Procedural Pain In Preterm Neonates Research Articles

A quality improvement initiative to improve management of procedural pain in preterm neonates.

Neonates managed in neonatal intensive care units undergo several invasive procedures. However, neonatal procedural pain is not well recognized and managed in most neonatal units. To decrease the severity of procedural pain in preterm neonates (<37weeks gestational age at birth), as measured by Premature Infant Pain Profile , by 50% by April 2020. A quality improvement initiative was conducted in a level 3 neonatal intensive care unit in South India. The pain was assessed independently by 2 interns not involved in clinical care using Premature Infant Pain Profile. After a baseline data recording and questionnaire assessing knowledge of healthcare personnel regarding neonatal pain, the interventions were planned. These were conducted as plan-do-study-act cycles-(i) Educational sessions, (ii) Introduction of bedside visual aids, (iii) Simulation sessions demonstrating the use of nonpharmacological measures and introduction of procedure surveillance chart in daily rounds, and (iv) Video feedback-based sessions. In the maintenance phase, the observations were continued. The healthcare personnel under recognized pain related to heel pricks and endotracheal intubation. They also had poor awareness of signs and symptoms of neonatal pain. A total of 202 procedures were observed during the study period. The mean pain score decreased significantly from 12.8±4.5 in baseline period to 6.2±1.8 in the maintenance phase. The use of analgesic measures increased from 13% in the baseline period to 73% in the maintenance phase. The use of automated lancet for heel prick increased from 0% to 94% in maintenance phase. More and more procedures were done with appropriate environment and baby state. The mean number of procedures per day decreased from 6.5±1.8 in baseline period to 2.7±0.9 in the maintenance phase. Targeted interventions can improve neonatal procedural pain management by improving use of analgesic measures, decreasing the number of procedures, and educating and training healthcare personnel.

Efficacy and safety of combined nonpharmacological interventions for repeated procedural pain in preterm neonates: A systematic review of randomized controlled trials

IntroductionPremature infants undergo numerous painful procedures during hospitalization. Some trials have examined the effectiveness and safety of combined nonpharmacological interventions in which two or more non-pharmacological interventions are used simultaneously or continuously to relieve repeated procedural pain via multisensory stimulation in preterm neonates. However, a systematic review of this topic has not yet been carried out. ObjectiveTo review the evidence on the efficacy and safety of combined nonpharmacological interventions for repeated procedural pain in preterm neonates. MethodEight databases were searched using keywords to identify peer-reviewed journal articles in English or Chinese. Randomized controlled trials (RCTs) focusing on combined nonpharmacological interventions for repeated procedural pain in preterm neonates published from database inception until May 2019 were included. ResultsEight RCTs were retrieved that included ten different combined nonpharmacological interventions. Different study designs were used in the included trials, which did not allow us to carry out a meta-analysis. The findings from the included articles were categorized in terms of efficacy and safety. With respect to efficacy, 1. two trials reported that combined nonpharmacological interventions were more effective than usual care during painful procedures; 2. three trials reported that combined nonpharmacological interventions were more effective than single nonpharmacological interventions; 3. three trials reported the effects of different combinations of nonpharmacological interventions and found that their effect depends on intervention type rather than number of interventions. Only four trials reported on safety, and they found that combined nonpharmacological interventions were safe for repeated procedural pain in preterm neonates. ConclusionAccording to the literature, combined nonpharmacological interventions may be effective and safe for repeated procedural pain in premature infants. However, due to the diversity of interventions included in this systematic review, the evidence is not strong enough to produce a best practice guideline. Further research is needed with larger sample sizes and less heterogeneity to adequately explore the efficacy and safety of combined nonpharmacological interventions for repeated procedural pain in premature infants.

Use of morphine before retinopathy of prematurity examinations

Use of morphine before retinopathy of prematurity examinations

The analgesic effect of non-pharmacological interventions to reduce procedural pain in preterm neonates

Painful procedures are unavoidable in the medical care of preterm babies. The unpleasant experience during the neonatal period may contribute to hyperalgesia and poor neurodevelopment outcome later. Seeking effective interventions to reduce pain are strongly indicated for these very small premature babies. The aim of this study is to investigate if instilling breast milk (BM) or dextrose water into oral cavity can reduce the procedural pain of heel stick for preterm babies. This is a prospective study; 20 premature neonates are enrolled. Each study case received heel stick 4 times. BM, 10% dextrose water (D10W), distilled water (placebo) and nothing (control group) were given one after the other in random order to the same patient before heel stick. Premature infant pain profile (PIPP) was used to assess the pain scores. The whole process consisted of 4 sections: a baseline period for 1min, intervention period for 1min, heel stick period for 20s, and recovery period for 5min. The primary outcome is to compare the PIPP scores in the 4 groups. Totally 20 babies completed this study. Median gestational age was 32 weeks 2 days (26 weeks 4 days-35 weeks 6 days) and median birth body weight was 1596g (766-2435g). The median PIPP scores and interquartile range at each time period were listed in the context. There are significant differences between BM/control group at all time periods, between BM/placebo group at 30-60s, 1-2min, and 2-3min, and between D10W/control group at 0-30s, 30-60s, 3-4min, and 4-5min. There are no significant differences between BM/D10W, D10W/placebo, and placebo/control groups at any time periods. Giving something with taste such as BM or D10W is safe and effective in reducing the procedural pain of heel stick in preterm neonates; BM is the priority.

Effect of Kangaroo Mother Care on Procedural Pain in Preterm Neonates

Effect of Kangaroo Mother Care on Procedural Pain in Preterm Neonates

Editorial: Neonatal Pain

Neonates exposed to painful stimuli are highly susceptible to acute, and long-term consequences of pain that negatively affect their psychological, emotional, behavioural, and cognitive development [6]. Animal model studies for neonatal pain have showed that persistent or repetitive pain increases apoptosis of neurone that could results in anxiety-disorders later in life [7]. In humans, the pain transmission and pain modulation pathways usually start developing from 22nd week of gestation and are fully developed till the age of 2 months [8]. It has been found that neonates subjected to nociceptive stimuli during this vulnerable period undergo long-term epigenetic changes, which affect their brain, neurodevelopment, pain modulation, and pain reactivity into adulthood [9]. Studies reported a strong association between neonatal pain/stress and altered IQ at age of seven years, probably due to irreversible changes in brain microstructure [10]. In a longitudinal cohort study of neonates (from birth to schoolage), it was found that painful experience in neonatal period is linked to the altered spontaneous oscillatory brain activity, which correlates with the visual problem-solving abilities later in life [11]. Procedural pain in preterm neonates is also found to be closely related to cognitive and learning disorders that surface later in life [12]. Therefore, for humanitarian reason it is very important to develop an effective and safe pain management strategy for treating neonatal pain and distress.

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.

Trial of Repeated Analgesia with Kangaroo Mother Care (TRAKC Trial)

BackgroundSkin-to-skin contact (SSC) between mother and infant, commonly referred to as Kangaroo Mother Care (KMC), is recommended as an intervention for procedural pain. Evidence demonstrates its consistent efficacy in reducing pain for a single painful procedure. The purpose of this study is to examine the sustained efficacy of KMC, provided during all routine painful procedures for the duration of Neonatal Intensive Care Unit (NICU) hospitalization, in diminishing behavioral pain response in preterm neonates. The efficacy of KMC alone will be compared to standard care of 24% oral sucrose, as well as the combination of KMC and 24% oral sucrose.Methods/designInfants admitted to the NICU who are less than 36 6/7 weeks gestational age (according to early ultrasound), that are stable enough to be held in KMC, will be considered eligible (N = 258). Using a single-blinded randomized parallel group design, participants will be assigned to one of three possible interventions: 1) KMC, 2) combined KMC and sucrose, and 3) sucrose alone, when they undergo any routine painful procedure (heel lance, venipuncture, intravenous, oro/nasogastric insertion). The primary outcome is infant’s pain intensity, which will be assessed using the Premature Infant Pain Profile (PIPP). The secondary outcome will be maturity of neurobehavioral functioning, as measured by the Neurobehavioral Assessment of the Preterm Infant (NAPI). Gestational age, cumulative exposure to KMC provided during non-pain contexts, and maternal cortisol levels will be considered in the analysis. Clinical feasibility will be accounted for from nurse and maternal questionnaires.DiscussionThis will be the first study to examine the repeated use of KMC for managing procedural pain in preterm neonates. It is also the first to compare KMC to sucrose, or the interventions in combination, across time. Based on the theoretical framework of the brain opioid theory of attachment, it is expected that KMC will be a preferred standard of care. However, current pain management guidelines are based on minimal data on repeated use of either intervention. Therefore, regardless of the outcomes of this study, results will have important implications for guidelines and practices related to management of procedural pain in preterm infants.Trial registrationClinicalTrials.gov Identifier: NCT01561547.

Expressed breast milk for procedural pain in preterm neonates: a randomized, double‐blind, placebo‐controlled trial

To determine whether expressed breast milk (milk) reduces procedural pain associated with heel lancing in preterm neonates. In this placebo-controlled trial, preterm neonates received 5 mL of distilled water as placebo (water, n = 44), 25% glucose water (glucose, n = 39) or milk (n = 40). Heel lancing was performed 2 min later. The primary outcome was the duration of first cry after lancing. Participants had similar baseline demographic and clinical characteristics. There was a significant difference in the median duration of first cry among the groups: water = 70.5 sec [interquartile range (IQR) = 5.5-104.5]; glucose = 2.0 sec (IQR = 0.0-45.0); milk = 29.5 sec (IQR = 0.0-65.0). Specifically, the duration of first cry was significantly shorter in the glucose group compared with the water group (Bonferroni adjustment, p = 0.011). Pain scores were significantly lower in the glucose and milk groups compared with the water group 1, 2 and 3 min after heel lancing (p < 0.05). Although milk did not significantly reduce crying time, our finding that pain scores were significantly lower in the milk group suggests that milk may reduce pain associated with heel lancing in preterm neonates.

Alternative female kangaroo care for procedural pain in preterm neonates: a pilot study

To determine the feasibility and effect size of kangaroo care (KC) for pain from heel lance in preterm neonates provided by either the infant's mother (MKC) or an unrelated alternate female (AFKC). Using a randomized crossover design, preterm neonates (n = 18) between 28 and 37 weeks gestational age within 10 days of life from two university-affiliated level III NICU's undergoing routine heel lance were assigned to receive KC 30 min before and during the procedure from either their mother (MKC) or an unrelated woman. In the second heel lance procedure at least 24 h later but within 10 days, the infants were crossed over to the other condition. There was a 48% participation rate, with only 40 of 82 eligible cases having maternal consent. The main reason for refusal was discomfort with another woman providing kangaroo care. The effect sizes on the pain scores (PIPP) were small, ranging from .23 to .43 across the first 2 min of procedure. The difference between nonrelated females and the mother in decreasing pain response is small, although not negligible. Given the high refusal rate, nonrelated females are a less desirable alternative to mothers than fathers.

Preterm infants receiving heel lance procedures have slightly lower pain scores and quicker time to return to baseline heart rate when held in kangaroo care by the mother than by the father

Commentary on: Johnston CC, Campbell-Yeo M, Filion F. Paternal vs maternal kangaroo care for procedural pain in preterm neonates: a randomized crossover trial. Arch Pediatr Adolesc Med 2011;165:792–6.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4]...

Paternal vs Maternal Kangaroo Care for Procedural Pain in Preterm Neonates

To test paternal vs maternal kangaroo care (KC) to reduce pain from heel lance. Randomized crossover design. Three university-affiliated level III neonatal intensive care units. Sixty-two preterm neonates at 28 to 36 weeks' gestational age who were expected to stay in the neonatal intensive care unit for at least 2 blood sampling procedures, without major congenital anomalies, grade III or IV intraventricular hemorrhage, or periventricular leukomalacia; without surgical interventions; not receiving parenteral analgesics or sedatives within 72 hours; and with parental consent. During 2 separate medically ordered heel lance procedures at least 24 hours apart, infants were held in KC for 30 minutes before and during the procedure with the mother or with the father, and with the other parent in the subsequent session. Which parent came first was randomized. The Premature Infant Pain Profile and time for heart rate to return to baseline were the primary outcomes. At 30 and 60 seconds after the heel lance, infants in maternal KC displayed significantly lower scores on the Premature Infant Pain Profile than when in paternal KC (30 seconds mean difference, 1.435 [95% confidence interval, 0.232-2.632]); 60 seconds mean difference, 1.548 [95% confidence interval, 0.069-3.027]). At 90 and 120 seconds, there were no differences. The difference in time to return to KC heart rate before the heel lance was significant, with the time in maternal KC being 204 seconds and in paternal KC, 246 seconds (mean difference, 42 seconds [95% confidence interval, 5.16-81.06 seconds]). Mothers were marginally more effective than fathers in decreasing pain response. Future research should address feasibility issues and nonparent providers of KC during painful procedures. clinicaltrials.gov Identifier: ISRCTN51481987.

PP-321. Paracetamol or sucrose for procedural pain in preterm neonates

PP-321. Paracetamol or sucrose for procedural pain in preterm neonates

Enhanced kangaroo mother care for heel lance in preterm neonates: a crossover trial

To test if enhancing maternal skin-to-skin contact, or kangaroo mother care (KMC) by adding rocking, singing and sucking is more efficacious than simple KMC for procedural pain in preterm neonates. Preterm neonates (n=90) between 32 0/7 and 36 0/7 weeks' gestational age participated in a single-blind randomized crossover design. The infant was held in KMC with the addition of rocking, singing and sucking or the infant was held in KMC without additional stimulation. The Premature Infant Pain Profile was the primary outcome with time to recover as the secondary outcome. A repeated-measures analysis of covariance was employed for analyses. There were no significant differences in any of the 30 s time periods over the 2 min of blood sampling nor in time to return to baseline. Compared to historical controls of the same age in incubator, the pain scores were lower and comparable to other studies of KMC. There were site differences related to lower scores with the use of sucrose in one site and higher scores in younger, sicker infants in another site. The sensorial stimulations from skin-to-skin contact that include tactile, olfactory sensations from the mother are sufficient to decrease pain response in premature neonates. Other studies showing that rocking, sucking and music were efficacious were independent of skin-to-skin contact, which, when used alone has been shown to be effective as reported across studies.

Pain in children: psychosocial: Maternal “Babytalk” for management of procedural pain in preterm neonates

Pain in children: psychosocial: Maternal “Babytalk” for management of procedural pain in preterm neonates