Premature Infant Pain Profile Scores Research Articles

Impact of Kangaroo Mother Care on Heart Rate Variability and Pain Score with Heel Lance Pain in Preterm Neonates: A Cross-over Randomized Controlled Trial

Introduction: To evaluate the effect of kangaroo care on response to pain due to heel lance in preterm infants using premature infant pain profile (PIPP). Design: Randomized cross-over design. Methods: Stable preterm neonates ( n = 70) who had completed 28–36 weeks of gestational age received either kangaroo mother care or were kept under control (bassinet) conditions for 30 minutes prior to a heel lance. The neonates were observed, and responses were scored as per PIPP. They were then crossed over to the other condition and scored similarly. The PIPP scores in the two study arms were then compared using appropriate statistical tools. Results: A total of 342 neonates were admitted during the study period, of which 95 were assessed for eligibility, and finally, 70 were included and randomized to be in one of the two arms. The facial actions differed in the two groups; the brow bulge and eye squeeze scores were significantly better at each observation in the KMC group. The nasolabial furrow score was significantly better at 60 and 90 seconds. The baseline PIPP scores were similar. In the KMC group, the scores were significantly lower at 30, 60, and 90 seconds post–heel lance. Conclusions: Kangaroo mother care is an effective way of reducing the physiological and behavioral effects of pain in preterm neonates.

Effect of Immediate Kangaroo Mother Care on Pain in Sick Low Birth Weight Neonates During Heel Prick in Mother–Newborn Intensive Care Unit

Introduction: In the Mother-Newborn Intensive Care Unit(M–NICU), sick, low birth weight(LBW) neonates are cared for along with their mothers with facilities of level-II newborn care and postnatal care for mothers. Babies weighing 1–1.8 kg are admitted and Kangaroo Mother Care (KMC) is started after birth without waiting for stabilization. This is immediate Kangaroo Mother Care (iKMC). There are studies on analgesic effect of KMC, but no studies on analgesic effect of iKMC in sick neonates; therefore, the present study was planned. Aims and objectives: To compare pain score and recovery time from pain following heel prick in sick LBW neonates weighing 1–1.8 kg in iKMC and under radiant warmer. Materials and methods: In the M-NICU, neonates are in iKMC for 12–18 hours. If iKMC is not possible, the baby is placed under radiant-warmer. LBW neonates are screened for hypoglycemia at 2, 6, 12, 24, 48-hour intervals by heel prick. Pain scoring was done by the Premature Infant Pain Profile (PIPP) score and the recovery time (time for heart rate to return to baseline) noted following heel prick in iKMC and under radiant warmer. Results: 75 babies enrolled, 150 episodes of glucose estimation in iKMC and 150 in radiant warmer included. Mean(SD) baby weight(Kg) was 1512.93(171.10). Mean(SD) gestational age(Weeks) was 33.77(2.54). In the iKMC group, mean pain score(SD) was 7.59(2.27) and median(IQR) was 8.00(2.75). In the radiant warmer group, mean pain score(SD) was 14.41(2.04) and median(IQR) was 15.00(3.00). Mean recovery time(seconds)(SD) was 33.3(20.22) in the iKMC group and 92.43(49.68) in the radiant warmer group. The difference was statistically significant( P = <0.001). Conclusion: In sick LBW neonates, painful procedures must be done in KMC, whenever possible.

The effect of music on pain management in preterm infants during daily painful procedures: a systematic review and meta-analysis.

The present systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to investigate the effects of music on pain management in preterm neonates during painful procedures. The PubMed, Embase, Web of Science, EBSCO and Cochrane Library databases were searched to identify relevant articles published from their inception to September 2023. The study search strategy and all other processes were implemented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four RCTs that satisfied the inclusion criteria were included in this meta-analysis. The music group had significantly lower Premature Infant Pain Profile (PIPP) scores during (RR = -1.21; 95% CI = -2.02--0.40, p = 0.0032) and after painful procedures (RR = -0.65; 95% CI = -1.06--0.23, p = 0.002). The music group showed fewer changes in PIPP scores after invasive operations than did the control group (RR = -2.06; 95% CI -3.16--0.96; p = 0.0002). Moreover, our results showed that music improved oxygen saturation during (RR = 3.04, 95% CI = 1.64-4.44, p < 0.0001) and after painful procedures (RR = 3.50, 95% CI = 2.11-4.90, p < 0.00001). However, the change in peak heart rate during and after painful procedures was not statistically significant (RR = -12.14; 95% CI = -29.70-5.41 p = 0.18; RR = -10.41; 95% CI = -22.72-1.90 p = 0.10). In conclusion, this systematic review demonstrated that music interventions are effective for relieving procedural pain in preterm infants. Our results indicate that music can reduce stress levels and improve blood oxygen saturation. Due to the current limitations, large-scale, prospective RCTs should be performed to validate the present results.

Non-pharmacological interventions for the prevention of pain during endotracheal suctioning in ventilated neonates.

Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations. Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain. To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention. We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion. We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals. Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE. We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates. Facilitated tucking versus standard care (four studies) Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD -2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence). Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD -3.06 beats per minute (bpm), 95% CI -9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI -1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD -1.20, 95% CI -3.47 to 1.07; 1 study, 20 infants; low-certainty evidence). Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence). No studies reported intraventricular haemorrhage (IVH). Familiar odour versus standard care (one study) Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD -0.30, 95% CI -2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD -6.30 bpm, 95% CI -16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD -0.80, 95% CI -4.82 to 3.22; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. White noise (one study) White noise during endotracheal suctioning probably has little or no effect on PIPP (MD -0.65, 95% CI -2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD -1.85 bpm, 95% CI -11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI -2.03 to 6.53; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning. Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.

Pain Assessment and Management Practices via Education & Reinforcement (PAMPER): A Quality Improvement Initiative.

To establish neonatal pain management practices as an essential developmental supportive measure at a tertiary care unit. This quality improvement initiative was conducted as per Point-of-Care-Quality-Improvement Model over 6 mo, followed by 2 y of sustenance phase at a Neonatal Intensive Care Unit (NICU) in northern India. Infants of birth weight ≤1800 g were included and assessed for pain. Pain Assessment and Management Practices via Education and Reinforcement (PAMPER) group was created by resident doctors and nursing staff. The Premature Infant Pain Profile score was used for the assessment of pain. Limiting factors were analyzed using a fishbone diagram and interventions were done in multiple Plan-Do-Study-Act cycles. At the end of interventions, 100% of procedures were assessed for pain. The mean (standard deviation) documented pain score for the first seven days was reduced from 12.8 (0.3) in the baseline phase to 7 (2.5). These interventions helped to sustain the practice in >70% of infants in the next 2 y. Low-cost interventions improved the pain assessment and management policy of authors' NICU with the establishment of a standard protocol. Audits and reinforcement at regular intervals helped in its long-term sustenance.

Pain-related changes in crSO2 among premature infants undergoing PICC insertion

Objective To evaluate the effectiveness of cerebral regional oxygen saturation (crSO2) values, measured using near-infrared spectroscopy (NIRS), in assessing pain associated with the peripherally inserted central catheter (PICC) in premature infants. Methods NIRS was used to measure the crSO2 levels of 48 premature infants with gestational age (GA) of < 32 weeks or a birth weight of < 1500 g. Premature infant pain profile (PIPP) scores, vital signs, transcutaneous oxygen tension (TcpO2), transcutaneous carbon dioxide tension (TcpCO2), and crSO2 values were monitored. One-way repeated measure analysis of variance was used to compare heart rate (HR), respiratory rate (RR), blood pressure (BP), peripheral oxygen saturation (SpO2), TcpO2, TcpCO2, and crSO2 values before (Time 1), during (Time 2), and after (Time 3) PICC insertion. The correlation between the PIPP scores at Time 2 and the fluctuations (values detected at Time 2 minus those at Time 1) of SpO2, TcpO2, and crSO2 were also analyzed. Results The PIPP score at Time 2 was significantly higher than those at Times 1 and 3. HR, RR, and BP values increased (p < .05), and SpO2 and crSO2 levels decreased at Time 2 (p < .05) compared with those at Time 1. Stratified analysis based on GA revealed significant differences in HR, RR, and crSO2 values between Times 1 and 2 in infants with a GA of ≥ 32 weeks. In infants with a GA < 32 weeks, significant differences were observed in HR, RR, SpO2, BP, and crSO2 values between Times 1 and 2. The fluctuation of the crSO2 level was strongly correlated with the PIPP score at Time 2 (r = −0.829, p < .001). A weak correlation was observed between the PIPP score at Time 2 and TcpO2 level fluctuation (r = 0.375, p = .009). No correlation was observed between the PIPP score at Time 2 and SpO2 level fluctuation (r = 0.242, p = .097). Conclusion The fluctuation of crSO2 levels strongly correlates with PICC procedural pain. Hence, crSO2 levels measured using NIRS may be used as an indicator for pain assessment in premature infants.

Efficacy of expressed breast milk alone or in combination with paracetamol in reducing pain during retinopathy of prematurity screening: A randomized controlled trial

Background: The aim of this study was to determine the efficacy of expressed breast milk (EBM) alone or in combination with oral paracetamol for pain reduction during retinopathy of prematurity (ROP) screening. Methods: A randomized control trial was conducted in two departments of Bangabandhu Sheikh Mujib Medical University. A total of 60 preterm neonates who underwent ROP screening were randomized into three equal groups. Group A got nesting and swaddling as per institutional protocol (control). Group B received 2 ml EBM two minutes prior to the ROP screening and Group C received 15 mg/kg syrup paracetamol 30 minutes prior to the ROP screening and EBM like Group B. Premature infant pain profile (PIPP) scores was used prior, during and 2 minutes after ROP screening procedure. Results: The three groups were similar in terms of baseline characteristics. The mean (standard deviation) PIPP scores during the procedure were 16.4 (1.1), 15.0 (1.8) and 13.4 (1.8) in control, EBM, and EBM with paracetamol groups respectively. The PIPP scores were significantly lower in the EBM and EBM with paracetamol groups during the procedure compared to control group. In the EBM and EBM with paracetamol groups, the mean difference in PIPP scores (between before and during the procedure) was also substantially lower. Conclusion: Breast milk alone or in combination with paracetamol can reduce significant pain during ROP screening than control group. Bangabandhu Sheikh Mujib Medical University Journal 2023;16(2): 106-110

Effects of fentanyl and sucrose on pain in retinopathy examinations with pain scale, near-infrared spectroscopy, and ultrasonography: a randomized trial.

This study aimedto compare the efficacy of intravenous, intranasal fentanyl and oral sucrose inreducing the pain response during retinopathy of prematurity examinations using premature infant pain profile (PIPP) scores. The study included 42 infants who underwent retinopathy screening examinations. The infants were divided into three groups: oral sucrose, intranasal fentanyl, and intravenous fentanyl. Vital signs (heart rate, arterial oxygen saturation, and mean arterial pressure) were recorded. The PIPP was used to determine pain severity. Cerebral oxygenation and middle cerebral artery blood flow were evaluated using near-infrared spectroscopy and Doppler ultrasonography, respectively. The data obtained were compared between groups. There was no significant difference between the three groups regarding postconceptional and postnatal ages or birth weights and weight at the time of examination. All babies had moderate pain during the examination. No correlation was observed between analgesia method and pain scores (P = 0.159). In all three groups, heart rate and mean arterial pressure increased, whereas oxygen saturation decreased during the exam compared with pre-examination values. However, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation (sPO2) values did not differ between groups (HR, P = 0.150; MAP, P = 0.245; sPO2, P = 0.140). The cerebral oxygenation (rSO2) values between the three groups were found to be similar [rSO2: P = 0.545, P = 0.247, P = 0.803; fractional tissue oxygen extraction (FTOE): P = 0.553, P = 0.278]. Regarding cerebral blood flow values, we also did not find any difference between the three groups [mean blood flow velocity (Vmean): P = 0.569, P = 0.975; maximum flow velocity (Vmax): P = 0.820, P = 0.997]. Intravenous and intranasal fentanyl and oral sucrose were not superior to each other in preventing pain during the examination for retinopathy of prematurity (ROP). Sucrose may be a good alternative for pain control during ROP examination. Our findings suggest that ROP exam may not affect cerebral oxygenation or cerebral blood flow. Larger scale studies are needed to determine the best pharmacological option to reduce pain during ROP exams and evaluate the effects of this procedure on cerebral oxygenation and blood flow.

The effect of using maternal voice, white noise, and holding combination interventions on the heel stick sampling

BackgroundHeel stick sampling, a common procedure in newborns, causes acute pain. AimsThis study aims to measure the outcome of five various non-pharmacologic pain relief groups; maternal voice, white noise, holding, maternal voice+holding, and white noise+holding. MethodsThe study is an open label, randomized controlled trial. A total of 178 newborns were included in this study. Newborns were randomly allocated to each group; white noise (n = 31), maternal voice (n = 31), holding (n = 30), white noise+holding (n = 29), maternal voice+holding (n = 28), and control (n = 29) interventions. Newborns' pain responses were evaluated using the Neonatal Infant Pain Scale (NIPS), and the Premature Infant Pain Profile (PIPP). The primary measured outcomes were the newborns' pain levels, while the secondary outcomes were the heart rate and changes in oxygen saturation. The mean values of pain in neonates between groups were evaluated one minute before (Phase1), during (Phase2), and one minute after (Phase3) the procedure. ResultsThe research results are given with comparisons in three time periods (Phase1, Phase2 and Phase3). White noise and white noise+holding were found to have the lowest mean NIPS and PIPP score (p < 0.001). The mean heart rate was found to be the lowest in the white noise+holding group (p < 0.001). There was no significant difference between the groups in terms of oxygen saturation score (p = 0.453). ConclusionThe white noise+holding applied to newborns during heel stick sampling were effective in pain reduction. Nurses and midwives can use white noise+holding method. Implications to practiceThese results contribute to the pain management of newborns.

Comparison of 25% Dextrose versus Expressed Breast Milk in Reducing Pain while Heel Prick Procedure in Preterm Neonates in a Tertiary Care Hospital, Vadodara, Gujarat, India: A Randomised Clinical Trial

Introduction: Preterm infants undergo repeated painful procedures during a period of rapid brain development and programming of stress systems. Newborn babies including preterm infants do feel pain. Although different interventions, such as skin-to-skin contact, glucose solutions, breastfeeding, and local anaesthetic agents, have been evaluated to reduce infants’ pain, there is no clinical trial available to identify the best method. Aim: To compare the dectrose 25% versus Expressed Breast Milk (EBM) in reducing pain while heel prick procedure in preterm neonates in a tertiary care hospital. Materials and Methods: The present randomised clinical trial was conducted at Neonatal Intensive Care Unit (NICU) of Kashiben Gordhandas Patel Children Hospital, Vadodara, Gujarat, India, from September 2019 to May 2020. Total 125 neonates with Gestational age between 28 weeks to 36 weeks were included in the study. Babies were divided into two groups by randomisation: Group-A: EBM and Group-B: Dextrose 25%. Premature Infant Pain Profile (PIPP) score was calculated from worst state of individual recovery period (0-½ minute, 1-1½ minute, 3-3½ minute) and compared to baseline period PIPP. Results: Mean gestational age on examination in Group-A was 34.48±6.14 weeks and in Group-B were 34.51±5.89 weeks. Out of total 125 preterm babies (Group-A-62, group B-63), 71 (56.8%) were male and 54 (43.2 %) were females. Comparison of PIPP at 1-1½ min of heel prick in EBM and Dextrose 25% group was statistically significant (p-value &lt;0.003) suggestive of continued analgesic effect of dextrose 25% better than EBM and PIPP scores after 3-3½ min of heel prick having no statistically significant difference. (p&gt;0.05) Mean difference between the PIPP score in the dextrose 25% and EBM groups was -1.25 and -1.33 at 0 and 1 minute after procedure (p-value,&lt;0.001), so pain relief was better in dextrose 25% group than EBM group. Conclusion: Dextrose 25% was better effective in reducing mean crying duration than EBM. Dextrose 25% had a better analgesic effect than EBM in 28 to 36 weeks gestational age neonates.

Efficacy of Enhanced Dose of Expressed Breast Milk in Neonatal Procedural Pain Relief: A Randomised Placebo-controlled Study

Introduction: Procedural pain remedies in neonates is an area of active research due to better understanding of short and long-term outcomes of neonatal painful exposures. Non pharmacological interventions are especially attractive as it avoids unnecessary drug exposure. While dextrose is known to be effective, results with small volumes (2 mL) of Expressed Breast Milk (EBM) are equivocal. There is recent theoretical evidence to show that larger doses of EBM may be more efficacious. Aim: To compare the efficacy of a larger volume of EBM 5 mL and 2 mL of 25% Dextrose (25D) in relief of procedural pain from venipuncture in term and preterm neonates. Materials and Methods: A single center randomised placebo- controlled study was conducted at Bokaro General Hospital, Bokaro Steel City, Jharkhand, India, between March 2014 and February 2016. Neonates ≥34 week gestation, requiring venipuncture in a neonatal care unit were randomly allocated into 3 equal groups using a random number table- Sterile Water (SW), 2mL 25D, 5 mL EBM was given two minutes prior to venipuncture. Video of facial response, cry times, Maximal Heart Rate (MHR), and minimum Oxygen Saturation (SpO2) were recorded till five minutes after venipuncture. The Premature Infant Pain Profile (PIPP) score was used to assess the effect of the interventions on procedural pain. Subgroup analysis was done in term and preterm neonates. Continuous variables were presented as mean±SD or median. Categorical variables were expressed as frequencies and percentages. The comparison of normally distributed continuous variables between the groups was performed using Analysis of Variance (ANOVA). Results: The PIPP score in the 25D group (2.94±1.41) was significantly lower than the EBM (7.42±1.69) and SW (10.56±1.69) groups (p-value&lt;0.001). MHR was significantly lower in the 25D group, but no difference was found between the EBM and SW groups (p-value=0.23). SpO2 was significantly higher in the 25D group but for the initial 2.5 minutes only. Cry times were significantly lower in the intervention groups. There was no difference in outcomes in term vs. preterm infants. Conclusion: The use of 2 mL 25D was more effective in reducing procedural pain from venipuncture compared to 5 mL EBM. The return of physiological markers (MHR and SpO2) to baseline were faster and more complete in the 25D group.

Agreement of Revised Premature Infant Pain Profile Scoring between Healthcare Providers and Laypersons: A Cross-sectional Study

Introduction: The experience of pain during the neonatal period has short and long-term consequences. The Revised Premature Infant Pain Profile (PIPP-R) is a globally accepted and validated tool for assessing pain in neonates. Adequate pain management measures can be implemented using the PIPP-R, even in the absence of consultants. Aim: To assess the agreement among healthcare providers and laypersons in scoring the PIPP-R. Materials and Methods: A cross-sectional study was conducted at Shree Krishna Hospital, a rural Tertiary Care Teaching Hospital in central Gujarat, India. The duration of the study was one year and six months, from January 2021 to June 2022. The study included 12 volunteers from various fields, such as consultant neonatologists, first year postgraduate students in Department of Paediatrics, neonatal nurses, social workers, Bachelor of Medicine, Bachelor of Surgery (MBBS) interns, and mothers of newborns. A neonatology consultant provided training on the PIPP-R scoring system using handouts and a presentation. The volunteers then evaluated 100 prerecorded videos of newborns undergoing painful procedures. Agreement between volunteers for the total PIPP-R score and its subcomponents was assessed using Bland-Altman analysis and Cohen’s Kappa statistics. Results: A total of 100 videos of newborns (51 girls, 49 boys) undergoing painful procedures were evaluated for the PIPP-R score. The mean age, gestational age, and birth weight of the newborns were 2.21±1.55 days, 37±2.44 weeks, and 2.56±0.72 kg, respectively. The procedures included heel prick for Random Blood Sugar (RBS) (44%), intravenous sampling/insertion (34%), and intramuscular vitamin K injection (22%). The mean difference with 95% Confidence Limits (CL) of total PIPP-R scores between the two consultants (neonatologists) was -0.640 (-5.196, 3.916). The length of the CL was -9.112, which fell outside the defined CL of 4.2 (20% of the total score), indicating unacceptable agreement between the two consultants. Similarly, agreement between each consultant and any of the other participants, including residents, nurses, interns, mothers, and social workers, regarding the total PIPP-R score, as well as its subcomponents, was also deemed unacceptable. Conclusion: The present study concluded that the inter-rater reliability of the PIPP-R score and its subcomponents was unacceptable between consultants and with any of the other participants.

The outcomes of a healing environment and clustering nursing care on premature infants' vital signs, pain, and sleeping

Our study aimed to assess the effects of creating a healing environment and clustering nursing care on premature infants' vital signs, pain, and sleeping. The study had an experimental research design for the control and study group, each with 53 premature infants. We collected the data through the Vital Signs Sheet, Premature Infant Pain Profile, and Neonatal behavioral state. We used T-tests and chi-square tests to assess the differences between groups. There was a highly statistically significant difference between the study and control groups concerning respiration (p-value<0.01) and heart rate, systolic blood pressure, and O2 saturation (p-value<0.05). 90.6% of participants in the study group had a mild total premature infant pain profile, while 37.7% of the control group had a moderate total premature infant pain profile score. Applying a healing environment and clustering nursing care significantly improved respiration, heart rate, oxygen saturation, and systolic blood pressure. Furthermore, it increased sleep time and decreased wake state and pain score.

Effect of Topical Anesthesia on Reducing Pain Associated with Mydriatic Eye Drops during Retinopathy of Prematurity Screening

Introduction: The study aimed to investigate the effectiveness of topical anesthetic drops in reducing the pain associated with mydriatic eye drops prior to the retinopathy of prematurity (ROP) examination. Methods: Premature infants who underwent first-time ROP examinations in an outpatient setting were included in this randomized controlled trial. The study group included the infants who were administered topical anesthesia prior to the first mydriatic drops, and the control group included the infants who were given preservative-free artificial tear drops. Pain assessment was performed using the premature infant pain profile (PIPP). Results: A total of 66 infants, 35 in the control group and 31 in the study group, were included in the study. The PIPP scores of the infants during the first, second, and third mydriatic drops were 5.3 ± 2.0; 4.9 ± 1.7; and 4.0 ± 1.8, respectively, in the study group and 5.3 ± 1.7; 5.6 ± 1.8; and 4.6 ± 1.8, respectively, in the control group. No significant difference was found in the scores between the two groups. The PIPP score after the third drop was significantly lower than that after the second drop in the control group, and the PIPP score after the third drop was significantly lower than that obtained after the first and second drops in the study group. Discussion/Conclusion: This study showed no significant benefit of the topical anesthetic drop in the prevention of pain associated with mydriatic eye drops. The decrease in the pain response observed in repeated administrations is a novel finding.

Nonpharmacological Applications During the Retinopathy of Prematurity Examination and Their Effects on Pain Control: A Systematic Review and Meta-analysis.

Examination for retinopathy of prematurity (ROP) is a very painful procedure. Therefore, pain management is essential given the possibility of sensory and behavioral problems in newborns, who are constantly exposed to painful stimuli. In this light, the use of nonpharmacological methods alone or in combination with pharmacological methods is recommended for pain control. This systematic review and meta-analysis was to evaluate the effects of nonpharmacological treatments on pain during ROP examination. Randomized controlled trials published in English between 2011 and 2021 and available in the electronic databases of Medline, Web of Science, Nursing & Allied Health, and PubMed were reviewed. The meta-analysis was performed using Review Manager 5.4. Six randomized controlled studies were included. Glucose (mean difference [MD]: -1.64, 95% confidence interval [CI]: -2.34 to 0.94, P < .0001) and sucrose (MD: -2.50, 95% CI: -3.20 to -1.79, P < .0001) solutions were effective in reducing pain. However, breast milk did not reduce the Premature Infant Pain Profile score (MD: -2.50, 95% CI: -6.10 to 1.10, P > .05). The application of sucrose and glucose solutions for pain management during ROP examination can be effective and safe.

Analgesia for retinopathy of prematurity screening: A systematic review.

Background and AimsPremature neonates require regular ophthalmological examination, generally indirect ophthalmoscopy, to screen for retinopathy of prematurity (ROP). Conventional analgesia is provided with topical anesthetic eyedrops and oral sugar solution, but neonates still experience significant pain. Here, the literature base was examined to evaluate the usefulness of other pharmacological analgesics.Materials and MethodsA systematic review was undertaken, adhering to a PROSPERO preregistered protocol in accordance with PRISMA guidelines (identifier CRD42022302459). Electronic databases were searched for primary research articles on pharmacological pain interventions used for ROP screening in neonates. The primary outcome measure was pain scores recorded using validated pain scoring tools, with and without pharmacological interventions in neonates during eye examination. For analysis, studies were separated into two categories: topical anesthesia and alternative pharmacological treatments.ResultsEleven studies met the inclusion criteria. Topical analgesia, oral paracetamol, and intranasal fentanyl were found to be effective in reducing the pain of eye examination. Oral morphine and inhaled nitrous oxide had no significant effect on premature infant pain profile (PIPP) scores during indirect ophthalmoscopy.DiscussionIn addition to topical anesthesia, premedication with oral paracetamol is recommended during screening examination for ROP. The routine use of fentanyl is not recommended due to the risk of potential side effects. Non‐pharmacological measures, such as sweet oral solutions and comfort techniques should also be employed. Further research is required to determine whether the use of nitrous oxide has a role, and to develop a safe and effective analgesic strategy to fully ameliorate the pain of ROP screening.

Near-infrared system’s efficiency for peripheral intravenous cannulation in a level III neonatal intensive care unit: a cross-sectional study

Venipuncture is a painful and invasive procedure for hospitalised newborns and represents a challenge for neonatal healthcare professionals. This study evaluated the most efficient cannulation method based on the proportion of success at the first attempt, standard care or near-infrared (NIR) device use, and pain assessment. An observational study with two arms was conducted in the neonatal intensive care unit (NICU) of a tertiary-care university hospital in Italy. All newborns undergoing peripheral vein cannulation and only nurses with more than 5 years of professional experience in the NICU were eligible for the first arm. Only newborns with a body weight of >2500 g at cannulation and all nurses working in the NICU were involved in the second arm. In the first arm of the study, no statistically significant differences between the NIR and control groups were found in terms of proportion of successful at the first attempt 60.6% (confidence interval [CI] 95%: 48.8; 72.4) vs. 56.1% (CI 95%: 44.1; 68.0) and the mean premature infant pain profile score 6.3 (CI 95%: 5.4-7.1) vs. 5.8 (CI 95%: 5.0-6.6). In the second arm, only among less experienced nurses (<1 year), we observed a significant increase in the proportion of success in the NIR group compared with the control group, nearly tripling the success rate (72.7% [54.1; 91.3] vs. 23.1% [0.2; 46.0]). Conclusion: This study reported no differences between the NIR and control groups. The results also suggest that using a NIR device may be advantageous for healthcare professionals with less experience during first-time cannulation. What is Known: • Venipuncture is a painful procedure commonly used to place a peripheral venous catheter for administering nutrients or drugs. • Near-infrared light facilitates the visualisation of veins and consequently, the performance of cannulation in the paediatric population. What is New: • The near-infrared light device was not associated with fewer attempts and a lower premature infant pain profile score in placing venous access in newborns than the traditional method. • The near-infrared light device could help nurses with less professional experience place a peripheral venous catheter.

25% Dextrose Versus 24% Sucrose for Heel Lancing in Preterm Infants: A Noninferiority RCT.

To compare the efficacy of 25% dextrose with 24% sucrose for heel-lance analgesia in preterm infants admitted to the NICU. In this noninferiority, double-blind, randomized controlled trial, preterm infants born at 28 weeks and 0 days to 35 weeks and 6 days of gestation who were due for a scheduled heel-lance procedure were enrolled. Infants randomly assigned to the intervention arm received 0.5 mL 25% dextrose, whereas infants in the active control group received 0.5 mL 24% sucrose orally just 2 minutes before the heel-lance procedure. The primary outcome was Premature Infant Pain Profile (PIPP) score 30 seconds after the procedure. Secondary outcomes included PIPP scores at 60 and 120 seconds, PIPP-Revised scores at 30, 60, and 120 seconds, and any adverse events. Sixty-four infants were enrolled (32 in each group). The mean (SD) PIPP score at 30 seconds was 6.41 (2.56) in the dextrose group and 7.03 (2.23) in the sucrose group (mean difference, -0.63 (95% confidence interval, -1.85 to 0.60; P = .31). The upper margin of the confidence interval did not cross the predefined noninferiority margin of 2. The mean PIPP scores at 60 (5.03 [2.18] vs 5.39 [1.48]) and 120 (4.75 [1.97] vs 4.94 [1.46]) seconds were also similar. The PIPP-Revised scores between the 2 groups at all time intervals were comparable. One infant in the intervention group had a transient coughing episode. In preterm infants under intensive care, 25% dextrose is noninferior to 24% sucrose for heel-lance analgesia as assessed by PIPP score.

Ketamine Analgesia as an Alternative to General Anesthesia During Laser Treatment for Retinopathy of Prematurity.

To determine the safety and efficacy of ketamine analgesia as an alternative to general anesthesia during laser treatment for retinopathy of prematurity (ROP). Eighteen premature neonates with ROP underwent laser treatment. The procedure was performed in the operating room, and the neonates were admitted to the neonatal intensive care unit (NICU) after the procedure. An initial dose of 1 mg/kg of ketamine was administered. If the neonate exhibited movement or distress during the procedure, incremental doses of ketamine were administered. Perioperative ventilation status, severity of pain during the procedure, surgeon satisfaction, and perioperative events were recorded. Eighteen premature neonates underwent ketamine analgesia during laser treatment for ROP. The procedure was performed in 16 patients with good tolerance and without events. The Premature Infant Pain Profile (PIPP) scores during the procedure were 5 or less in 12 neonates (44.4%), 5 to 10 in 4 neonates (22.2%), and greater than 10 in 2 (11.1%) neonates. Three neonates had perioperative events, which resolved completely with minimal intervention. None of the neonates needed intubation perioperatively, and hemodynamic instability, hypotension, and bradycardia were not recorded in any of the neonates during or after the procedure. The ROP laser treatment under ketamine sedation could be performed in premature neonates with few perioperative complications and provide satisfactory operative conditions. [J Pediatr Ophthalmol Strabismus. 2022;59(6):416-421.].

Premedication with Fentanyl for Less Invasive Surfactant Application (LISA): A Randomized Controlled Trial.

Currently, there is no consensus regarding analgesic premedication before the surfactant administration by less invasive surfactant application (LISA) procedure. In this randomized controlled trial, we compared the level of comfort of preterm infants receiving fentanyl as analgesic and sedative versus no fentanyl during LISA procedure. We randomized 34 preterm infants of 28+0-33+6 weeks of gestation with respiratory distress syndrome (RDS) within 6 h of birth to receive either fentanyl (1 μg/kg intravenous) or no premedication during surfactant administration by LISA procedure. Primary objective was to assess the proportion of preterm infants to be comfortable during the procedure [revised premature infant pain profile (R-PIPP) score ≤12] and secondarily complications occurring during the procedure, hemodynamically significant patent ductus arteriosus (hsPDA), intraventricular hemorrhage (IVH) (≥ grade 3), bronchopulmonary dysplasia (BPD) and composite outcome of BPD/mortality. Proportion of preterm infants with a R-PIPP score ≤12 during LISA was significantly higher in the fentanyl group [15/17 (88.23%) vs. 8/17 (47.05%); p value 0.025]. There were no differences in secondary outcome parameters. Low-dose fentanyl during LISA procedure resulted in more comfort in preterm infants and without increased complication of both the LISA procedure and fentanyl administration. Further studies are needed to determine the safest and most effective pharmacologic measures to prevent pain and discomfort during LISA.