Sucrose for analgesia in newborn infants undergoing painful procedures

The effect of combined non-pharmacological interventions on venous blood sampling pain in preterm infants: a clinical trial study

BACKGROUND

Using non-pharmacological methods to reduce the pain of hospitalized infants is one of the most important priorities in the health of newborns. Pain relief during painful procedures can help prevent unwanted physical and psychological effects. This study was conducted with the aim of investigating the effect of combined non-pharmacological interventions on venous blood sampling pain in preterm infants.

METHODS

In this clinical trial study, 88 preterm infants admitted to the Neonatal Intensive Care Unit of Rouhani Hospital was randomly assigned to four groups of sucrose (S), the combined group of sucrose and non-nutritive sucking (NS), the combined group of swaddle and sucrose (SS) and the combined group of sucrose, non-nutritive sucking and swaddling (NSS). In order to collect information, were used the premature Infant Pain Profile Scale (PIPP) and demographic characteristics questionnaire.

RESULTS

This study showed that during blood sampling, the difference in the mean pain score of two groups of S and NS was equal to 3.54 (95% CI = 1.85, 5.24) and in two groups S and NSS was equal to 4.68 (95% CI = 2.99, 6.38), and these differences were significant (P < 0.001). In addition, the mean pain difference in all study groups was significant in two time periods before-during and during-after blood sampling (P < 0.001). Also, the mean pain difference in the two time periods before-during and during-after in NS and NSS groups was significant compared to the control group (sucrose) (P < 0.001).

CONCLUSIONS

Based on the results of this study, the use of combined non-pharmacological interventions of NSS has been more effective in reducing the pain caused by venous blood sampling than other conditions where two or one non-pharmacological intervention were used.

Neonatal Sucrose and Internalizing Behaviors at 18 Months in Children Born Very Preterm

Importance

In the neonatal intensive care unit (NICU), neonates born very preterm (<33 weeks' gestation) are exposed to great numbers of painful procedures, which is associated with more internalizing (anxiety and depressive) behaviors later in childhood. Oral sucrose is commonly used in NICUs to treat acute procedural pain and is effective in reducing behavioral responses, but the long-term associations between oral sucrose and child behaviors have not yet been examined.

Objective

To examine associations between cumulative neonatal pain and sucrose exposure in early life (prior to approximately 32 weeks postmenstrual age), in relation to child behaviors (internalizing and externalizing) at 18 months corrected age (CA) in children born very preterm and to examine whether the associations are sex specific.

Design, Setting, and Participants

In a prospective, longitudinal cohort study, children born very preterm (24-32 weeks' gestational age [GA]) were recruited from 2015 to 2019 from 3 tertiary NICUs in Canada and attended a follow-up visit at 18 months CA. Data analysis was performed from February to May 2024.

Exposures

The clinical protocol to treat acute procedural pain at site 1 was facilitated tucking with nonnutritive sucking; sites 2 and 3 used 24% sucrose with nonnutritive sucking. Prospective clinical record review was conducted (eg, number of painful procedures, cumulative sucrose dose, analgesia, sedation, days receiving mechanical ventilation, and surgical procedures).

Main Outcomes and Measures

Parents reported on their child's behavior on the Child Behavior Checklist (CBCL; 1.5 to 5 years) yielding internalizing and externalizing scores.

Results

In total, 192 children (110 male [57%]) were included in the current study. After applying propensity score weights to adjust for clinical factors across sucrose and nonsucrose sites and accounting for neonatal pain, cumulative sucrose (milliliters) in early life was not associated with internalizing scores (B = 0.62; 95% CI, -0.46 to 1.99). However, greater neonatal pain exposure was significantly associated with higher 18-month CBCL internalizing scores (B = 0.01; 95% CI, 0.0003 to 0.0135; R2 = 1.8%). There were no associations with externalizing scores, and associations were not moderated by child sex.

Conclusions and Relevance

In this cohort study of children born very preterm across 3 tertiary NICUs in Canada, cumulative sucrose exposure in early life demonstrated no association with child behavior and did not ameliorate the association between greater neonatal pain and internalizing behaviors. Further research is needed to identify pain management strategies that can effectively mitigate or protect against adverse behavioral outcomes in children born very preterm.

[Translating evidence: pain treatment in newborns, infants, and toddlers during needle-related procedures : German version]

INTRODUCTION

Treatment of pain in preterm, sick, and healthy newborns and infants and toddlers (up to 2 years of age) is consistently reported to be inadequate, and effective strategies are poorly implemented.

OBJECTIVES

To present existing evidence of effective pain treatment strategies during needle-related procedures and to highlight initiatives focused on translating evidence into practice.

METHODS

This Clinical Update focuses on the 2022 International Association for the Study of Pain Global Year for Translating Pain Knowledge to Practice in the specific population of newborns, infants, and toddlers. Best evidence is reviewed, and existing knowledge translation strategies and programs available to implement evidence into practice are presented.

RESULTS

Effective strategies for newborn and young infants during frequently occurring needle procedures include small volumes of sweet solutions, breastfeeding, or skin-to-skin care when feasible and culturally acceptable. In addition, strategies such as nonnutritive sucking, positioning, swaddling, gentle touch, facilitated tucking, and secure holding can be used. For toddlers, the evidence is less robust, and discerning between pain and distress is challenging. However, strategies recommended for needlerelated procedures include upright secure comfort holding by parents/caregivers, age-appropriate distraction, and topical anesthetics. Translation of effective pain management needs to involve the family, who need to be supported and empowered to comfort their child during painful procedures. Organizational, nationwide, and global initiatives aimed at improving implementation of effective pain treatments exist.

CONCLUSION

There is evidence of effective pain management strategies for newborns, infants, and toddlers, and a great deal of effort is being made to translate knowledge into action.

Multisensory stimulation to reduce procedural pain in retinopathy of prematurity: A randomized controlled trial

BACKGROUND

Retinopathy is frequently seen in the neonatal intensive care unit (NICU), and its examination is a painful procedure for infants.

AIM

This randomized active-controlled trial aimed to investigate the impact of multisensory stimulation (MSS) on neonatal pain during retinopathy of prematurity (ROP) examinations, in comparison with a white noise (WN) and control group receiving standard care.

STUDY DESIGN

Conducted as a three-arm, randomized controlled trial, the study was implemented in the NICU of a local university hospital. Recruitment spanned from July 2023 to November 2023, with preterm infants (gestational age < 37 weeks) randomly assigned to either a MSS, WN or a control group. MSS components included visual, auditory, tactile, olfactory and gustatory stimuli, all designed to create a synergistic, comforting environment for the infant during the procedure. Procedural pain, heart rate and oxygen saturation were assessed at various stages before and after ROP examinations.

RESULTS

Analysis of 90 participants revealed that the MSS group exhibited lower Premature Infant Pain Profile (PIPP) scores than the WN and control groups (mean difference: -2.12, 95% confidence interval [CI]: -2.62 to -1.62; odds ratio [OR]: 0.004, 95% CI [0.001, 0.012], p < 0.001). Additionally, heart rates were significantly lower in the MSS group (mean difference: -15.3 beats/min, 95% CI: -20.5 to -10.1; OR: 0.025, 95% CI [0.008, 0.073], p < .001) and oxygen saturation levels were higher (mean difference: 3.2%, 95% CI: 1.8% to 4.6%; OR: 1.12, 95% CI [1.05, 1.20], p < .001) than in the other groups.

CONCLUSIONS

MSS emerges as a favourable, safe and non-pharmacological intervention for pain management in ROP and similar procedures.

RELEVANCE TO CLINICAL PRACTICE

Multisensory stimulation can be effectively integrated into the routine care provided by critical care nurses during retinopathy of prematurity examinations in preterm infants. This non-pharmacological intervention offers a practical approach for critical care nurses to reduce procedural pain and improve physiological stability in this vulnerable population.

Increasing the Use of Newborn Pain Treatment Following the Implementation of a Parent-Targeted Video: An Outcome Evaluation

BACKGROUND/OBJECTIVES

Despite strong evidence that breastfeeding, skin-to-skin care, and sucrose reduce pain in newborns during minor painful procedures, these interventions remain underutilized in practice. To address this knowledge-to-practice gap, we produced a five-minute parent-targeted video demonstrating the analgesic effects of these strategies and examined whether the use of newborn pain treatment increased in maternal-newborn care settings following the introduction of the video by nurses.

METHODS

The design was a pre-post outcome evaluation. The participants were infants born in eight maternal-newborn hospital units in Ontario, Canada. Data on newborn pain treatment were obtained from a provincial birth registry. Descriptive statistics and chi square tests were used to compare the before-and-after changes in the use of pain treatment.

RESULTS

Data on 15,524 infants were included. Overall, there was an increase in the proportion of newborns receiving any pain treatment comparing before (49%) and after (54%) the video intervention (p < 0.0001) and a decrease in the proportion of newborns receiving no pain treatment pre- (17.6%) and post-intervention (11.5%) (p < 0.0001). Most of the change aligned with increased sucrose use (35% to 47%, p < 0.0001) in three of the larger units. Nevertheless, considerable increases in the use of breastfeeding and/or skin-to-skin care (24% to 38%, p < 0.0001) were also observed in three of the smaller units.

CONCLUSIONS

The video intervention was effective at increasing the use of pain treatment for newborns. Though the overall increases were modest, there were some large increases for specific methods of pain treatment in certain maternal-newborn units, reflecting the diversity in practice and context across different sites.

Brain health in preterm infants: importance of early-life pain and analgesia exposure

"Everyday" exposures in the neonatal period, such as pain, may impact brain health in preterm infants. Specifically, greater exposure to painful procedures in the initial weeks after birth have been related to abnormalities in brain maturation and growth and poorer neurodevelopmental outcomes in preterm infants. Despite an increasing focus on the importance of treating pain in preterm infants, there is a lack of consensus of optimal approaches to managing pain in this population. This may be due to recent findings suggesting that commonly used analgesic and sedative medications in preterm infants may also have adverse effects of brain maturation and neurodevelopmental outcomes. This review provides an overview of potential impacts of pain and analgesia exposure on preterm brain health while highlighting research areas in need of additional investigations for the development of optimal pain management strategies in this population.

The effects of maternal voice on pain during placement of peripherally inserted central catheter in neonates

Background

Peripherally inserted central catheter (PICC) are a necessary procedure for preterm newborns care. Despite the use of analgesic treatments, its insertion can be painful. Our objective was to study the effect of maternal voice on pain during PICC insertion.

Method

We conducted a pre post study for 2 years. Pain was compared between the two groups (with/without maternal presence) using a neonatal pain scale (FANS). Infection rate, procedure time, number of failures, mothers' anxiety and caregivers'anxiety were compared between the two groups.

Results

Ninety neonates were eligible. Finally, 63 neonates were included. Thirty-four placements were realized without maternal voice (first period) and 29 with maternal voice (second period). Mean FANS during PICC placement was lower in the maternal voice group than in the control group (1.15 ± 1.27 vs. 1.41 ± 1.49, p = 0.033). The FANS was also lower in the maternal voice group during the time of the first cutaneous effraction (p = 0.032). There was no significant difference between the two groups concerning the other outcomes.

Conclusion

Maternal voice added to conventional care decreased acute pain during PICC insertion without increasing infection rate, number of failures or procedure time.

Comparing the effects of oral sucrose and kangaroo mother care on selected physiological variables and pain resulting from venipuncture in premature newborns admitted to neonatal intensive care units

BACKGROUND

Premature newborns admitted to neonatal intensive care units (NICUs) undergo numerous painful interventions during care and treatment. The purpose of this study was to compare the effects of using sucrose and kangaroo mother care by on selected physiological variables and pain resulting from venipuncture in premature infants admitted to NICUs affiliated with Shiraz University of Medical Sciences.

METHODS

This clinical trial included premature infants admitted to 2 NICUs. The sample size consisted of 66 neonates, with 22 newborns in each group. Randomization was performed using the block allocation method. Data collection involved a demographic questionnaire, the neonatal infant pain scale, and a pulse oximetry device. Friedman, Kruskal-Wallis, and Dunn's post hoc tests employed for data analysis, with a significance level of P < 0.05.

RESULTS

The use of oral sucrose and kangaroo care demonstrated significant differences in breathing rate, heart rate, and average arterial blood oxygen saturation during and after venipuncture (P < 0.05). Oral sucrose was found to be significantly more effective than kangaroo care. Neonates under kangaroo care exhibited more regular heart rates compared to the other group (P < 0.05). The utilization of oral sucrose and kangaroo care had varying effects on the average pain score resulting from venipuncture in premature neonates (P < 0.05).

CONCLUSIONS

Both methods proved effective in reducing pain and improving physiological variables. However, due to the superior effectiveness of sucrose administration, it is recommended as a cost-effective and easily implementable method in NICUs.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20191215045749N1. (29/03/2020).

Flicker electroretinogram in preterm infants

BACKGROUND

Infants born prematurely are at risk of developing retinopathy of prematurity, which is associated with abnormalities in retinal function as measured using electroretinography. The aim of this study was to record non-invasive flicker electroretinograms (ERGs) in preterm infants and compare function of moderate and very or extremely preterm infants.

METHODS

In this non-randomized, cross-sectional study, 40 moderate preterm (gestational age (GA) 34 0/7 to 36 6/7 weeks, Group A) and 40 very or extremely preterm infants (GA ≤ 31 weeks, Group B) were recruited for flicker ERG recording through closed eyelids using the RETeval® device and skin electrodes. Group A was tested within the first week of life and Group B between 34th and 37th week postmenstrual age. Flicker stimuli were presented at 28.3 Hz with stimulus levels of 3, 6, 12, 30 and 50 cd•s/m2. Primary endpoints were peak time (ms) and amplitude (µV).

RESULTS

Flicker ERGs were recordable in most infants with the highest proportion of reproducible ERGs at 30 cd•s/m2. Amplitudes increased with stronger flicker stimulation, while peak times did not differ significantly between stimulus levels nor groups. Amplitudes were significantly greater in Group B at the strongest stimulus level (Mann-Whitney-U-Test=198.00, Z = 4.097, p = <0.001).

CONCLUSIONS

Feasibility of collecting flicker ERG data in most preterm infants was confirmed. We found no evidence of reduced retinal responses to flicker stimuli associated with extreme prematurity. Higher amplitudes in very and extremely preterm infants could indicate acceleration of retinal development following birth, triggered by visual stimulation.

Comparison of Sucrose vs. Swaddling in Pain Management during Birth Dose of Hepatitis B Vaccine: A Randomized Control Trial

OBJECTIVES

To evaluate the efficacy of pain management of 1 ml of 24% sucrose given orally compared to routine care given one minute before vaccination for reduction of pain.

METHODS

This double-blind randomized controlled trial included term neonates visiting Pediatric OPD for immunization. Neonates were randomly assigned into two groups (Group A- Sucrose, Group B- Swaddling). Commercially available sucrose solution (StayHappi solution 24%) was given in a dose of 1 ml to the neonates. Video recording of the neonate's facial expression was done during the procedure. Duration of cry, latency of onset of cry as well Modified Neonatal Facial Coding Score (MFCS) were the outcome variables.

RESULTS

The mean (SD) of birth weight and gestational age was 2729 (321.6) g and 38.24 (0.84) d, respectively. Analysis showed significant difference in total MFCS across the groups (P <0.001). Total MFCS was significantly lower in sucrose group [4.88 (1.07) vs. 7.17 (0.95)]. The duration of cry (in seconds) was also found to be significantly lower in sucrose group.

CONCLUSIONS

Administration of 1 ml 24% sucrose one minute prior to immunization is efficacious in pain management during injectable immunization.

Oral Sucrose in Infants Undergoing Flexible Nasolaryngoscopy: A Blinded Randomized Pilot Study

INTRODUCTION

Flexible nasolaryngoscopy (FNL) is a common, uncomfortable procedure performed to assess the upper airway in infants. Oral sucrose is used during various painful procedures in infants but has not been used during FNL. Our objective was to understand the impact of oral sucrose on discomfort in infants undergoing FNL.

METHODS

Infants (<12-months-old) undergoing FNL in the otolaryngology clinic were randomized to treatment (0.5 mL 24% oral sucrose) or standard management (no sucrose). Sucrose was administered <2 min prior to FNL performed by a single endoscopist. Outcome measures included: EVENDOL pain scale and cry duration and visit duration. Infant discomfort was measured by a second observer who was blinded to treatment group.

RESULTS

Forty-seven infants were included, 23 were treated with sucrose and 24 with standard management. The median (IQR) age was 3.0 (2-5.7) months. There were no significant differences in age, weight, or sex across groups. The median (IQR) duration of FNL was 35.2 (26.5-58.4) and 36.4 (28.9-51.8) seconds for treatment and standard management groups, respectively. Mean (SD) EVENDOL scores were significantly lower in the sucrose group [4.9 (2.0)] than standard group (6.7 [2.1]) (p = 0.003). Mean cry duration after FNL was significantly shorter in the sucrose group (29.9 [20.4] seconds) than the standard group (52.7.0 [40.6] seconds) (p = 0.02). Median (IQR) visit duration did not differ across groups (1.1 [0.9-1.3] vs. 1.1 [0.7-1.4] h [p = 0.15]).

CONCLUSION

Oral sucrose given before FNL reduced EVENDOL scores and cry duration after FNL and did not prolong clinic visits in this randomized pilot study.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:3826-3831, 2024.

Nonpharmacological Interventions to Mitigate Procedural Pain in the NICU: An Integrative Review

BACKGROUND

Small infants experience a myriad of stimuli while in the Neonatal Intensive Care Unit (NICU), with many being painful or stressful experiences, although medically necessary.

PURPOSE

To determine what is known about nonpharmacological developmental care interventions used in the NICU to mitigate procedural pain of infants born under 32 weeks gestation.

SEARCH/STRATEGY

Five electronic databases were searched: Medline, CINAHL, Scopus, Embase and the Cochrane Library. The inclusion criteria were as follows: experimental and nonexperimental studies from all publication years with infants born at less than 32 weeks gestational age; peer-reviewed research articles studying nonpharmacological interventions such as skin-to-skin care, facilitated tucking, nonnutritive sucking, hand hugs, and swaddling; and English language articles. Our search yielded 1435 articles. After the elimination of 736 duplicates, a further 570 were deemed irrelevant based on their abstract/titles. Then, 124 full-text articles were analyzed with our inclusion and exclusion criteria.

FINDINGS

Twenty-seven studies were reviewed. Sucrose, facilitated tucking, pacifier, skin-to-skin care, and human milk appeared to lessen pain experienced during heel sticks, suctioning, nasogastric tube insertions, and echocardiograms. All nonpharmacological interventions failed to prove efficacious to adequately manage pain during retinopathy of prematurity (ROP) examinations.

IMPLICATIONS FOR PRACTICE

Evidence review demonstrates that healthcare practitioners should use nonpharmacological measures to help prevent pain from day-to-day procedures in the NICU including heel sticks, nasogastric tube insertions, suctioning, echocardiograms, and subcutaneous injections.

IMPLICATIONS FOR RESEARCH

Future research is necessary to better understand and measure how pain is manifested by very small premature infants. Specific research on mitigating the pain of examinations for retinopathy of prematurity is also needed.

Scoping review of systematic reviews of nursing interventions in a neonatal intensive care unit or special care nursery

AIM(S)

To identify, synthesise and map systematic reviews of the effectiveness of nursing interventions undertaken in a neonatal intensive care unit or special care nursery.

DESIGN

This scoping review was conducted according to the JBI scoping review framework.

METHODS

Review included systematic reviews that evaluated any nurse-initiated interventions that were undertaken in an NICU or SCN setting. Studies that reported one or more positive outcomes related to the nursing interventions were only considered for this review. Each outcome for nursing interventions was rated a 'certainty (quality) of evidence' according to the Grading of Recommendations, Assessment, Development and Evaluations criteria.

DATA SOURCES

Systematic reviews were sourced from the Cochrane Database of Systematic Reviews and Joanna Briggs Institute Evidence Synthesis for reviews published until February 2023.

RESULTS

A total of 428 articles were identified; following screening, 81 reviews underwent full-text screening, and 34 articles met the inclusion criteria and were included in this review. Multiple nursing interventions reporting positive outcomes were identified and were grouped into seven categories. Respiratory 7/34 (20%) and Nutrition 8/34 (23%) outcomes were the most reported categories. Developmental care was the next most reported category 5/34 (15%) followed by Thermoregulation, 5/34 (15%) Jaundice 4/34 (12%), Pain 4/34 (12%) and Infection 1/34 (3%).

CONCLUSIONS

This review has identified nursing interventions that have a direct positive impact on neonatal outcomes. However, further applied research is needed to transfer this empirical knowledge into clinical practice.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implementing up-to-date evidence on effective nursing interventions has the potential to significantly improving neonatal outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement in this scoping review.

Comparative Study of Acute Stress in Infants Undergoing Percutaneous Achilles Tenotomy for Clubfoot vs. Peripheral Line Placement

INTRODUCTION

Percutaneous tenotomy of the Achilles tendon is a procedure that is part of the Ponseti method for clubfoot correction. The need to apply general anesthesia or sedation for this procedure is controversial. The objective of this study is to compare the acute stress generated in infants by percutaneous Achilles tenotomy under local anesthesia vs. peripheral line placement.

MATERIAL AND METHODS

This cross-sectional study compares the discomfort experienced by 85 infants undergoing percutaneous Achilles tenotomy with local anesthesia with that experienced by 39 infants undergoing peripheral line placement. The following parameters were determined: the duration of the procedure, crying time, average crying intensity, and maximum crying intensity. Other data recorded included the infant's age and complications arising during the procedure.

RESULTS

The mean ages of these patients were 1.95 and 2.18 months, respectively. The following data were obtained: the mean duration of the procedure for Group A was 8.13 s and for Group B it was 127.43 s; the mean duration of crying for Group A was 84.24 s and for Group B it was 195.82 s; the mean intensity of crying for Group A was 88.99 dB and for Group B it was 100.98 dB; and the maximum crying intensity for Group A was 96.56 dB and for Group B it was 107.76 dB.

CONCLUSIONS

Percutaneous Achilles tenotomy can be safely performed as an outpatient procedure, under local anesthesia. This method generates less discomfort than peripheral line placement.

Effect of pacifier and pacifier with dextrose in reducing pain during orogastric tube insertion in newborns: a randomized controlled trial

OBJECTIVE

This study aimed to assess the efficacy of pacifier use, with and without 25% dextrose, in reducing pain during orogastric tube insertion in newborns.

STUDY DESIGN

In a randomized controlled trial involving 60 newborns at a public hospital from April to December 2019, participants were divided into three groups: pacifier (n = 20), pacifier with 25% dextrose (n = 20), and control (n = 20). A pacifier, with and without dextrose, was used for the experimental groups, while the control group performed a routine procedure. Neonatal infant pain scale, crying duration, heart rate (HR), and oxygen saturation (SpO2) were evaluated.

RESULTS

Results indicated that the control group experienced significantly higher pain levels, elevated HRs, decreased SpO2, and prolonged crying. Conversely, the pacifier with 25% dextrose group showed a notable reduction in crying duration.

CONCLUSION

A pacifier, with and without 25% dextrose, effectively reduces pain and improves physiological and behavioral parameters during orogastric tube insertion.

CLINICAL TRIAL NUMBER

NCT05462964 CLINICAL TRIAL REGISTRATION: The protocol for this randomized controlled experimental trial is registered on ClinicalTrials.gov. The clinical trial registration number is https://clinicaltrials.gov ; NCT05462964.

The effect of the simulated intrauterine sound on behavioral and physiological indices of pain during capillary blood sampling for screening preterm infants: a randomized clinical trial study

INTRODUCTION

Due to medical procedures, preterm infants are at high risk for side effects of pain. In this regard, heel lancing for capillary blood sampling is a common painful procedure. The present study was conducted to assess the effectiveness of a simulated intrauterine sound on behavioral and physiological indices of pain due to heel-prick blood sampling in preterm infants.

METHODS

A double‑blind randomized clinical trial (RCT) was conducted. The data were collected from September 23 to December 22, 2019. We measured the effect of a simulated intrauterine sound on changes in the behavioral and physiological parameters of pain (heart rate, SPO2) caused by heel lance that was measured 5 min before the intervention, during the sampling, and 5 min after the procedure. We measured behavioral pain by video recording the infants' faces and then the scoring neonatal infant pain scale (NIPS). Heart rate and SPO2 were measured using a pulse oximeter device. The data were analyzed using analysis of variance (ANOVA) and independent t‑test in SPSS software version 20.0.

RESULTS

Eighty infants were randomized (40 in each group). Mean scores NIPS during and after intervention were in the intervention group (3.55 ± 0.84, 95% CI: 3.30-3.80(, and (1.15 ± 0.84, 95%: 0.95-1.35) and in the control group (5.57 ± 0.95, 95% CI:5.30-5.85) and (3.00 ± 0.98) respectively. There were significant differences in scores of NIPS between the two study groups during (p < 0.001) and five min after heel lancing (p < 0.001). Mean scores of heart rate in the three phases of before, during, and five min after the intervention were respectively in the intervention group (127.57 ± 4.45, 95% CI:126.27-128.99), (131.07 ± 6.54, 95% CI:129.20-133.22), (128.45 ± 5.15, 95% CI:127.02-130.07) and in the control group (128.67 ± 4.57, 95% CI:127.32-130.07), (136.07 ± 7.24, 95% CI:133.90-138.37), and (132.42 ± 6.47, 95% CI:130.37-134.49). There were significant differences in heart rate between the intervention and the control group during (p = 0.002) and five min after the heel lance (p = 0.003). Mean scores of SPO2 in the three phases of baseline, during, and five min after the intervention were respectively in the intervention group (96.72 ± 0.93, 95% CI:96.42-97.00), (91.47 ± 1.46, 95% CI:91.05-91.92), (94.17 ± 1.03, 95% CI:93.22-94.00) and in the control group (96.6 ± 0.84, 95% CI:96.35-96.85), (91.5 ± 1.24, 95% CI:91.12-91.87), and (93.60 ± 1.27, 95% CI:93.85-94.50).

CONCLUSION

This study showed that the simulated intrauterine sound reduces the behavioral pain and heart rate in the intervention group during and after heel lance. These results suggest using the method during the painful heel lancing to reduce pain parameters in preterm infants.

Efficacy and safety of dexmedetomidine for analgesia and sedation in neonates: a systematic review

Opioids and benzodiazepines have historically been employed for pain relief; however, they are associated with detrimental long-term neurodevelopmental consequences. Dexmedetomidine, a highly selective alpha-2-adrenoreceptor agonist, has piqued interest as a viable alternative for neonates, owing to its potential analgesic and neuroprotective attributes. We conducted a systematic review to assess the efficacy and safety of dexmedetomidine utilization in neonates. We conducted a comprehensive search of Ovid, MEDLINE, EMBASE, PubMed, Cochrane, and CINAHL, spanning from January 2010 to September 2022. Our review encompassed six studies involving 252 neonates. Overall, dexmedetomidine may be effective in achieving sedation and analgesia. Furthermore, it may reduce the need for adjunctive sedation or analgesia, shorten the time to extubation, decrease the duration of mechanical ventilation, and accelerate the attainment of full enteral feeds. Notably, no significant adverse effects associated with dexmedetomidine were reported. Nevertheless, additional well-designed studies to establish both the efficacy and safety of dexmedetomidine in neonatal care are needed.

Comparative Efficacy of Breastfeeding or Feeding of Breast Milk on Blood Sampling Pain Relief in Full-Term Neonates: A Systematic Review and Meta-Analysis

Objectives: To evaluate the efficacy of breastfeeding or feeding of breast milk in reducing blood sampling pain in full-term neonates by comparing with other intervention measures. Methods: Related literature was searched from PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials (Central). Only randomized controlled trials (RCTs), which reported the effect of breastfeeding or feeding of breast milk on blood sampling pain in full-term neonates, were eligible. The primary outcome was set as pain score on scales, and the secondary outcomes as physiological and behavioral indicators. The risk of bias in included studies was assessed by the Cochrane Collaboration's tool. Data analysis was performed using RevMan 5.4.1. Main Results: A total of 17 RCTs were included. Breastfeeding showed a stronger effectiveness in reducing blood sampling pain, compared with nonintervention, placebo, mother's holding, breast milk odor, mother's heartbeat, music therapy, skin-to-skin, and Eutectic Mixture of Local Anesthetics ointment. However, the efficacy of glucose or sucrose (12.5%-30% concentration) seems better than breastfeeding. When compared with other interventions, feeding of breast milk yielded different results. Its effect was only stronger than placebo (sterile water or distilled water), massage, or nonintervention. Conclusions: Breastfeeding might be effective for alleviating blood sampling pain in full-term neonates. Its effect is second only to that of glucose/sucrose. The efficacy of feeding of breast milk in reducing blood sampling pain in full-term neonates might not be guaranteed.

Music for pain relief of minor procedures in term neonates

BACKGROUND

Music for neonatal pain has not been exclusively studied in term neonates in a well-designed trial compared to the standard of care. This study aims to assess the effectiveness of music intervention as an adjuvant in relieving acute pain in term newborns undergoing minor painful procedures.

METHODS

This randomized, controlled, blinded trial included any term neonate undergoing heel prick. Both control and intervention groups received oral sucrose 2 min before heel prick. Intervention group was exposed to 'Bedtime Mozart' lullaby recorded music via bedside speakers. Pain was measured using Neonatal Infant Pain Scale (NIPS) at 1-min intervals. Investigators were blinded using noise-canceling headphones that played random music.

RESULTS

A total of 100 neonates were enrolled. Mean gestational age was 39.2 weeks, and mean duration of the procedure was 113 s. Music group was found to have significantly lower pain scores [OR = 0.42 (0.31, 0.56), p < 0.001]. Baseline NIPS scores were similar across groups and there was no interaction effect between groups and time. When NIPS were categorized as pain and no pain, there continued to be statistically significant lower NIPS scores in the music group (p < 0.001).

CONCLUSION

Recorded music, in addition to sucrose, is efficacious in reducing pain, encouraging its use in term neonates.

IMPACT

Recorded music effectively reduces pain induced by minor procedures in term neonates. Clinical studies have shown that live and recorded music induces changes in vital signs and pain scores in the NICU's predominantly preterm population. Most of these studies were also conducted in the white ethnic population. Our study objectively proves reduction in pain scores by using recorded music in a randomized, controlled, blinded study of predominantly non-white, term neonates. Recorded music is effective in reducing acute pain in term neonates and can be widely used even in low-resource nurseries.

Effect of cryoanesthesia and sweet tasting solution in reducing injection pain in pediatric patients aged 7-10 years: a randomized controlled trial

Background

The delivery of profound local anesthetics helps children receive successful treatment by reducing fear, anxiety, and discomfort during dental procedures. Local anesthetic injections are the most anticipated stimuli in dental surgery. Children's perceptions of pain can be altered by applying cryotherapy to precool the oral mucosa or by diverting their minds through taste distractions before administering local anesthetic injections. This study aimed to evaluate the efficacy of cryoanesthesia and xylitol sweet-tasting solution at the injection site in 7-10-year-old children.

Methods

A total of 42 participants, aged 7-10 years, who underwent dental treatment requiring local anesthesia, were enrolled in the study. The children were randomly divided into three groups. In group I, sterile water was held in the mouth for 2 minutes before anesthetic administration, similar to group II, and in group III, a xylitol sweet-tasting solution was used for 2 minutes before needle insertion. The analysis of pain perception was carried out based on the Visual Analog Scale (VAS) and the Sound, Eyes, and Motor (SEM) scale. For VAS analysis, a one-way analysis of variance (ANOVA) was performed for intergroup comparison, and a post hoc Tukey test was performed for subgroup analysis. For the categorical SEM scale, the Kruskal-Wallis test followed by the post hoc test was performed for intergroup comparison. Where a P value of <0.05 was considered statistically significant at 95% confidence intervals.

Results

Cryoanesthesia significantly reduced pain scores on VAS (4.21 ± 1.42) when compared to those on VAS with xylitol sweet-tasting solution (5.50 ± 1.40) and that with sterile water (6.14 ± 2.47). Intergroup comparison of the VAS scores among the three groups was performed using one-way ANOVA, which demonstrated statistically significant differences (P value <0.026) on the VAS scale. Intergroup comparison of the SEM scale was performed using the Kruskal-Wallis test, followed by post hoc comparison, which exhibited statistically significant differences (P < 0.007) among the three groups for the SEM scale.

Conclusion

Cryoanesthesia demonstrated higher efficacy in reducing injection pain than that exhibited by the xylitol sweet-tasting solution.

Sustained pacifier use is associated with smaller vocabulary sizes at 1 and 2 years of age: A cross-sectional study

Pacifier use during childhood has been hypothesized to interfere with language processing, but, to date, there is limited evidence revealing detrimental effects of prolonged pacifier use on infant vocabulary learning. In the present study, parents of 12- and 24-month-old infants were recruited in Oslo (Norway). The sample included 1187 monolingual full-term born (without visual, auditory, or cognitive impairments) infants: 452 (230 girls; 222 boys) 12-month-olds and 735 (345 girls; 390 boys) 24-month-olds. Parents filled out an online Norwegian Communicative Development Inventory (CDI), which assesses the vocabulary in comprehension and production for 12-month-old infants and in production only for 24-month-old infants. CDI scores were transformed into age- and sex-adjusted percentiles using Norwegian norms. Additionally, parents retrospectively reported their child's daytime pacifier use, in hours, at 2-month intervals, from birth to the assessment date. Maternal education was used to control, in the analyses, for the socio-economic status. We found that greater pacifier use in an infant's lifespan was associated with lower vocabulary size. Pacifier use later in life was more negatively associated with vocabulary size than precocious use, and increased the odds of being a low language scorer. In sum, our study moves beyond the findings of momentary effects of experimentally induced "impairment" in articulators' movement on speech perception and suggests that, from 12 months of age, constraints on the infant's speech articulators (pacifier use) may be negatively associated with word comprehension and production. RESEARCH HIGHLIGHT: 1.We examined the relationship between pacifier use and vocabulary sizes in production at 24 months of age and comprehension and production at 12 months of age. 2.Lifespan Pacifier Use (LPU) was negatively correlated with vocabulary sizes in comprehension and production among 12-month-old infants and negatively correlated with production for 24-month-olds. 3.Later pacifier use was found to be more negatively correlated with vocabulary size in infants, as compared to more precocious use. 4.The amount of pacifier use in the 2 months prior to a child's second birthday was predictive of a higher prevalence of low vocabulary scores in 24-month-olds.

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

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Effects of white noise on preterm infants in the neonatal intensive care unit: A meta-analysis of randomised controlled trials

AIM

To critically assess the effects of white noise on the pain level, weight gain and vital signs (heart rate, respiratory rate and oxygen saturation) of preterm infants in neonatal intensive care units (NICUs).

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

Ten databases (PubMed, Cochrane Library, Embase, Web of Science, CINAHL, PsycINFO, SinoMed, China National Knowledge Infrastructure, VIP and Wanfang Data) were systematically reviewed from inception to July 2022. Two reviewers evaluated the risk of bias separately using the Cochrane Collaboration criteria and extracted data using a predesigned information form.

RESULTS

The meta-analysis included eight eligible RCTs. According to statistical analysis, white noise significantly affected the pain level, weight gain, heart rate, respiratory rate and oxygen saturation in preterm infants. Regardless of the outcome measurement timing, gestational age and birth weight of preterm infants, subgroup analysis demonstrated that white noise reduced the pain level, heart rate and respiratory rate and promoted weight gain in preterm infants in NICUs.

CONCLUSION

White noise is a practical and potentially useful therapy for premature neonates in NICUs. No Patient or Public Contribution.

Non-pharmacological pain relief interventions in preterm neonates undergoing screening for retinopathy of prematurity: a systematic review

OBJECTIVE

The objective of this review was to determine the efficacy of non-pharmacological interventions for pain management during retinopathy of prematurity (ROP) screening.

METHODS AND ANALYSIS

Electronic search of Ovid MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Google Scholar and ClinicalTrials.gov (USA) was conducted. Search terms from the research question and inclusion criteria were used to select randomised control trials (RCT) published from January 2000 to May 2023. Relevant data were extracted, and risk of bias was assessed using the Cochrane Risk of Bias tool V.2. Critical appraisal and grading of the quality of evidence were done using the Critical Appraisal Skills Programme tool for RCTs and the Grading of Recommendations Assessment, Development and Evaluation, respectively.

RESULTS

Twenty-one RCTs were included; 14 used sweet taste, while 7 used modified developmental care, touch or positioning, multisensory stimulation, non-nutritive sucking or music. Six studies on sweet taste and all seven latter studies showed a difference in the pain scores in favour of the interventions. The quality of evidence was however judged low and moderate due to some concerns in the randomisation process, measurement of outcome assessment and selection of reported results domains.

CONCLUSION

The use of gentle touch, nesting, positioning, music, multisensory stimulation and developmental care in reducing pain during ROP screening is promising, however, larger studies designed to eliminate the identified concerns are needed. More evidence is also needed before sweet taste interventions can be recommended in routine practice.

Sucking lollipop after awakening from sevoflurane anesthesia reduces the degree of emergence agitation in children undergoing ambulatory surgery: A prospective randomized controlled trial

BACKGROUND

Emergence agitation (EA) is a common complication in pediatric anesthesia, especially in preschool children maintained by sevoflurane, with incidence ranging up to 80%. The purpose of the study was to determine whether sucking lollipop after awakening from sevoflurane anesthesia reduced the degree of EA in children undergoing ambulatory surgery.

METHODS

In this prospective study, 40 children aged 2 to 6 years scheduled for ambulatory surgery with sevoflurane were enrolled. They were randomly allocated to 1 of 2 groups after evaluating baseline EA levels using the pediatric anesthesia emergence delirium (PAED) scale immediately after awakening from general anesthesia: group L (sucking lollipop) or group C (control group, without sucking lollipop). The primary outcome was the overall PAED score after intervention. Pain score, parental satisfaction, the incidence of propofol rescue and negative postoperative behavioral changes (NPOBCs) were assessed.

RESULTS

The overall PAED score after intervention was significantly lower in Group L compared with Group C, with an estimated difference of -1.857 (95% CI, -2.884 to -0.831; P < .001) using generalized estimating equations. However, no significant intergroup differences were observed in the pain score, parental satisfaction, the incidence of propofol rescue and NPOBCs.

CONCLUSIONS

Sucking lollipop after awakening from sevoflurane anesthesia reduced the degree EA in children undergoing ambulatory surgery.

Sucrose solution for alleviating needle pain during inferior alveolar nerve block in children aged 7-10 years: a randomized clinical trial

Background

Intraoral local anesthesia is essential for delivering dental care; however, injection of this local anesthetic is perceived as the most painful and distressing agent for children, parents, and healthcare providers. Reducing pain as much as possible is essential to ensure smooth subsequent treatment procedures, especially in pediatric dentistry. In clinical practice, oral sucrose administration has been reported to decrease the pain during heel lance and cold pressor tests in neonates and children. This study aimed to determine whether the prior administration of a 30% sucrose solution reduced the pain related to inferior alveolar nerve block in children.

Methods

A total of 42 healthy children aged 7-10 years requiring dental treatment of mandibular molars involving inferior alveolar nerve block were recruited. The participants' demographic details were recorded, height and weight were measured, and the anesthetic injection was delivered after receiving the respective intraoral sucrose solution and distilled water by the intervention (group 1) and control (group 2) group participants for 2 min. The subjective pain perceived during injection was measured using an animated emoji scale. The pain scores between the groups were compared using the Mann-Whitney U test.

Results

The median pain score and range for the intervention and control groups were 4 (2 - 6) and 6 (4 - 8), respectively, and statistically significant differences (P < 0.001) were observed in the intervention group. Age, sex, height, and weight did not influence the analgesic effect of the sucrose solution.

Conclusion

Oral administration of sucrose may relieve pain associated with inferior alveolar nerve block in children.

Indications, Measurements, and Complications of Ten Essential Neonatal Procedures

About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit.

Sucrose analgesia for heel-lance procedures in neonates

BACKGROUND

Sucrose has been examined for calming and pain-relieving effects in neonates for invasive procedures such as heel lance.

OBJECTIVES

To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long-term outcomes SEARCH METHODS: We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries.

SELECTION CRITERIA

We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non-nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin-to-skin care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. We assessed heterogeneity by the I2 test. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD -1.74 (95% CI -2.11 to -1.37); I2 = 62%; moderate-certainty evidence) and 60 seconds after lancing (MD -2.14, 95% CI -3.34 to -0.94; I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD -1.90, 95% CI -8.58 to 4.78; heterogeneity not applicable (N/A); very low-certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD -2.00, 95% CI -2.42 to -1.58; heterogeneity N/A; moderate-certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI -0.30 to 1.50; heterogeneity not applicable; very low-certainty evidence) and on DAN scores at 30 seconds after lancing (MD -1.20, 95% CI -7.87 to 5.47; heterogeneity N/A; very low-certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD -4.90, 95% CI -5.73 to -4.07; heterogeneity not applicable; very low-certainty evidence) and during recovery after lancing (MD -3.80, 95% CI -4.47 to -3.13; heterogeneity N/A; very low-certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD -0.60, 95% CI -1.47 to 0.27; heterogeneity N/A; very low-certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI -0.70 to 1.22; heterogeneity not applicable; low-certainty evidence) and 60 seconds after lancing (MD -0.02, 95% CI -0.79 to 0.75; heterogeneity N/A; low-certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD -0.70, 95% CI -0.49 to 1.88; I2 = 94%; very low-certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD -2.60, 95% CI -3.06 to -2.14; heterogeneity N/A; very low-certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP-R scores compared to expressed breast milk during (MD 0.3, 95% CI -0.24 to 0.84; heterogeneity not applicable; low-certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI -0.11 to 0.71; heterogeneity N/A; low-certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP-R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low-certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD -1.80, 95% CI -8.47 to 4.87; heterogeneity N/A; very low-certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP-R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD -0.86, 95% CI -1.43 to -0.29; heterogeneity N/A; very low-certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD -2.27, 95% CI -4.66 to 0.12; heterogeneity N/A; very low-certainty evidence) and during recovery after lancing (MD -0.31, 95% CI -1.72 to 1.10; heterogeneity N/A; very low-certainty evidence). Sucrose vs skin-to-skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 30 seconds after 1st (MD 0.13, 95% CI -0.70 to 0.96); 2nd (MD -0.56, 95% CI -1.57 to 0.45); or 3rd lancing (MD-0.15, 95% CI -1.26 to 0.96); heterogeneity N/A, low-certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 60 seconds after 1st (MD -0.61, 95% CI -1.55 to 0.33); 2nd (MD -0.12, 95% CI -0.99 to 0.75); or 3rd lancing (MD-0.40, 95% CI -1.48 to 0.68); heterogeneity N/A, low-certainty evidence for all comparisons. Minor adverse events required no intervention.

AUTHORS' CONCLUSIONS

Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate-certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin-to-skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence.

Breastfeeding or breast milk for procedural pain in neonates

BACKGROUND

Pain in the neonate is associated with acute behavioural and physiological changes. Cumulative pain is associated with morbidities, including adverse neurodevelopmental outcomes. Studies have shown a reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in neonates experiencing pain or stress. Non-pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for analgesia. This is an update of a review first published in 2006 and updated in 2012.

OBJECTIVES

The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries (ICTRP, ISRCTN and clinicaltrials.gov) in August 2022; searches were limited from 2011 forwards. We checked the reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates. We included both term (≥ 37 completed weeks postmenstrual age) and preterm infants (< 37 completed weeks' postmenstrual age) up to a maximum of 44 weeks' postmenstrual age. The study must have reported on either physiological markers of pain or validated pain scores.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a mean difference (MD). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Of the 66 included studies, 36 evaluated breastfeeding, 29 evaluated supplemental breast milk and one study compared them against each other. The procedures conducted in the studies were: heel lance (39), venipuncture (11), intramuscular vaccination (nine), eye examination for retinopathy of prematurity (four), suctioning (four) and adhesive tape removal as procedure (one). We noted marked heterogeneity in the control interventions and pain assessment measures amongst the studies. Since many studies included multiple arms with breastfeeding/supplemental breast milk as the main comparator, we were not able to synthesise all interventions together. Individual interventions are compared to breastfeeding/supplemental breast milk and reported. The numbers of studies/participants presented with the findings are not taken from pooled analyses (as is usual in Cochrane Reviews), but are the overall totals in each comparison. Overall, the included studies were at low risk of bias except for masking of intervention and outcome assessment, where nearly one-third of studies were at high risk of bias. Breastfeeding versus control Breastfeeding may reduce the increase in heart rate compared to holding by mother, skin-to-skin contact, bottle feeding mother's milk, moderate concentration of sucrose/glucose (20% to 33%) with skin-to-skin contact (low-certainty evidence, 8 studies, 784 participants). Breastfeeding likely reduces the duration of crying compared to no intervention, lying on table, rocking, heel warming, holding by mother, skin-to-skin contact, bottle feeding mother's milk and moderate concentration of glucose (moderate-certainty evidence, 16 studies, 1866 participants). Breastfeeding may reduce percentage time crying compared to holding by mother, skin-to-skin contact, bottle feeding mother's milk, moderate concentration sucrose and moderate concentration of sucrose with skin-to-skin contact (low-certainty evidence, 4 studies, 359 participants). Breastfeeding likely reduces the Neonatal Infant Pain Scale (NIPS) score compared to no intervention, holding by mother, heel warming, music, EMLA cream, moderate glucose concentration, swaddling, swaddling and holding (moderate-certainty evidence, 12 studies, 1432 participants). Breastfeeding may reduce the Neonatal Facial Coding System (NFCS) score compared to no intervention, holding, pacifier and moderate concentration of glucose (low-certainty evidence, 2 studies, 235 participants). Breastfeeding may reduce the Douleur Aigue Nouveau-né (DAN) score compared to positioning, holding or placebo (low-certainty evidence, 4 studies, 709 participants). In the majority of the other comparisons there was little or no difference between the breastfeeding and control group in any of the outcome measures. Supplemental breast milk versus control Supplemental breast milk may reduce the increase in heart rate compared to water or no intervention (low-certainty evidence, 5 studies, 336 participants). Supplemental breast milk likely reduces the duration of crying compared to positioning, massage or placebo (moderate-certainty evidence, 11 studies, 1283 participants). Supplemental breast milk results in little or no difference in percentage time crying compared to placebo or glycine (low-certainty evidence, 1 study, 70 participants). Supplemental breast milk results in little or no difference in NIPS score compared to no intervention, pacifier, moderate concentration of sucrose, eye drops, gentle touch and verbal comfort, and breast milk odour and verbal comfort (low-certainty evidence, 3 studies, 291 participants). Supplemental breast milk may reduce NFCS score compared to glycine (overall low-certainty evidence, 1 study, 40 participants). DAN scores were lower when compared to massage and water; no different when compared to no intervention, EMLA and moderate concentration of sucrose; and higher when compared to rocking or pacifier (low-certainty evidence, 2 studies, 224 participants). Due to the high number of comparator interventions, other measures of pain were assessed in a very small number of studies in both comparisons, rendering the evidence of low certainty. The majority of studies did not report on adverse events, considering the benign nature of the intervention. Those that reported on adverse events identified none in any participants. Subgroup analyses were not conducted due to the small number of studies.

AUTHORS' CONCLUSIONS

Moderate-/low-certainty evidence suggests that breastfeeding or supplemental breast milk may reduce pain in neonates undergoing painful procedures compared to no intervention/positioning/holding or placebo or non-pharmacological interventions. Low-certainty evidence suggests that moderate concentration (20% to 33%) glucose/sucrose may lead to little or no difference in reducing pain compared to breastfeeding. The effectiveness of breast milk for painful procedures should be studied in the preterm population, as there are currently a limited number of studies that have assessed its effectiveness in this population.

Timing for maximum anaesthetic effect of topical cream during early infant circumcision (EIC) in Rakai, Uganda

Objectives

The objective of this study is to determine the optimal timing for device-based infant circumcision under topical anaesthesia.

Subjects/patients

We include infants aged 1-60 days who were enrolled in a field study of the no-flip ShangRing device at four hospitals in the Rakai region of south-central Uganda, between 5 February 2020 and 27 October 2020.

Methods

Two hundred infants, aged 0-60 days, were enrolled, and EMLA cream was applied on the foreskin and entire penile shaft. The anaesthetic effect was assessed every 5 min by gentle application of artery forceps at the tip of the foreskin, starting at 10 min post-application until 60 min, the recommended time to start circumcision. The response was measured using the Neonatal Infant Pain Scale (NIPS). We determined the onset and duration of anaesthesia (defined as <20% of infants with NIPS score >4) and maximum anaesthesia (defined as <20% of infants with NIPS score >2).

Results

Overall, NIPS scores decreased to a minimum and reversed before the recommended 60 min. Baseline response varied with age, with minimal response among infants aged 40 days. Overall, anaesthesia was achieved after at least 25 min and lasted 20-30 min. Maximum anaesthesia was achieved after at least 30 min (except among those aged >45 days where it was not achieved) and lasted up to 10 min.

Conclusion

The optimal timing for maximum topical anaesthesia occurred before the recommended 60 min of waiting time. A shorter waiting time and speed may be efficient for mass device-based circumcision.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Assessment of Comfort during Less Invasive Surfactant Administration in Very Preterm Infants: A Multicenter Study

INTRODUCTION

This study was set up to investigate if and to what extent non-pharmacological analgesia is able to provide comfort to very preterm infants (VPI) during less invasive surfactant administration (LISA).

METHODS

This was a prospective non-randomized multicenter observational study performed in level IV NICUs. Inborn VPI with a gestational age between 220/7 and 316/7 weeks, signs of respiratory distress syndrome, and the need for surfactant replacement were included. Non-pharmacological analgesia was performed in all infants during LISA. In case of failure of the first LISA attempt, additional analgosedation could be administered. COMFORTneo scores during LISA were assessed.

RESULTS

113 VPI with a mean gestational age of 27 weeks (+/- 2.3 weeks) and mean birth weight of 946 g (+/- 33 g) were included. LISA was successful at the first laryngoscopy attempt in 81%. COMFORTneo scores were highest during laryngoscopy. At this time point, non-pharmacological analgesia provided adequate comfort in 61% of the infants. 74.4% of lower gestational aged infants (i.e., 220-266 weeks) were within the comfort zone during laryngoscopy compared to 51.6% of higher gestational aged infants (i.e., 270-320 weeks) (p = 0.016). The time point of surfactant administration did not influence the COMFORTneo scores during the LISA procedure.

CONCLUSION

Non-pharmacological analgesia provided comfort in as much as 61% of the included VPI during LISA. Further research is needed to both develop strategies to identify infants who, despite receiving non-pharmacological analgesia, are at high risk for experiencing discomfort during LISA and define patient-tailored dosage and choice of analgosedative drugs.

A new technology for pacifier weaning: a thematic analysis

Introduction

Babies and toddlers often become accustomed to using baby pacifiers. However, pacifiers may harm children's health and lead to various problems, such as less frequent breastfeeding, shorter breastfeeding duration, dental deformities, tooth decay, recurrent acute otitis media, sleep disorders, and the potential for accidents. This study aims to introduce new technology that may prevent babies from becoming used to a pacifier (patent titled "Prevents Getting Used to Pacifier Baby, Number SA10609, Saudi Authority for Intellectual Property"). This study used a descriptive qualitative design.

Methods

The participants included three pediatricians, three psychologists, three dentists, three family doctors, and three mothers of babies and toddlers, with a mean age of 42.6 years old (SD = 9.51). Semi-structured interviews were used, and thematic analysis was conducted to generate a thematic tree.

Results and Discussion

The thematic analysis resulted in three themes: (1) the disadvantages of pacifier use, (2) the introduction of new technology for the patent, and (3) the expectations for this technology. The results showed that a pacifier might negatively affect the health of babies and toddlers. However, the new technology may prevent children from becoming used to pacifiers and protect them from any possible physical or mental issues.

The role of time interval elimination on pain control of preterm infants by sucrose administration

PURPOSE

The 2-min time interval of sucrose administration given before minor painful procedures in preterm infants is based on a few limited studies. We aimed to assess availability of sucrose analgesia in emergency states of minor procedural pain by eliminating the 2-min time interval prior to heel lance in preterm infants. The primary outcome was Premature Infants Pain Profile-Revised (PIPP-R) at 30 and 60 s.

METHODS

Healthy 69 preterms undergoing a heel lance, who were assigned randomly to 1 of 2 groups, i.e., group I, with the 2-min time interval of per oral 24% sucrose given prior to heel lance, or group II, without a time interval of per oral 24% sucrose, were recruited. Premature Infants Pain Profile-Revised, crying incidence, duration, and heart rate at 30 and 60 s following heel lance were the outcome measures in this single-center, randomized, prospective study.

RESULTS

The 2 groups did not differ significantly in PIPP-R scores at 30 s (6.63 vs. 6.32, p = .578) and 60 s (5.80 vs. 5.38, p = .478). The crying incidence was similar between the 2 groups (p = .276). The median crying duration was 6 s (range: 1-13 s) in group I and 4.5 s (range: 1-18 s) in group II (p = .226). No significant differences in the heart rates between the 2 groups and the proportion of adverse events by time interval elimination were recorded.

CONCLUSIONS

Eliminating the time interval did not decrease the analgesic effect of orally administered 24% sucrose given prior to heel lance. In emergency states of minor procedural pain, eliminating the 2-min time interval following sucrose administration is safe and efficacious in preterm infants.

Medication Use in the Diagnostic Pediatric Lumbar Puncture

The lumbar puncture (LP) is a common procedure in the pediatric emergency department. A retrospective review was conducted of patients who had LPs from 2012 to 2016 at 2 children's hospitals to (1) characterize medication use during the pediatric LP and (2) test the hypothesis that varied medication use influences LP outcome. Outcomes were defined as unsuccessful if the LP was documented as unsuccessful, had a cerebrospinal fluid (CSF) red blood cell (RBC) count >400 cells/µL, or if a second LP was performed within 24 hours. In total, 8463 patients were reviewed and 2806 (33%) were included in the study. We noted significant variation in LP medication use. When adjusted for patient demographics, location, weight, position, and provider experience, our regression model revealed that the use of fentanyl, ketamine, nitrous oxide, and propofol were best associated with LP success. These data suggest the need for a standardized LP medication protocol as provider choice in medication significantly influences LP outcome.

The actual duration of preoperative fasting in pediatric patients, and its effects on hunger and thirst: a prospective observational study

BACKGROUND

Preoperative fasting time for food and clear liquid was recommended as 2 and 6 h to prevent pulmonary aspiration. Prolonged fasting led to ketosis, hypotension, and patient discomfort. This study aimed to investigate the actual duration of preoperative fasting in pediatric patients, its effects on hunger and thirst, and factors that influence hunger and thirst.

METHODS

This prospective observational study recruited participants aged 0-15 years who were scheduled for elective surgery or for other procedures to be performed under general anesthesia in a tertiary care center. All parents or participants were asked to report the fasting time for food and clear liquid. Participants aged 7-15 years self-rated their degree of hunger and thirst using a 0-10 scale. For participants aged less than 7 years, parents were asked to rate their child's degree of hunger based on the child's behavior. Dextrose-containing intravenous fluid administration and anesthesia start time were collected.

RESULTS

Three hundred and nine participants were included. The overall median [interquartile range; IQR] fasting duration for food and clear liquid was 11.1 h [IQR: 8.0, 14.0] and 10.0 h [IQR: 7.2, 12.5], respectively. The overall median hunger and thirst score was 7 [IQR: 5, 9] and 5 [IQR: 0, 7.5], respectively. High hunger score was reported in 76.4% of participants. There was no correlation between fasting time for food and hunger score [Spearman's rank correlation coefficient (Rho): -0.150, P=0.008], or between fasting time for clear liquid and thirst score (Rho: 0.007, P=0.955). Zero to 2-year-old participants had a significantly higher hunger score compared to older participants (P<0.001) and a higher proportion (80-90%) of high hunger score regardless of anesthesia start time. Although dextrose-containing fluid was administered ≥10 mL/kg, 85.7% of this group still reported high hunger score (P=0.008). Ninety percent of participants who had anesthesia start time after 12:00 PM reported high hunger score (P=0.044).

CONCLUSIONS

The actual duration of preoperative fasting was found to be longer than the recommendation for both food and liquid in pediatric surgical population. Younger age group and anesthesia start time in the afternoon were factors associated with high hunger score.

[Evidence-based guideline for neonatal pain management in China (2023)]

Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.

Effect of Non-Pharmacological Methods in the Reduction of Neonatal Pain: Systematic Review and Meta-Analysis

In neonatology, neonates have traditionally been considered incapable of feeling pain, due to the immaturity of their nervous system. Currently, there is sufficient information on the perception of pain in neonates; however, this treatment at this crucial stage for development requires a better approach. For this reason, the aim of this study was to analyse the efficacy of non-pharmacological analgesia interventions during heel prick, and to assess their effects on heart rate (HR), premature infant pain profile (PIPP) and O2 saturation. A systematic review and meta-analysis was performed following the guidelines of the preferred reporting items for systematic reviews and meta-analyses (PRISMA), and the Cochrane collaboration handbook. The databases PubMed, Cochrane Library, Web of Science, Scopus, CINAHL and Science Direct were searched until the end of January 2022. The DerSimonian and Laird methods were used to estimate the effect size with a 95% confidence interval (CI95%). Effect size estimates were 0.05 (95% CI: -0.19, 0.29) for HR, -0.02 (95% CI: -0.24, 0.21) for PIPP scale, and -0.12 (95% CI: -0.29, 0.05) for O2 saturation. The non-pharmacological interventions analysed (breastfeeding, kangaroo-mother care method, oral sucrose and non-nutritive sucking) were not statistically significant in reducing neonatal pain, but did influence the decrease in pain score and a faster stabilisation of vital signs.

Efecto de un programa de enfermería sobre los cuidados centrados en el desarrollo del recién nacido prematuro

Objetivo. Determinar el efecto de un programa de enfermería sobre los cuidados centrados en el desarrollo (neurodesarrollo) del recién nacido prematuro (RNPT) en el servicio de cuidados intensivos neonatal del Instituto Nacional Materno Perinatal (INMP) 2021. Materiales y Métodos. Investigación preexperimental, nivel aplicativo y enfoque cuantitativo, población enfermeras asistenciales del servicio de cuidados intensivos neonatal del INMP, muestra constituida por 26 enfermeras. Las técnicas empleadas fueron la observación y la encuesta y dos instrumentos, lista de chequeo (KR 0.792) y escala de Likert (Alfa de Crombach 0.917), aplicados en 2 fases antes y después del programa de intervención. Los datos recolectados fueron procesados con el programa SPSS y para medir el efecto del programa de intervención se empleó la prueba de Mc Nemar. El estudio fue autorizado por la unidad funcional de investigación del Instituto Nacional Materno Perinatal. Resultados. Existe diferencia en las prácticas sobre los cuidados centrados en el desarrollo del RNPT aplicados por las enfermeras del servicio de cuidados intensivos neonatal del INMP, evidenciado por un p=0.031 (p<0.05). Antes del programa de intervención las enfermeras tenían 73.1% de prácticas adecuadas, posterior al programa de intervención las practicas adecuadas incrementaron a 96,2% y las practicas inadecuadas disminuyeron de 26.9% a 3,8%. Conclusiones. El programa de intervención de enfermería sobre los cuidados centrados en el desarrollo en el servicio de cuidados intensivos neonatal del INMP, puede mejorar la efectividad en la atención del RNPT. Hallándose en su mayor porcentaje practicas adecuadas después del programa de intervención.

Analgesic Role of Breastfeeding: Analysis of Effectiveness, Implementation Barriers, and Strategies to Promote Evidence-Based Practice

Objective:

Exposure to painful stimuli serves as toxic stress for infants, increasing their subsequent pain sensitivity and resulting in neurodevelopmental impairments. Besides offering nutritional, psychological, immunological, and economic benefits, breastfeeding is reported as the most effective analgesia for the management of minor procedural pain in infants. Although breastfeeding holds several advantages, implementation of this nonpharmacological intervention is still uncommon in many clinical settings.

Methods:

This scoping review presents an analysis of 29 clinical trials that compare the effectiveness of breastfeeding with other nonpharmacological methods.

Findings:

Breastfeeding is an efficacious analgesia compared with sucrose, sweet solutions, and other nonpharmacological methods. When used alone or in combination with other nonpharmacological interventions, breastfeeding reduces infants’ biobehavioral responses to pain and promotes faster physiologic recovery after painful procedures. Breastfeeding is recommended as the first choice whenever feasible. Barriers to the uptake of this effective pain management method in clinical practice include misinformation/inconsistent use of evidence, an infant’s impaired sucking reflex, maternal–child separation, the workload of healthcare professionals, a lack of parental involvement, assumptions of healthcare providers, and a lack of adequate information/guidance for parents. Strategies to promote the uptake of breastfeeding for the management of procedural pain in infants include an effective partnership between healthcare providers and breastfeeding mothers, knowledge mobilization resources in multiple languages, informational support and media campaigns, and experiential learning opportunities for breastfeeding mothers.

Conclusions:

Successful implementation of baby-friendly hospital initiatives, a patient-centered approach, family-centered care, and the collaborative efforts of healthcare providers in all healthcare settings is recommended to promote the uptake of breastfeeding as analgesia.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

Possibilities of Influencing Procedural Pain Associated with Premature Newborn Retinopathy Screening with Oral Clonidine

BACKGROUND

The aim of our study was to compare the analgesic/sedative effects of various fundus-related procedural pain management strategies on the risk of retinopathy in premature infants.

METHOD

This was a prospective comparative study involving a total of 94 neonates randomized to three groups meeting the criteria for at-risk neonates. Ophthalmologic screening was performed to evaluate the outcome of three procedural pain management strategies. The intensity of pain over time during and after the screening examination was evaluated. At the same time, we also looked at the occurrence of vegetative symptoms and their influence by the chosen medication. Pain response was observed in all 94 neonates enrolled in the study. In group A, no pain treatment was given. Group B had a local anesthetic oxybuprocaine hydrochloride 0.4% introduced into both eyes immediately prior to the examination. Group C received oral clonidine. The study was conducted as a pilot project and aimed to clarify the problem so that a project with a higher proband representation could take place in the future. Consequently, we performed quantitative analysis of complete pain and vegetative functions, followed by a qualitative analysis of their internal components.

RESULTS

In our study, we identified the most considerable effects for all three groups, including NIPS (Neonatal Infant Pain Scale) responses immediately during and after the examination. The influence of vegetative functions is of a longer-term nature and increased values can be clearly demonstrated even six hours after the examination.

CONCLUSION

The current results identify and quantify differences among all three methods of pain treatment on the level of single variables. Their internal structures, however, can be analysed only qualitatively because of the small size of the analysed sample.

Quantification of Procedure Time and Infant Distress Produced (as Crying) When Percutaneous Achilles Tenotomy Is Performed under Topical Local Anaesthesia: A Preliminary Study

INTRODUCTION

Percutaneous tenotomy of the Achilles tendon is part of the clubfoot management procedure known as the Ponseti method and is necessary for most infants requiring this treatment. However, the need to apply general anaesthesia or sedation during this procedure remains controversial. To our knowledge, no previous studies have been conducted to quantify infant distress, expressed as crying, when tenotomy is performed under local anaesthesia.

MATERIAL AND METHODS

This clinical, prospective, cross-sectional, and observational study was composed of infants subjected to percutaneous Achilles tenotomy with local anaesthesia at an outpatient clinic. The degree of distress was measured using two smartphone apps (voice recorder and timer) in two iPhones, with each apparatus placed one meter from the baby. The following parameters were determined: procedure duration, crying duration, average crying intensity and maximum crying intensity. In addition, the following data were obtained: age, complications (if any) and the caregiver's satisfaction with the process.

RESULTS

Among the 85 infants submitted to percutaneous tenotomy, the mean age was 1.95 (+/-1.632) months (ranging from 0 to 7 months), the mean duration of the procedure was 8.134 (+/-5.97) seconds, (range 2.1 to 33.5 s), the infants' mean crying intensity was 88.99 dB and the maximum crying intensity was 96.56 dB. No vascular or anaesthetic-related complications were recorded. 96% of the caregivers were absolutely satisfied with the process.

CONCLUSIONS

Percutaneous Achilles tenotomy performed under local anaesthesia can safely be performed at the outpatient clinic. The procedure is fast and the crying time and intensity (mean values: 84 s and 89 dB, respectively) are minimal and tolerable. Knowledge of these parameters provides more accurate knowledge about the procedure. The caregivers consulted were absolutely satisfied with the tenotomy performed under local anaesthesia. In future studies, these parameters can be used for comparison with related surgical approaches.

Procedural Pain Management During Tenotomy for Congenital Talipes Equinovarus

The majority of infants with congenital talipes equinovarus (CTEV) require tenotomy of the tendoachilles. The pain response of this procedure in the awake infant has not been previously reported. In this observational study, multimodal pain management strategies, including oral sucrose, oral paracetamol, topical anesthetic, local anesthetic, a pacifier (dummy), and swaddling, were used. Physiological responses and pain were recorded. Pain was rated out of 10 at regular intervals, using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Ninety-one infants (65 men, mean age = 53 days, range = 19-217 days) were observed. At baseline, median FLACC, heart rate (HR), and oxygen saturation (Spo₂) were 1, 159, and 97% respectively. Peak median FLACC and HR were 9 and 200, respectively, and lowest median Spo₂ was 92%. The median (interquartile range) time for FLACC to return to 3 or less was 2 (2-5) minutes. Achilles tenotomy for CTEV in the awake infant is associated with high pain levels despite provision of multimodal pain relief measures.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

Efficacy and safety of non-pharmacological interventions for neonatal pain: an overview of systematic reviews

OBJECTIVES

To synthesise current evidence from systematic reviews (SRs) regarding the efficacy and safety of non-pharmacological interventions to prevent and treat pain in newborn infants.

DESIGN

Overview of SRs.

DATA SOURCES

We searched PubMed, Embase, Cochrane Library, Web of Science, CINAHL, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, Chinese Science and Technology Periodical Database (VIP) and Google Scholar to identify all relevant SRs published in the last 5 years.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included SRs that evaluated the efficacy and safety of non-pharmacological interventions for neonatal pain.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data, assessed the methodological quality using a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 and graded the evidence quality with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 29 SRs were included in this overview, of which 28 focused on procedural pain and only 1 focused on postoperative pain. Based on AMSTAR 2, seven reviews were found to be of 'high quality', eight of 'moderate quality', five of 'low quality' and nine of 'critically low quality'. The GRADE results suggested that facilitated tucking, kangaroo care, sweet solutions, familiar odour or combined non-pharmacological interventions, such as a combination of sucrose and non-nutritive sucking, were effective and safe in reducing pain from medical procedures in neonates. However, sucrose alone was less effective than local anaesthesia or a combination of the two during circumcision.

CONCLUSIONS

Facilitated tucking, small volumes of sweet solutions, kangaroo care and familiar odour were recommended. Scientific implementation strategies should be developed to promote the clinical use of these effective non-pharmacological interventions. Meanwhile, further rigorous trials and SRs are needed to identify the best non-pharmacological approaches for pain from common surgery and illnesses in neonates.

PROSPERO REGISTRATION NUMBER

CRD42021292583.