Premature Infant Pain Research Articles

Effect of White Noise in Relieving Vaccination Pain in Premature Infants

The purpose of this study was to evaluate the effect of white noise as a distraction method in relieving procedural pain caused by vaccination for premature infants. This experimental study was performed at a neonatal intensive care unit (NICU) of a university hospital in Turkey between July and September 2013. The study population was composed of 75 premature infants (35 in the study group and 40 in the control group) who met the inclusion criteria. Premature infants in the study group were exposed to white noise using MP3 players placed at the head of the infants’ open crib for 1 minute before vaccination. The white noise continued until 1 minute after vaccination. Premature infants in the control group were not exposed to white noise. The Premature Infant Information Form, Intervention Follow-up Form, and Premature Infant Pain Profile (PIPP) were used to collect study data. Descriptive statistics, chi-square test, and independent sample t-tests were used to evaluate the data. The pain level of the control group (PIPP = 14.35 ± 2.59) was significantly higher than the pain level of the study group (PIPP = 8.14 ± 3.14) (p < .05). The authors found that 67.6% of the infants in the study group had moderate pain during vaccination and only 2.9% had severe pain. Most of the infants in the control group (82.5%) had severe pain, whereas 17.5% had moderate pain (p < .05). White noise was found to be effective for this sample; however, there is a dire need for extensive research on white noise and its use with this vulnerable population.

Can topical anesthetic eye drops prevent pain in preterm infants undergoing screening for retinopathy?

Can topical anesthetic eye drops prevent pain in preterm infants undergoing screening for retinopathy?

Lomb algorithm versus fast Fourier transform in heart rate variability analyses of pain in premature infants.

Heart rate variability analysis is a promising method for measuring pain in premature infants. The Lomb algorithm was adapted and compared with fast Fourier transform (FFT) for the purposes of PSD estimation. Both FFT and the Lomb algorithm had similar low frequency (LF) estimation error rates. However, the Lomb algorithm had a significant smaller error rate than FFT when estimating high frequency (HF). In addition, the ECG signals of two premature infants in the newborn intensive care unit were analyzed while undergoing a routine heel stick, a common painful procedure. The Lomb algorithm performed as expected marking a decrease in both LF and HF power in the presence of pain.

A feasibility and efficacy randomised controlled trial of swaddling for controlling procedural pain in preterm infants.

This study aimed to investigate the feasibility and efficacy of swaddling to control procedural pain among preterm infants. Swaddling has been recommended for controlling neonatal pain. However, the feasibility for use is uncertain and insufficient evidence is available among preterm infants. A two-arm randomised controlled trial with repeated measures. The study was conducted in a 21-bed neonatal intensive care unit of a regional hospital in Hong Kong. Preterm infants who required heelstick procedure were eligible. Fifty-four preterm infants between 30-37 gestational weeks were randomly assigned to swaddling (n=27) and control (standard care, n=27) groups. Pain assessment was performed pre, during, immediate, two, four, six and eight minutes after heelstick procedure using the Premature Infant Pain Profile. The mean Premature Infant Pain Profile scores were significantly reduced in the intervention group compared to the control group during, immediate, two, four, and six minutes after the heelstick procedure. The mean changes of heart rate and oxygen saturation in the intervention group were significantly lower than that of the control group at all measured time points. Notably, the swaddled infants quickly resumed to the baseline level at two minutes whereas the control group reached the stable state at an extended period of six minutes. The findings show that swaddling is feasible and efficacious in controlling pain for heelstick procedure among preterm infants. No adverse effects were observed. This article presents the feasibility and efficacy of swaddling as a non-pharmacological and non-invasive intervention to relieve pain during the heelstick procedures among preterm infants. Swaddling can contribute to control minor procedural pain in neonates as one of the simple, safe, cost effective, humanistic and natural analgesia alternatives.

Maternal assessment of pain in premature infants

Objective: to identify mothers' perceptions about the pain in their premature babies in the Neonatal Intensive Care Unit. Methods: evaluative, quantitative study with investigative nature conducted with 19 mothers of hospitalized premature newborns. Data were obtained from closed questions, answered by mothers. Results: from the participants, two (10.5%) reported that newborns are unable to feel pain. From the 17 mothers who said that premature babies can feel pain, the majority (94.1%) identified crying as a characteristic of pain sensation. Eleven (64.7%) stated that uneasiness is a sign of pain in newborns. Conclusion: for the proper management of neonatal pain it is essential that mothers know the signs of pain in premature newborns, and that health professionals instruct this recognition, through the enhancement of the maternal presence and practice of effective communication between professionals and newborns’ families.

Avaliação materna da dor em recém-nascidos prematuros

Objetivo: identificar a percepcao das maes sobre a dor de seus filhos prematuros internados na Unidade de Terapia Intensiva Neonatal. Metodos: pesquisa avaliativa, quantitativa e de cunho investigativo com 19 maes de recem-nascidos prematuros hospitalizados. Os dados foram obtidos atraves de questoes fechadas, preenchidas pelas maes. Resultados: das participantes, duas (10,5%) referiram que os recem-nascidos sao incapazes de sentir dor. Das 17 maes que afirmaram que o prematuro sente dor, a maioria (94,1%) identificou o choro como caracteristica de sensacao dolorosa. Onze (64,7%) afirmaram que a agitacao e um sinal de dor no recem-nascido. Conclusao para o adequado manejo da dor neonatal e essencial que as maes conhecam os sinais de dor nos recem-nascidos prematuros, e que os profissionais de saude as instruam neste reconhecimento, por meio da valorizacao da presenca materna e a pratica de uma comunicacao eficaz entre os profissionais e a familia do recem-nascido.

NON PHARMACOLOGICAL METHODS TO REDUCE PAIN IN NEWBORNS; SYSTEMATIC REVIEW

newborns require diagnostic and preventive procedures since the early days of life, such as the heel prick screening for metabolic disorders, intramuscular injection of vaccines and, in some cases, channeling venous route. Which are often associated with a painful sensation. The evaluation of the intensity of painful stimuli in newborns has been studied in recent years. Various scales that collect physiological and behavioral parameters have been used. This somewhat has allowed us to get closer to the intensity of pain perceived by the child, and to decide if analgesia is necessary. In regards of methods of pain relief, the most important ones are the nonpharmacological approaches due to their safety, effectiveness and low cost. Therefore, we analyze the studies that evaluate the effectiveness of nonpharmacological interventions for painful procedures (IFN) in reducing pain in neonates. a systematic search would be performed and 21 specific articles on the subject would be selected, following the PRISMA guidelines. numerous studies have proven the effectiveness of nonpharmacological interventions in relieving pain in term and preterm infants. It highlights a methodological choice, especially in the measuring of painful stimulus. It requires greater involvement on the part of health workers due to the negative consequences that entails the feeling of pain at an early age, including sleep disturbances. we conclude that some of the nonpharmacological interventions are most commonly used oral administration of sweet solutions, breastfeeding and kangaroo, which have proven effective, as it involves numerous benefits for the baby. However, further studies are required in this regard, and the implementation of a universal evaluation method for the subsequent evaluation of results in the medium and long term.

Facilitated Tucking to Reduce Pain in Neonates

Increasing survival rates of preterm infants and a greater understanding of the long-term consequences of early exposure to pain have generated a greater need for nonpharmacologic pain management strategies in the neonatal intensive care unit (NICU) setting. Facilitated tucking supports the preterm infant and is a valuable strategy to manage neonatal pain. Alternative nonpharmacologic approaches to pain management in neonates include nonnutritive sucking and kangaroo care. In premature and critically ill infants, what is the effect of facilitated tucking on pain behaviors in those who received the intervention compared with those who did not, and what alternative interventions for nonpharmacologic pain reduction are supported by strong research evidence? Studies were identified in the PubMed database using the search terms: facilitated tucking, NICU, pain management, preterm infant, and nonpharmacologic. Studies were included if they were peer reviewed, were published in the last 5 years (or considered classic), and if they used experimental study designs. The studies identified demonstrate that facilitated tucking reduces the expression of pain in premature infants. As a whole, existing research supports the use of facilitated tucking for infants as early as 23 weeks' gestational age, during painful procedures including: heel stick, endotracheal suctioning, and venipuncture. Pain management interventions are necessary to decrease the potentially unfavorable consequences of early exposure to pain and to promote positive outcomes. Additional research is indicated to discover the effects of nonpharmacologic interventions in neonates with severe illness, congenital abnormalities, and/or assisted breathing.

Effect of repeated Kangaroo Mother Care on repeated procedural pain in preterm infants: A randomized controlled trial.

Preterm infants' repeated exposure to painful procedures may lead to negative consequences. Thus, non-pharmacological pain management is essential due to medication side effects. Kangaroo Mother Care, which aims at offering human care to neonates, has been established for the treatment of a single painful procedure, but the effectiveness of Kangaroo Mother Care across repeated painful procedures is unknown. To test the effectiveness of repeated Kangaroo Mother Care on repeated heel-stick pain in preterm neonates. Randomized controlled trial. Level III Neonatal Intensive Care Unit at a large teaching hospital in northeast China. Preterm infants (gestational age less than 37 weeks) (n=80) were recruited and randomly assigned using a random table format to either an incubator group (n=40) or Kangaroo Mother Care group (n=40). Pain assessments were carried out during four routine heel stick procedures. For the first heel stick, preterm infants in each group received no intervention (routinely stayed in incubator). During the next three heel sticks, the infants in Kangaroo Mother Care group received heel sticks during Kangaroo Mother Care, while infants in the incubator group received heel sticks in incubator. The procedure of each heel stick included 3 phases: baseline, blood collection and recovery. Crying, grimacing and heart rate in response to pain were evaluated at each phase across four heel sticks by three trained independent observers who were blinded to the purpose of the study. Data were analyzed by analysis of variance (ANOVA), with repeated measures at different evaluation phases of heel stick. 75 preterm infants completed the protocol. Between-group comparison revealed that preterm infants' heart rate was significantly lower, and the duration of crying and facial grimacing were both significantly shorter in the Kangaroo Mother Care group (n=38) than the incubator group (n=37) from the blood collection phase to recovery phase during repeated heel sticks. No significant within-group difference was found in heart rate between the baseline phase and recovery phase through repeated heel sticks for Kangaroo Mother Care group. In contrast, the incubator group experienced significant within group differences in heart rate between baseline and recovery through repeated heel sticks. The effect of repeated Kangaroo Mother Care analgesia remains stable in preterm infants over repeated painful procedures. Given the many invasive procedures that are part of clinical care in preterm infants and most mothers preferred to provide comfort for their infants during painful procedures, Kangaroo Mother Care may be a safe analgesic alternative in preterm infants in whom it is feasible.

Perceptions of health professionals on pain in extremely low gestational age infants.

Extremely low gestational age infants (<28 weeks at birth) experience significant pain from repeated therapeutic procedures while hospitalized in the neonatal intensive care unit. As part of a program of research examining pain in preterm infants, we conducted a qualitatively driven mixed-methods design, supplemented with a qualitative and quantitative component, to understand how health care professionals (HCPs) assess and manage procedural pain for tiny and underdeveloped preterm infants. Fifty-nine HCPs from different disciplines across four tertiary-level neonatal units in Canada participated in individual or focus group interviews and completed a brief questionnaire. Four themes from the content analysis were (a) subtlety and unpredictability of pain indicators, (b) infant and caregiver attributes and contextual factors that influence pain response and practices, (c) the complex nature of pain assessment, and (d) uncertainty in the management of pain. The information gleaned from this study can assist in identifying gaps in knowledge and informing unit-based and organizational knowledge translation strategies for this vulnerable population.

Escala de avaliação da dor: percepção dos enfermeiros em uma Unidade de Terapia Intensiva Neonatal

Aim: to identify the perceptions of nurses in relation to the use of an instrument to assess pain in preterm infants. Method: qualitative, exploratory and descriptive research conducted in a Neonatal Intensive Care Unit, in a University Hospital in Pelotas, Rio Grande do Sul. The study included four nurses, in the period of October to November 2010. Data were collected through semi-structured interviews and analyzed according to thematic analysis. Results: the following categories were addressed: Scale to assess pain in premature newborns: perception of nurses, and Pain Scale and premature newborns: implementation. Conclusion: nurses do not know the new technologies used to measure pain; however, all nurses demonstrated committment to a humanized assistance, as they reported being interested in the inclusion of this instrument of assessment

Effect of Mozart music on heel prick pain in preterm infants: a pilot randomized controlled trial

Objective: The aim of this pilot study was to determine the effect of music by Mozart on heel prick procedural pain in premature infants.Background: Painful procedures are routinely performed in the setting of neonatal intensive care unit (NICU). Pain may exert short- and long-term deleterious effects on premature babies. Many non-pharmacological interventions have been proven efficacious for blunting neonatal pain.Study design: Randomized, controlled trial.Methods: The study was carried out in the NICU of the “G. Rummo” Hospital in Benevento, Italy. The sample consisted of 42 preterm infants, with no hearing loss or significant cerebral lesions on cranial ultrasound. They were randomized to receive heel lance during a music condition or a no-music control condition. We set strict criteria for selecting and delivering the music. Baseline and postprocedural heart rate and transcutaneous oxygen saturation were manually recorded. The Premature Infant Pain Profile (PIPP) score was used to measure the behavioral response to prick. An unpaired t-test was performed for the intergroup comparisons.Results: There were significant differences between groups on heart rate increase, oxygen saturation reduction and PIPP score following the procedure.Conclusions: Listening to Mozart music during heel prick is a simple and inexpensive tool for pain alleviating in preterm stable neonates.

Pain assessment scales in newborns: integrative review

OBJECTIVE: To analyze studies on methods used to assess pain in newborns.DATA SOURCES: Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.DATA SYNTHESIS: 29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.CONCLUSION: Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

Oral glucose solution to alleviate pain induced by intramuscular injections in preterm infants.

The purpose was to assess the effectiveness of 5% oral glucose solution in reducing pain in preterm infants during intramuscular injection. We conducted a prospective, randomized, controlled, unblinded trial to investigate the effect of glucose solution on the pain of intramuscular injection in preterm infants (N = 80). Infants who received oral glucose had significantly lower pain scores (p < .001), less crying time (p < .001), higher oxygen saturation (p < .001), and lower heart rate after compared with during the procedure (p = .02). Our results suggest that oral glucose, even if used in the lowest dose, may have a pain-relieving effect in preterm infants if administered pre-procedure.

Music and 25% glucose pain relief for the premature infant: a randomized clinical trial.

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.

PO-0279 Skin Conductance Changes Differ Between Painful Stimuli And General Hypoxia Different From Peripheral Oxygen Saturation: Abstract PO-0279 Table 1

Background and aims Peripheral oxygen saturation (SpO 2 ) decreases during general hypoxia and painful events in preterm infants. Skin conductance responses per sec (SCR/sec) increase during painful procedures. The purpose of this observational study was to examine if SCR/sec can help to diagnose if SpO 2 is due to general hypoxia or painful events. Methods Ten infants, diagnosed as ventilator unstable with birth weight 1248 (± 710) grams, gestational age 30 (± 5) weeks and at postnatal day 3 (± 1) were observed for 1 h when venous blood sampling was performed. SpO 2 , SCR/sec, heart rate (HR), and respiratory rate (RR) were recorded each 2nd minute and during the painful and hypoxic events (defined as SpO 2 lower than 80%). The variables were studied during the painful and hypoxic events as well as in situations without events. Non-parametric tests for within individual variables (Friedman’s Anova) were used. Results There were statistical differences for physiological measures during the no- painful- and hypoxic events; mean (SD): Conclusion SCR/sec does not increase during SpO 2 and may be used to differ between pain and general hypoxia in preterm infants.

The effect of facilitated tucking during endotracheal suctioning on procedural pain in preterm neonates: a randomized controlled crossover study.

Background:Premature infants not only feel and understand the pain, but also respond more intensively compared with term infants. Non-pharmacological methods of pain control are suitable to relieve pain in painful procedures. The facilitated tucking position is considered as a non-pharmacological method of pain control in infants; however, its impact on frequent and repeated procedural pain such as endotracheal suctioning remains to be studied.Objectives:This paper is the report of a study that examined the impact of facilitated tucking position on behavioral pain during suctioning in premature neonates. Design: This was a clinical trial study with a crossover design. Settings: The study was conducted in a level II Neonatal Intensive Care Unit, located in a teaching hospital, affiliated to Tehran University of Medical Sciences, Tehran, Iran. Participants: Thirty four infants were enrolled in this study based on the following inclusion criteria: age between 29 to 37 weeks of gestational age, birth weight 1200 grams or more, having an endotracheal tube, no congenital anomalies, no seizures diagnosis, no chest tubes, no intracranial hemorrhage higher than degree II, not receiving opiates and sedatives four hours before intervention and not receiving any painful procedure at least half an hour before the intervention. Methods: The samples were randomly received a sequence of suctioning with/without or suctioning without/with facilitated tucking. Preterm Infant Pain Profile (PIPP) was used to collect the data. SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.Results:While 38.2% of infants experienced severe pain during suctioning without intervention, only 8.8% of them experienced severe pain during suctioning with intervention. The results of the paired t-test show that there is a statistically significant difference in the mean scores of pain between non-intervention and intervention cases (p<0.001), and the mean pain score substantially reduced in cases with intervention.Conclusions:Given the multiplicity of endotracheal suctioning frequency and the impossibility of frequent use of pharmacological methods of pain relief, the facilitated tucking position can be used as a safe non-pharmacological method for procedural pain management.

Development and preliminary validation of the Neonatal Infant Acute Pain Assessment Scale (NIAPAS)

BackgroundSeveral pain scales are available for neonates, but, unfortunately they are only rarely used in clinical practice. To help with the current situation of unrecognized and under-treated pain in neonatal intensive care units (NICUs), we developed an assessment tool in close collaboration with clinical staff. ObjectivesTo develop a multidimensional scale, NIAPAS (the Neonatal Infant Acute Pain Assessment Scale), that is sensitive to the needs of infants in neonatal intensive care units, and to test the validity, reliability, feasibility and clinical utility of the scale for this population. DesignInstrument development and psychometric analysis. MethodsPain assessments (n=180) were made of 34 neonates born between 23 and 42 weeks gestational age who were undergoing 60 painful procedures (heel lance 77%, tracheal suctioning 23%) in the NICU. Using bedside video recordings, each neonate was observed through three phases of the procedure: 1min before the procedure, during the procedure (lasting from 0.6 to 11.2min, mean 2.6), and 1min after the procedure. In addition, an expert panel (n=5) and nurses (n=26) participated in the validation of the scale. ResultsA pool of 8 pain indicators (5 behavioral and 3 physiological indicators), including the gestational age of neonates as a contextual factor, was identified based on the nurses’ expertise in neonatal intensive care. Scores on the NIAPAS changed significantly across the phases (p<0.001), indicating a good construct validity of the scale. Correlations between the NIAPAS and NIPS (the Neonatal Infant Pain Score) were high (0.751–0.873). The study also demonstrated high coefficients for inter-rater (r=0.991–0.997) and intra-rater reliability (r=0.992–1.00), with an internal consistency of 0.723. The content validity was very good (Mean I-CVI 1.00), as evaluated by the expert group. The nurses agreed that the scale was easy to administer and that it helped decision-making in the pain management of infants. ConclusionsThe NIAPAS was shown to be a valid and reliable scale for assessing acute pain in preterm and full-term infants in the NICU. It allows nurses to evaluate infants’ acute pain especially during painful procedures and help to provide pain relief for the infants.

Nonpharmacological Techniques to Reduce Pain in Preterm Infants Who Receive Heel-Lance Procedure: A Randomized Controlled Trial

The heel-lance (HL) method for blood collection from the newborn is controversial for the pain it causes. This is the first randomized controlled trial on the management and reduction of pain using the music of Wolfgang Amadeus Mozart ("Sonata K. 448") in premature infants hospitalized in a neonatal intensive care unit (NICU). This study has compared nonpharmacological techniques with standard procedure for reducing pain during HL procedure. Thirty-five premature infants were enrolled, each for 3 HL procedures, of which each was randomized to 1 of the 3 study arms. Arms were then compared in terms of the Premature Infant Pain Profile (PIPP) changes by analysis of variance (ANOVA). One hundred five HL procedures were available for analysis (35 standard procedure, 35 music, 35 glucose). Median baseline PIPP was 3, and median PIPP after the HL procedure was 5. PIPP scale change was +3 in the control arm, +1 in the glucose arm, +2 in the music arm (p = .008). Both glucose and music were safe and effective in limiting pain increase when compared to standard procedure in HL procedures in preterm infants.

Neonatal pain: What's age got to do with it?

Background:The neurobiology of neonatal pain processing, especially in preterm infants, differs significantly from older infants, children, adolescence, and adults. Research suggests that strong painful procedures or repeated mild procedures may permanently modify individual pain processing. Acute injuries at critical developmental periods are risk factors for persistent altered neurodevelopment. The purpose of this narrative review is to present the seminal and current literature describing the unique physiological aspects of neonatal pain processing.Methods:Articles describing the structures and physiological processes that influence neonatal pain were identified from electronic databases Medline, PubMed, and CINAHL.Results:The representation of neonatal pain physiology is described in three processes: Local peripheral nervous system processes, referred to as transduction; spinal cord processing, referred to as transmission and modulation; and supraspinal processing and integration or perception of pain. The consequences of undermanaged pain in preterm infants and neonates are discussed.Conclusion:Although the process and pain responses in neonates bear some similarity to processes and pain responses in older infants, children, adolescence, and adults; there are some pain processes and responses that are unique to neonates rendering them at risk for inadequate pain treatment. Moreover, exposure to repeated painful stimuli contributes to adverse long-term physiologic and behavioral sequelae. With the emergence of studies showing that painful experiences are capable of rewiring the adult brain, it is imperative that we treat neonatal pain effectively.