Effect of multisensory stimulation on analgesia in term neonates: a randomized controlled trial

Oral glucose solution as pain relief in newborns: results of a clinical trial

BACKGROUND

It was long believed that newborns could not experience pain. As it is now documented that newborns have all the necessary systems to perceive pain, pain management can no longer be ignored. The objective of this study is to investigate which concentration of glucose is most effective in reducing pain for venipuncture in the newborn.

METHODS

This double-blind clinical trial of 304 newborns was conducted on a maternity and neonatal ward (neonatal medium intensive care unit). During at least 1 month, one of the four selected solutions (10, 20, 30% glucose, and placebo) was administered orally, 2 minutes before the venipuncture was performed. The pain from the skin puncture was scored using a validated pain scale (the "Leuven Pain Scale").

RESULTS

This study showed a significantly lower average pain score in the 30 percent glucose group (3.99) when compared with the placebo group (8.43). The average pain scores in the 20 percent glucose group (5.26) and the 10 percent glucose group (5.92) were also significantly lower than those in the placebo group.

CONCLUSION

Oral administration of 2 mL of 30 percent glucose 2 minutes before the venipuncture provides the most effective pain reduction in newborns.

Skin-to-skin contact and/or oral 25% dextrose for procedural pain relief for term newborn infants

OBJECTIVE

The goal was to compare the efficacy of oral 25% dextrose treatment and/or skin-to-skin contact for analgesia in term newborns during intramuscular injection of a hepatitis B vaccine.

METHODS

A prospective, randomized, partially blinded, clinical trial was performed with 640 healthy term newborns. Infants at 12 to 72 hours of life were assigned randomly to receive an intramuscular injection of hepatitis B vaccine in the right thigh according to 4 analgesia groups, that is, no analgesia (routine); oral 25% dextrose treatment, given 2 minutes before the injection; skin-to-skin contact, initiated 2 minutes before the injection and persisting throughout the procedure; and a combination of the oral dextrose treatment and skin-to-skin contact strategies. For all groups, Neonatal Facial Coding System and Neonatal Infant Pain Scale scores were evaluated before the procedure, during thigh cleansing, during the injection, and 2 minutes after the injection. Premature Infant Pain Profile scores also were assessed for all infants. Pain scores were compared among the 4 groups.

RESULTS

The use of oral 25% dextrose treatment reduced the duration of procedural pain in the studied population. Skin-to-skin contact decreased injection pain and duration. The combination of the 2 analgesic measures was more effective than either measure separately for term newborns.

CONCLUSIONS

Nonpharmacologic analgesic measures were effective for the treatment of procedural pain in term infants. The combination of oral 25% dextrose treatment and skin-to-skin contact acted synergistically to decrease acute pain in healthy neonates.

[Analgesic effect of breastfeeding when taking blood by heel-prick in newborns]

OBJECTIVE

To compare the analgesic effectiveness of breastfeeding when taking blood by the heel-lance procedure in healthy newborns, as opposed to other procedures.

PATIENTS AND METHODS

We studied 228 term infants from the Maternity Unit of our Hospital. The study was developed in two consecutive phases. In the first stage, 150 newborns were distributed into three randomised groups, the first group (50 newborns) did not receive any specific analgesic intervention; the second and third groups (50 newborns) received non-nutritive sucking-placebo or non-nutritive sucking-24% sucrose respectively. In the second phase, 78 newborns participated, and the blood was taken during breast-feeding. The results on a discomfort scale were compared with those obtained in the rest of examined analgesic procedures.

RESULTS

The group that received analgesia with breast-feeding showed a score on the discomfort scale of 0'62 and an average time of crying of 0'19s. The comparative analysis of the results obtained during breastfeeding, as opposed to the rest of procedures, showed that breast-feeding is the best analgesic option, with a reduction in the discomfort of 51% and of 98% in the time of crying (P<0,001).

CONCLUSIONS

Breast-feeding during the blood test by heel-prick procedure represents the most effective analgesic method. A containment procedure along with non-nutritive sucking is the analgesic method of choice in the newborn that does not receive maternal lactation.

[The use of sucrose for the prevention of pain during venipuncture in neonates]

OBJECTIVE

To evaluate the effectiveness of sucrose use in the prevention of pain during venipuncture in neonates.

METHOD

Double blind randomized control trial. The population consisted of hospitalized neonates subjected to venipuncture. Sample size was calculated with a 95% confidence level, 80% power, minimum proportion of neonates with pain 40% in the study group and 70% in the control group. The minimum sample size was 49 newborns per group. Five minutes before venipuncture, the neonates received 1cc of oral solution of 12% sucrose (study group) or distilled water (control group). During the procedure the pain level was evaluated with NIPS (Neonatal Infant Pain Scale). A data base was created, and the information processed and analysed using the SPSS program.

RESULTS

A total of 111 neonates were analysed, (55 in study group and 56 in control group). Bivariate analysis showed a smaller NIPS score in the group that received sucrose. Linear regression model explained that the significant variables for pain during the procedure were: hours since birth and the absence of non-nutritious suction, not being related to the sucrose administration.

CONCLUSION

Neonates that received the oral solution of sucrose before venipuncture had an average pain score lower than the placebo controlled group.

Guidelines for procedural pain in the newborn

Despite accumulating evidence that procedural pain experienced by newborn infants may have acute and even long-term detrimental effects on their subsequent behaviour and neurological outcome, pain control and prevention remain controversial issues. Our aim was to develop guidelines based on evidence and clinical practice for preventing and controlling neonatal procedural pain in the light of the evidence-based recommendations contained in the SIGN classification. A panel of expert neonatologists used systematic review, data synthesis and open discussion to reach a consensus on the level of evidence supported by the literature or customs in clinical practice and to describe a global analgesic management, considering pharmacological, non-pharmacological, behavioural and environmental measures for each invasive procedure. There is strong evidence to support some analgesic measures, e.g. sucrose or breast milk for minor invasive procedures, and combinations of drugs for tracheal intubation. Many other pain control measures used during chest tube placement and removal, screening and treatment for ROP, or for postoperative pain, are still based not on evidence, but on good practice or expert opinions.

CONCLUSION

These guidelines should help improving the health care professional's awareness of the need to adequately manage procedural pain in neonates, based on the strongest evidence currently available.

[Analgesia when taking heel-lance blood in the newborn]

OBJECTIVE

To evaluate the pain in healthy newborns requiring blood test by a heel-prick procedure and compare different pain management methods.

PATIENTS AND METHOD

We studied 150 term infants, in three randomised groups, from the Maternity Unit of our Hospital for a period of three months. The first group of 50 newborns, received no specific analgesic intervention during blood tests, except our usual nursing intervention ("facilitated tucking"). The second and third group (50 newborns), received non-nutritive sucking-placebo and non-nutritive sucking-24% sucrose respectively.

RESULTS

In the control group, the average score on the scale of discomfort was 3.92, moderate pain, causing a crying time of 51.72 seconds; the group receiving a non-nutritive sucking-placeboscored 2.1, slight pain, 10.68 seconds crying, while the group receiving non-nutritive sucking-24 % sucrose, expressed a level of discomfort of 1.5 points, slight, with an average crying time of 10.70 seconds. The comparative results between the control group and groups of non-nutritive sucking on placebo and 24% sucrose, both showed significant differences in the scores of the scale of discomfort, as well as in the time crying (p < 0.001). The comparative analysis between groups of non-nutritive sucking sucrose and placebo showed no significant differences.

CONCLUSIONS

The blood test by heel lance represents a painful procedure of moderate intensity capable of analgesic treatment. A proper nursing method, along with a complement of non-nutritive sucking during extraction, significantly decreases the discomfort and crying, it being unnecessary to consider other analgesics.

The effect of multimodal stimulation and cutaneous application of vegetable oils on neonatal development in preterm infants: a randomized controlled trial

BACKGROUND

Preterm newborns admitted to the Neonatal Intensive Care Unit are deprived of sensory stimulation. Tactile/kinaesthetic stimulation results in weight gain. Studies involving the cutaneous application of vegetable oils have shown improvement in somatic growth and on skin barrier function.

OBJECTIVE

To assess the neurodevelopmental and biological benefits of the simultaneous use of multimodal stimulation (SMS) and the cutaneous application of vegetable oils. Setting Tertiary referral centre serving the Poitou-Charentes region of France.

METHODS

Randomized controlled trial of 49 low-risk preterm infants, born at 31- to 34-week gestation. Each infant was randomly assigned to one of three treatment groups, Sensori-Tonico-Motor (STM) touch for 10 days with either: sweet almond oil, ISIO4 blended oil, or placebo - normal saline, or to a control group who did not receive any intervention. The primary outcome was weight gain. Secondary outcomes were linear growth, neurological maturation, psychomotor development and number of days of admission. Analysis was by intention-to-treat.

RESULTS

The group who received STM with ISIO4 oil demonstrated enhanced weight gain (+57%, 95% CI 37-76) compared with controls (P = 0.030). All STM groups showed shorter admission times (mean reduction 15 days, 95% CI 23-50 days hospitalised, P = 0.005), and an increase in body length (P = 0.030). Both groups of oil massaged babies (almond and ISIO4) showed an increased neurological score (P = 0.001) compared to controls. The infants receiving ISIO4 oil had an associated increase in psychomotor scores (P = 0.028), time spent in quiet wakefulness (P = 0.036), improved orientation (P = 0.036), and enhanced development of the oculomotor (P = 0.012) and sensorimotor (P = 0.003) systems. An additional benefit seen was improved moisturization (P = 0.001), and quicker recovery of dermatological conditions. No adverse dermatological events were observed.

CONCLUSIONS

The combination of STM and cutaneous application of oils to healthy preterm babies resulted in enhanced weight gain and neurological development, and a shorter stay in hospital.

Breastfeeding or oral sucrose solution in term neonates receiving heel lance: a randomized, controlled trial

OBJECTIVE

The purpose of this work was to compare the efficacy of breastfeeding versus orally administered sucrose solution in reducing pain response during blood sampling through heel lance. METHODS; We conducted an open-label, randomized, controlled trial at a neonatal unit of a public hospital in northern Italy on 101 term neonates undergoing heel lance with an automated piercing device for routine neonatal screening for congenital disorders. Newborn infants were randomly assigned to breastfeeding during blood sampling or to the oral administration of 1 mL of 25% sucrose solution. We validated the multidimensional acute pain rating scale of the Premature Infant Pain Profile, heart rate increase, oxygen saturation decrease, crying behavior (duration of first cry, cry percentage in 2 minutes, and during blood sampling), duration of sampling, and the number of performed heel lances.

RESULTS

Median Premature Infant Pain Profile scores were lower in the breastfeeding group (3.0) than in the sucrose-solution group (8.5), and the median group difference was -5.0. The median heart rate increase, oxygen saturation decrease, and duration of first cry for the breastfeeding group were, respectively, 13.0, -1, and 3 and for sucrose group were 22, -3, and 21. Medians were significantly different between the groups. There were no significant differences in the sampling duration and numbers of heel lances.

CONCLUSIONS

This study suggests that breastfeeding provides superior analgesia for heel lance compared with oral sucrose in term neonates.

A Review of CAM for Procedural Pain in Infancy: Part I. Sucrose and Non-nutritive Sucking

There is increasing concern regarding the number of painful medical procedures that infants must undergo and the potential risks of alleviating infant pain with conventional pharmacologic agents. This article is Part I of a two-part series that aims to provide an overview of the literature on complementary and alternative (CAM) approaches for pain and distress related to medical procedures among infants up to six weeks of age. The focus of this article is a review of the empirical literature on sucrose with or without non-nutritive sucking (NNS) for procedural pain in infancy. Computerized databases were searched for relevant studies including prior reviews and primary trials. The most robust evidence was found for the analgesic effects of sucrose with or without NNS on minor procedural pain in healthy full-term infants. Despite some methodological weaknesses, the literature to date supports the use of sucrose, NNS and other sweetened solutions for the management of procedural pain in infancy.

A Review of CAM for Procedural Pain in Infancy: Part II. Other Interventions

This article is the second in a two-part series reviewing the empirical evidence for complementary and alternative medicine (CAM) approaches for the management of pain related to medical procedures in infants up to 6 weeks of age. Part I of this series investigated the effects of sucrose with or without non-nutritive sucking (NNS). The present article examines other CAM interventions for procedural pain including music-based interventions, olfactory stimulation, kangaroo care and swaddling. Computerized databases were searched for relevant studies including prior reviews and primary trials. Preliminary support was revealed for the analgesic effects of the CAM modalities reviewed. However, the overall quality of the evidence for these approaches remains relatively weak. Additional well-designed trials incorporating rigorous methodology are required. Such investigations will assist in the development of evidence-based guidelines on the use of CAM interventions either alone or in concert with conventional approaches to provide safe, reliable analgesia for infant procedural pain.

Non-pharmacological techniques for pain management in neonates

Significant progress in understanding the physiology, clinical correlates, and consequences of neonatal pain have resulted in greater attention to pain management during neonatal intensive care. A number of nonpharmacological therapies have been investigated, including nonnutritive sucking, with and without sucrose use, swaddling or facilitated tucking, kangaroo care, music therapy, and multi-sensorial stimulation. Although the efficacy of these approaches is clearly evident, they cannot provide analgesia for moderate or severe pain in the neonate. Further, some of these therapies cannot be effectively applied to all populations of critically ill neonates. Acupuncture, an ancient practice in Chinese medicine, has gained increasing popularity for symptom control among adults and older children. Acupuncture may provide an effective nonpharmacological approach for the treatment of pain in neonates, even moderate or severe pain, and should be considered for inclusion in a graduated multidisciplinary algorithm for neonatal pain management.

Familiarity breeds content? Soothing effect of a familiar odor on full-term newborns

OBJECTIVE

This study tested the effects of familiar and unfamiliar odors during a heel stick in full-term newborns.

METHOD

Forty-four newborns were exposed to vanillin (via their mother or via their crib) or no odor prior to a heel stick. On the day of the heel stick, infants were either exposed to a familiar odor, an unfamiliar odor, or no odor before, during, and after the procedure. Crying, grimacing, and oral movements were scored.

RESULTS

Infants exposed to a familiar odor displayed little distress and more oral movements during the procedure compared to the unfamiliar group. No advantage was found when infants were exposed to an odor learned via their mother compared to when the odor was learned via the crib. Exposure to an unfamiliar odor did not lessen distress compared to exposure to no odor.

CONCLUSION

A familiar odor is effective in significantly reducing crying and grimacing during a minor painful procedure. Olfactory support is a useful intervention that may potentially help minimize deleterious effects of neonatal pain.

Sensorial saturation for neonatal analgesia

AIM

Sensorial saturation (SS) is a procedure in which touch, massage, taste, voice, smell, and sight compete with pain, producing almost complete analgesia during heel prick in neonates. SS is an apparently complex maneuvre, but when correctly explained it is easily learnt. In the present paper, we studied its feasibility, assessing whether a long training is really needed to achieve good results.

MATERIALS AND METHODS

We enrolled 66 consecutive babies and divided them randomly into 3 groups which received the following forms of analgesia: glucose plus sucking (A), SS performed by nurses (B), SS performed by mothers (C). We did not use perfume on the caregivers' hands, so that babies could smell the natural scent of the hands. We assessed pain level by the ABC scale.

RESULTS

Median scores of groups A, B, and C were: 1 (0 to 6), 0 (0 to 4), and 0 (0 to 6), respectively. Mean scores were: 0.6, 0.6, and 1.7 and standard errors were 0.38, 0.22, and 0.32, respectively. Scores of groups B and C were significantly lower than that of A (P=0.03 and 0.006, respectively). No significant difference was found between values of scores of groups B and C.

CONCLUSIONS

Even without the use of perfume on the hands, SS was effective as an analgesic maneuvre. It made no difference whether SS was performed by mothers who applied it for the first time or experienced nurses. SS is rapid to learn and any caregiver (mother, pediatrician or nurse) can effectively use it.

The use of breast-feeding for pain relief during neonatal immunization injections

The objective of this study was to examine the pain-relieving effect of breast-feeding during immunization injections in healthy neonates. Sixty-six healthy infants returning to a clinic for their second-, third-, or fourth-month immunization with intramuscular diphtheria, tetanus, and pertussis were randomized to be breast-fed before, during, and after the injection or to be given the injection according to routine clinic procedure (no breast-feeding). To assess the pain responses of the neonates during and after immunization, we noted their heart rates, oxygen saturation levels, and length of crying. The crying time was shorter in the experimental (breast-feeding) group (M +/- SD duration, 35.85 +/- 40.11 seconds) than in the control group (M +/- SD duration, 76.24 +/- 49.61 seconds; p = .001). The heart rate and oxygen saturation levels were almost the same in both groups. We concluded that breast-feeding, maternal holding, and skin-to-skin contact significantly reduced crying in infants receiving an immunization injection for diphtheria, tetanus, and pertussis.

Analgesic effect of watching TV during venipuncture

AIMS

To assess the analgesic effect of passive or active distraction during venipuncture in children.

METHODS

We studied 69 children aged 7-12 years undergoing venipuncture. The children were randomly divided into three groups: a control group (C) without any distraction procedure, a group (M) in which mothers performed active distraction, and a TV group (TV) in which passive distraction (a TV cartoon) was used. Both mothers and children scored pain after the procedure.

RESULTS

Main pain levels rated by the children were 23.04 (standard deviation (SD) 24.57), 17.39 (SD 21.36), and 8.91 (SD 8.65) for the C, M, and TV groups, respectively. Main pain levels rated by mothers were 21.30 (SD 19.9), 23.04 (SD 18.39), and 12.17 (SD 12.14) for the C, M, and TV groups, respectively. Scores assigned by mothers and children indicated that procedures performed during TV watching were less painful (p<0.05) than control or procedures performed during active distraction.

CONCLUSION

TV watching was more effective than active distraction. This was due either to the emotional participation of the mothers in the active procedure or to the distracting power of television.

Prior leg massage decreases pain responses to heel stick in preterm babies

AIM

Leg massage could inhibit the transmission of pain by 'closing the gate' or by activating the endogenous opioid pathway to decrease nociceptive transmission of pain associated with heel stick. The aim of this study is to determine the effects of massage therapy prior to heel stick on responses assessed by the Neonatal Infant Pain Scale (NIPS) (primary outcome), heart rate, respiratory rate and oxygen saturation (secondary outcomes) in infants who required a heel stick for blood sampling.

METHODS

This randomised, double-blind, crossover trial with infants from 1 to 7 days post birth excluded those with prior surgery, septicaemia, current assisted ventilation or an analgesic within 48 h. After informed consent, 13 infants received a 2-min massage of the ipsilateral leg prior to heel stick on the first study sampling and no massage on the next sampling 2-7 days later and 10 infants had the reverse order. The bedside nurse, blinded to the intervention, measured NIPS, heart rate, respiratory rate, and oxygen saturation prior to massage, after massage, and 5 min after heel stick. Serum cortisol was measured with the blood sampling.

RESULTS

In 23 infants (birthweight 795-2507 g), there were no adverse physiologic effects of massage. After heel stick, NIPS (P < 0.001) and heart rate (P = 0.03) were increased in the no-massage group compared with the massage group. Respiratory rate, oxygen saturation and serum cortisol were not significantly different.

CONCLUSION

Gentle massage of the leg prior to heel stick is safe and decreases pain responses in preterm infants.

Pode a amamentação promover alívio da dor aguda em recém-nascidos?

Trata-se de um estudo de revisão cujo objetivo foi identificar a eficácia da amamentação e dos aspectos que a congregam (contato, sucção, odor e leite) como medidas não- farmacológicas no alívio da dor aguda em recém-nascidos. Os 14 artigos analisados foram obtidos pelo Medline/PubMed. Verificou-se diferenças metodológicas quanto à amostragem, procedimentos dolorosos, períodos e maneira de administrar o tratamento e variáveis mensuradas. Percebeu-se a eficácia da amamentação e dos aspectos que a congregam, no alívio da dor aguda. Percebe-se a necessidade de estudos que avaliem o seu efeito analgésico antes do procedimento doloroso, até a recuperação, tempo este, suficiente para atingir-se o efeito analgésico pós-absortivo do leite. Deve-se considerar a interação entre todos os componentes que estão contidos na amamentação.

Pain in infants who are younger than 2 months during suprapubic aspiration and transurethral bladder catheterization: a randomized, controlled study

OBJECTIVE

Proper diagnosis of urinary tract infections depends on obtaining an uncontaminated urine sample for culture. Suprapubic aspiration and transurethral catheterization are the 2 recommended procedures for obtaining specimens for urine culture from young infants. The objective of the current study was to compare the pain that is experienced during these 2 procedures when performed in young infants.

METHODS

A prospective, single-blind, randomized, controlled study was conducted at a university-affiliated hospital in Israel. Institutional Research Ethics Board approved the study. Infants who were 0 to 2 months of age and presented to the emergency department with fever and therefore required urine collection for culture were randomly assigned evenly into 2 sample collection groups: suprapubic aspiration or transurethral catheterization. Patients were excluded when they were born prematurely or had had a previous sepsis workup or other painful procedures or an anomaly of the urogenital system or abdominal wall. Eutectic mixture of local anesthetic cream that contained lidocaine and prilocaine was applied 1 hour before the procedure. The urethra was catheterized using a 5-Fr latex-free feeding tube that was lubricated with sterile water-soluble jelly that contained 2% lidocaine hydrochloride. Pediatric residents who were experienced with the procedures performed both suprapubic aspiration and transurethral catheterization. The parents were instructed to use any comfort strategies that they wished, including verbal or physical comforting and pacifiers. Pain during collection was assessed on a 100-mm visual analog scale by a nurse and a parent. In addition, the infant's upper part of the body was videotaped during the procedure. An investigator, who was blinded to the procedure, assigned a point score according to the Douleur Aigue du Nouveaune neonatal acute pain scale. For ensuring a successful blinding process, the following steps were taken. First, camera recording started 30 seconds before the procedure to prevent the possibility of distinguishing between the procedures on the basis of their duration. Second, the physician and the nurse were asked not to speak during the procedure to avoid revealing the nature of the procedure. Third, the person who videotaped the procedure watched the tape before it was analyzed to ensure the impossibility of identifying the procedure from the tape. The Student's t test was used to compare the groups. The primary outcome was the mean Douleur Aigue du Nouveaune score. Secondary outcomes were the mean visual analogue scale for pain as estimated by the parents and by the nurse. We estimated that 25 patients would be needed in each group to detect a difference in the mean Douleur Aigue du Nouveaune score of at least 2 points with a power of 80% and alpha of .05.

RESULTS

The study was conducted between April 1, 2004, and April 30, 2005. Fifty-eight infants were recruited; 29 were randomly assigned to suprapubic aspiration, and 29 were randomly assigned to transurethral catheterization. Seven infants were excluded because of consent withdrawal (3 patients), because of technical difficulties during videotaping (3 patients), or because the child voided during the procedure (1 patient). Twenty-seven infants in the suprapubic aspiration group and 24 in the transurethral catheterization group completed the study. All male infants were circumcised. An adequate urine sample was obtained in 18 (66%) of 27 patients in the suprapubic aspiration group and in 20 (83.3%) of 24 in the transurethral catheterization group. The mean Douleur Aigue du Nouveaune score was significantly higher in patients who were randomly assigned to suprapubic aspiration compared with patients who were randomly assigned to transurethral catheterization (7 and 4.5, respectively). The differences in Douleur Aigue du Nouveaune score also were significant in a subgroup analysis of boys and girls. Mean visual analogue scale scores by parents was higher in the suprapubic aspiration group compared with transurethral catheterization (63 +/- 27 mm vs 46 +/- 26, respectively). Similarly, mean visual analogue scale scores by nurses was higher in the suprapubic aspiration group compared with transurethral catheterization (3 +/- 18 mm vs 43 +/- 25 mm, respectively).

CONCLUSIONS

In infants who are younger 2 months, suprapubic aspiration is more painful than transurethral catheterization. Health professionals should consider these differences when choosing a method for obtaining a urine sample from young infants.

Differences in survival and neonatal metabolism in lambs from flocks selected for or against staple strength

In the field, we found that lamb mortality was lower (P < 0.01) in a flock selected for wool staple strength (SS+) than in a flock selected against staple strength (SS–), or a random-bred control flock (R); mortality rates calculated from 4200 records were 17.0, 22.8, and 24.1%, respectively. The proportion of twins was similar in all flocks, but birth weights differed (P < 0.01), being 4.40, 4.25, and 4.14 kg, respectively. Biochemical profiles were measured in lambs from 20 ewes from each flock around the time of birth in an animal-house study, to define potential causes of the genetic difference in survival. In the intensive study, birth weight was similar for all groups; however, gestation length was slightly shorter in the SS+ lambs (P < 0.05 for SS+ v. R). All lambs had low plasma concentrations of the essential amino acids and glucose at birth, compared with after suckling. Plasma concentrations of glucose, non-esterified fatty acids (NEFA), and blood urea nitrogen (BUN) at birth differed between lambs from the flocks with the greatest difference in mortality (i.e. SS+ v. R); that is, SS+ lambs had higher concentrations of glucose (1.84 v. 1.23 mm; P < 0.01) and NEFA (1.52 v. 1.08 mm; P < 0.05), and lower concentrations of BUN (7.7 v. 9.7 mm; P < 0.01) at birth, and for the next 9 h. The semimembranosus and semitendinosus muscle of the SS+ lambs also had lower concentrations of ATP (7.4 v. 5.0 μmol/g, respectively) compared with lambs from the other flocks, immediately post-partum. Muscle phosphocreatinine was also slightly lower in the SS+ lambs. No differences between the genotypes were observed in reserves of glycogen, carcass fat, brown adipose tissue, or in neonatal thyroid hormones. In summary, sheep selected for high wool staple strength had lower lamb mortality than the other 2 flocks. This was accompanied by metabolic differences at birth that can be associated with greater metabolic maturity, rather than greater energy reserves.

A Taste Comparison of Two Different Liquid Colecalciferol (Vitamin D3) Preparations in Healthy Newborns and Infants

BACKGROUND

It is recommended that Swiss infants have a minimum intake of 10.0 microg of colecalciferol (vitamin D3) per day during the first 12 months of life. For this reason they are prescribed an alcoholic solution containing colecalciferol. However, it has been stated that the palatability to infants of the alcoholic colecalciferol preparation is poor.

METHODS

In an ambulatory care setting, the palatability of two liquid preparations that contained colecalciferol dissolved in either alcohol or in vegetable oil was investigated in 40 healthy newborns and 30 infants. Each study subject sampled both preparations once, and the blinded mother rated the child's reaction on a visual analogue scale that incorporated a facial hedonic scale.

RESULTS

In 38 newborns, oily colecalciferol was preferred with no difference between the two preparations in the remaining two cases. In 27 infants, oily colecalciferol was preferred with no difference between the two preparations in three infants. None of the 70 study subjects preferred the alcoholic preparation. The difference between the two preparations was significant both in newborns (p < 0.0001) and in infants (p < 0.0005).

CONCLUSION

From the perspective of the child, the taste of oily colecalciferol is superior to that of alcoholic colecalciferol.

Pain management in the neonatal intensive care unit: a national survey in Italy

BACKGROUND

This study assessed current medical practice in preventative analgesia and sedation for invasive procedures in neonatal intensive care units (NICU) in Italy.

METHODS

A questionnaire was sent to level II and III Italian NICUs to investigate pain management, pharmacological treatment and the use of pain scores during invasive procedures. Main outcome measures were the extent to which analgesia and sedation are currently used for invasive procedures in Italian neonatal units.

RESULTS

The rate of response to the questionnaire was 88%. Written guidelines were available on acute pain control in 25% of the NICUs, and on prolonged pain control in 50%. Routine use of preventative pharmacological and nonpharmacological measures for painful procedures ranged from 13% for elective tracheal intubation to 68% for chest tube insertion. Thirty-six percent of NICUs routinely use sedation with opioids for mechanical ventilation; 14% prevent distress and pain for tracheal suctioning, 44% for heel lancing, 50% for venepuncture and percutaneous venous catheter insertion; 58% use analgesia before lumbar puncture. Validated pain assessment scores were used by 19% of NICUs.

CONCLUSIONS

The need for adequate analgesia is still underestimated. Further information on the safety of analgesics in neonatology is imperative, as is an adequate education of physicians and nurses on the use of pain control guidelines as part of the standard of care in the NICU.

Analgesic Effects of Breast-feeding or Pacifier Use With Maternal Holding in Term Infants

OBJECTIVES

First, to compare analgesic effects of breast-feeding versus pacifier use in newborn infants undergoing blood collection via heel sticks. Second, to compare analgesic effects of pacifier use with maternal holding versus nonmaternal holding.

DESIGN

A prospective, randomized, controlled trial.

SETTING

Normal newborn nursery at academic teaching hospital.

PARTICIPANTS

Full-term breast-feeding infants scheduled for routine newborn screening blood test via heel stick (n = 96). Interventions.-Infants randomized to 3 groups for analgesia: 1) breast-feeding, 2) pacifier use while held by mothers, 3) pacifier use while held by research assistants (nonmothers).

OUTCOME MEASURES

Primary outcome was crying (percent of infants who cried during the procedure and mean percent of procedure time that infants cried). Secondary outcomes were physiologic measures.

RESULTS

Fewer breast-feeding infants cried than infants using a pacifier while held by nonmothers both during the procedure (69% vs 100%, P < .01) and after the procedure (28% vs 60%, P = .03). Those infants crying during the procedure cried for less time if held by their mothers either breast-feeding (33%, P < .01) or using a pacifier (45%, P = .03) than those using a pacifier while being held by nonmothers (66%).

CONCLUSION

Breast-feeding is more analgesic than pacifier use with nonmaternal holding. Maternal holding with either breast-feeding or pacifier use is more analgesic than nonmaternal holding with pacifier use, suggesting that maternal holding itself has an analgesic effect. Breast-feeding and maternal holding should be considered as pain-control measures for the neonate during heel-stick procedures.

Development and validation of the ABC pain scale for healthy full-term babies

AIM

We developed and validated a pain scale (ABC scale) for term babies based on acoustic features of crying.

METHODS

The scale consisted of three different cry parameters: (a) pitch of the first cry; (b) rhythmicity of the crying bout; (c) constancy of crying intensity. These parameters were previously found to distinguish between medium and high levels of pain measured by spectral analysis of crying. We validated the scale using healthy term babies undergoing routine heel prick. Concurrent validity was assessed comparing pain values obtained with our scale with those obtained with another pain scale; this relationship was also used to assess the sensitivity of the scale. To assess specificity we compared the ABC scores during a painful event (heel prick) with two non-painful events (preliminary phase of prick in the same group of babies, and heel prick with analgesia in another group).

RESULTS

Specificity: (a) analgesic/non-analgesic comparison, p < 0.0001; (b) pain/sham comparison, p < 0.0001). Sensitivity: a high correlation between scores of the ABC scale and the Douleur Aigue du Nouveau-Né scale indicates good sensitivity. Concurrent validity: Spearman rho = 0.91. Internal consistency: Cronbach's alpha = 0.76. Inter-rater reliability: Cohen's kappa for multiple raters = 0.83. Intra-rater reliability: Cohen's kappa = 0.85. Practicality: All nurses who used it scored the scale as "good".

CONCLUSION

The ABC scale proved to be simple and reliable for assessing pain in healthy, non-intubated term newborns.

Pain relief for neonatal circumcision

BACKGROUND

Circumcision is a painful procedure that many newborn males undergo in the first few days after birth. Interventions are available to reduce pain at circumcision; however, many newborns are circumcised without pain management.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of interventions for reducing pain at neonatal circumcision.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), MEDLINE (1966 - April 2004), EMBASE (1988 - 2004 week 19), CINAHL (1982 - May week 1 2004), Dissertation Abstracts (1986 - May 2004), Proceedings of the World Congress on Pain (1993 - 1999), and reference lists of articles. Language restrictions were not imposed.

SELECTION CRITERIA

Randomised controlled trials comparing pain interventions with placebo or no treatment or comparing two active pain interventions in male term or preterm infants undergoing circumcision.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed trial quality and extracted data. Ten authors were contacted for additional information. Adverse effects information was obtained from the trial reports. For meta-analysis, data on a continuous scale were reported as weighted mean difference (WMD) or, when the units were not compatible, as standardized mean difference.

MAIN RESULTS

Thirty-five trials involving 1,984 newborns were included. Thirty-three trials enrolled healthy, full term neonates, and two enrolled infants born preterm. Fourteen trials involving 592 newborns compared dorsal penile nerve block (DPNB) with placebo or no treatment. Compared to placebo/no treatment, DPNB demonstrated significantly lower heart rate [WMD -35 bpm, 95% CI -41 to -30], decreased time crying [WMD -54 %, 95% CI -64 to -44], and increased oxygen saturation [WMD 3.2 %, 95% CI 2.7 to 3.7]. Six trials involving 190 newborns compared eutectic mixture of analgesics (EMLA) with placebo. EMLA demonstrated significantly lower facial action scores [WMD -46.5, 95% CI -80.4 to -12.6], decreased time crying [WMD - 15.8 %, 95% CI -20.8 to -6.8] and lower heart rate [WMD -15 bpm, 95% CI -19 to -10]. DPNB, compared with EMLA in four trials involving 164 newborns, demonstrated significantly lower heart rate [WMD -17 bpm, 95% CI -23 to -11] and pain scores. When compared with sucrose in two trials involving 126 newborns, DPNB demonstrated less time crying [MD -166 s, 95% CI -211 to -121], and lower heart rate [WMD -27 bpm, 95% CI -33 to -20]. Results obtained for trials comparing oral sucrose and oral analgesics to placebo, and trials of environmental modification were either inconsistent or were not significantly different. Adverse effects included gagging, choking, and emesis in placebo/untreated groups. Minor bleeding, swelling and hematoma were reported with DPNB. Erythema and mild skin pallor were observed with the use of EMLA. Methaemoglobin levels were evaluated in two trials of EMLA, and results were within normal limits.

REVIEWERS' CONCLUSIONS

DPNB was the most frequently studied intervention and was the most effective for circumcision pain. Compared to placebo, EMLA was also effective, but was not as effective as DPNB. Both interventions appear to be safe for use in newborns. None of the studied interventions completely eliminated the pain response to circumcision.

Olfaction in the fetal and premature infant: functional status and clinical implications

This article considers olfaction as a functioning source of information for the fetus and the neonate, born on term or prematurely. It aims to present how odors are involved in the sensory continuity between the prenatal and postnatal environments and how they influence the earliest adaptive responses of newborns in the realms of self-regulation, emotional balance, feeding, and social interactions.Finally, it evaluates odors as sensory means to ameliorate the physiologic and behavioral responses of preterm infants to the adverse impacts of separation from mother, nonoral feeding, or iatrogenic distress.

Oral glucose before venepuncture relieves neonates of pain, but stress is still evidenced by increase in oxygen consumption, energy expenditure, and heart rate

Oral glucose was recommended as pain therapy during venepuncture in neonates. It is unclear whether this intervention reduces excess oxygen consumption (o(2)), energy loss, or cardiovascular destabilization associated with venepuncture, and whether <2 mL glucose solution is effective. We tested the hypothesis that oral glucose solution attenuates the increases in neonatal oxygen consumption, energy expenditure (EE), and heart rate associated with venepuncture for two different volumes of glucose solution (2 and 0.4 mL). In this prospective, randomized, controlled, double-blind trial, 58 neonates (gestational age, 31-42 wk; postnatal age, 1-7 d) were randomized to 2 mL glucose 30%, 0.4 mL glucose 30%, or 2 mL water by mouth before venepuncture. The videotaped behavioral pain reactions were scored with the Premature Infant Pain Profile. Cry duration, o(2), EE (indirect calorimetry), and heart rate were measured. The 2 mL glucose solution reduced pain score and crying after venepuncture compared with controls [median pain score, 5.5 (interquartile range, 4-9) versus 11 (7-12), p = 0.01; median duration of first cry, 0 s (0-43 s) versus 13 s (2-47 s), p < 0.05, respectively]. The 0.4 mL glucose solution had no effect. The 2 mL glucose solution did not attenuate the o(2) increase during venepuncture (1.5 +/- 0.2 mL/kg min (water) versus 1.7 +/- 0.5 (0.4 mL glucose) versus 1.1 +/- 0.2 (2 mL glucose) (mean +/- SEM) nor EE nor heart rate. We conclude that oral administration of 2 mL glucose 30% before venepuncture reduced pain expression and crying, but did not prevent the rise in o(2), EE, or heart rate. Alternative therapies against the stress of nonpainful handling during venepuncture should be explored.

Cry features reflect pain intensity in term newborns: an alarm threshold

The purpose of this study was to assess differences in sound spectra of crying of term newborns in relation to different pain levels. Fifty-seven consecutively born neonates were evaluated during heel-prick performed with different analgesic techniques. Crying was recorded and frequency spectrograms analyzed. A pain score on the DAN (Douleur Aiguë du Nouveau-né) scale was assigned to each baby after the sampling. Three features were considered and correlated with the corresponding DAN scores: 1) whole spectral form; 2) the fundamental frequency of the first cry emitted (F0); and 3) root mean square sound pressure normalized to its maximum. After emission of the first cry, babies with DAN scores >8, but not with DAN scores < or =8 (p < 0.001), showed a pattern ("siren cry") characterized by a sequence of almost identical cries with a period on the order of 1 s. A statistically significant correlation was found between root mean square (r2 = 89%, p < 0.01), F0 (r2 = 32%, p < 0.05), siren cry (r2 = 68.2%, p = 0.02), and DAN score. F0 did not show significant correlation with DAN score in the subset of neonates with DAN scores < or =8 (r2 = 1.4%, p = 0.94), and babies with a DAN score >8 had a significantly higher F0 than those with lower DAN scores (p = 0.016). An alarm threshold exists between high (>8) and low (< or =8) DAN scores: crying has different features in these two groups. When pain exceeds a DAN score of 8, usually a first cry at a high pitch is emitted, followed by the siren cry, with a sound level maintained near its maximum.

Analgesic effect of breast feeding in term neonates: randomised controlled trial

OBJECTIVES

To investigate whether breast feeding is effective for pain relief during venepuncture in term neonates and compare any effect with that of oral glucose combined with a pacifier.

DESIGN

Randomised controlled trial.

PARTICIPANTS

180 term newborn infants undergoing venepuncture; 45 in each group.

INTERVENTIONS

During venepuncture infants were either breast fed (group 1), held in their mother's arms without breast feeding (group 2), given 1 ml of sterile water as placebo (group 3), or given 1 ml of 30% glucose followed by pacifier (group 4). Video recordings of the procedure were assessed by two observers blinded to the purpose of the study.

MAIN OUTCOME MEASURES

Pain related behaviours evaluated with two acute pain rating scales: the Douleur Aiguë Nouveau-né scale (range 0 to 10) and the premature infant pain profile scale (range 0 to 18).

RESULTS

Median pain scores (interquartile range) for breast feeding, held in mother's arms, placebo, and 30% glucose plus pacifier groups were 1 (0-3), 10 (8.5-10), 10 (7.5-10), and 3 (0-5) with the Douleur Aiguë Nouveau-né scale and 4.5 (2.25-8), 13 (10.5-15), 12 (9-13), and 4 (1-6) with the premature infant pain profile scale. Analysis of variance showed significantly different median pain scores (P<0.0001) among the groups. There were significant reductions in both scores for the breast feeding and glucose plus pacifier groups compared with the other two groups (P<0.0001, two tailed Mann-Whitney U tests between groups). The difference in Douleur Aiguë Nouveau-né scores between breast feeding and glucose plus pacifier groups was not significant (P=0.16).

CONCLUSIONS

Breast feeding effectively reduces response to pain during minor invasive procedure in term neonates.