pain [8, 9, 10], but these data cannot necessarily be extrapolated to infants. Here we have simultaneously measured nociceptive behavior, brain activity, and levels of physiological stress in a sample of 56 newborn human infants aged 36–42 weeks. Salivary cortisol (hypothalamic pituitary axis), heart rate variability (sympathetic adrenal medullary system), EEG event-related potentials (nociceptive cortical activity), and facial expression (behavior) were acquired in individual infants following a clinically required heel lance. We show that infants with higher levels of stress exhibit larger amplitude cortical nociceptive responses, but this is not reflected in their behavior. Furthermore, while nociceptive behavior and cortical activity are normally correlated, this relationship is disrupted in infants with high levels of physiological stress. Brain activity evoked by noxious stimulation is therefore enhanced by stress, but this cannot be deduced from observation of pain behavior. This may be important in the prevention of adverse effects of early repetitive pain on brain development.

The effect of nesting positions on pain, stress and comfort during heel lance in premature infants

BackgroundNesting positions are commonly used in procedural analgesic administration in premature neonates. The effectiveness of nesting positions is questioned. The aim of the this study was to assess the pain, stress, comfort and salivary cortisol and melatonin values in nesting positions during the heel lance procedure in premature infants at the NICU. MethodsExperimental research; repeated measurement design. The sample comprised 33 premature neonates with gestational age of 31–35 weeks who had been hospitalized in the NICU. Nesting positions were given using linen or towels. The procedure of heel lance was recorded on camera. The camera recordings were evaluated according to the NIPS and the COMFORTneo scale. Saliva samples were obtained five minutes prior to and 30 min after the heel lance procedure. Salivary Cortisol and Melatonin were measured using the Salimetrics Cortisol Elisa Kit and the Salimetrics Melatonin Elisa Kit. ResultsThe crying time, the mean NIPS score, the COMFORTneo score, the COMFORTneo NRS-pain scores and the COMFORTneo NRS-distress scores for premature neonates who were in the prone position during the procedure were significantly lower than the scores in the supine position (p < 0.000). Furthermore, the level of salivary cortisol five minutes prior to and 30 min after the heel lance procedure had significantly decreased in the prone position; however, there were insignificant differences in the mean levels of salivary melatonin between the positions. ConclusionsNesting in the prone position has a pain reducing effect, enhancing comfort and reducing stress in premature infants.

The Effect of Swaddling on Pain, Vital Signs, and Crying Duration during Heel Lance in Newborns

To determine the effect of swaddling on pain, vital signs, and crying duration during heel lance in the newborn. This was a randomized controlled study of 74 (control: 37, experiment: 37) newborns born between December 2013 and February 2014 at the Ministry of Health Bagcılar Training and Research Hospital. An information form, observation form, and Neonatal Infant Pain Scale were used as data collection tools. Data from the pain scores, peak heart rates, oxygen saturation, total crying time, and duration of the procedure were collected using a video camera. Newborns in the control group underwent routine heel lance, whereas newborns in the experimental group underwent routine heel lance while being swaddled by the researcher. The newborns’ pain scores, peak heart rates, oxygen saturation values, and crying durations were evaluated using video recordings made before, during, and 1, 2, and 3 minutes after the procedure. Pain was assessed by a nurse and the researcher. No statistically significant difference was found in the characteristics of the two groups (p > .05). The mean pain scores of swaddled newborns during and after the procedure were lower than the nonswaddled newborns (p < .05). In addition, crying duration of swaddled newborns was found to be shorter than the nonswaddled newborns (p < .05). The average preprocedure peak heart rates of swaddled newborns were higher (p < .05); however, the difference was not significant during and after the procedure (p > .05). Although there was no significant difference in oxygen saturation values before and during the procedure (p > .05), oxygen saturation values of swaddled newborns were higher afterward (p < .05). For this study sample, swaddling was an effective nonpharmacologic method to help reduce pain and crying in an effort to soothe newborns. Although pharmacologic pain management is the gold standard, swaddling can be recommended as a complementary therapy for newborns during painful procedures. Swaddling is a quick and simple nonpharmacologic method that can be used by nurses to help reduce heel stick pain in newborns.